Outcomes of popliteal vascular injuries at Sri Lankan war-front military hospital: case series of 44 cases

The construction and application of a trauma limb salvage map in Shaanxi province

Trauma is an important cause of death in young- and middle-aged people. Trauma is comprehensive and includes many surgical specialties, and the surgical techniques of these specialties have long been mature. To reduce the mortality and disability rate of trauma patients, it is necessary to improve trauma management. Trauma has attracted attention in China and trauma treatment and care developed rapidly in recent years. To decrease traumatic mortality and disability rates, our team is committed to building an efficient trauma system in Shaanxi province and has successfully developed a trauma limb salvage map to address the high rates of amputation and disability in patients with limb injuries. This article elaborates on the construction experience of a trauma limb salvage map and its application details in Shaanxi province of China.

Concomitant vascular and orthopedic trauma: 10 points to consider

Although vascular injuries complicate only 1-2% of patients with orthopedic trauma, they may be encountered in a much higher rate of around 10 % in injuries around the knee and elbow joints following both fractures and dislocations. In case of vascular involvement, specific diagnostic and therapeutic challenges arise and there is a higher risk for significant morbidity (i.e. limb loss) or mortality. In the absence of randomized data, diagnostic and therapeutic algorithms are not always straightforward and clinical practice may be based on experience and local protocols rather than firm evidence. With this article we intend to review available literature regarding concomitant skeletal and vascular trauma in order to provide concise information and clear guidelines of when to operate with least investigations and when to go for a full spectrum of investigations in the absence of hard clinical signs. Additionally, other aspects concerning the manipulation of these patients are discussed, such as the indications of primary amputation, the potential role of endovascular techniques and the value of the Resuscitative Endovascular Balloon Occlusion of the Aorta. In summary, this scoping review summarizes current practices in the diagnostic and therapeutic management of patients with concomitant orthopedic and vascular injuries, discusses different treatment strategies and gives a practical perspective for implementation on every day practice.

Reduced Time to Surgery and Prophylactic Fasciotomy May Result in Improved Outcomes in Popliteal Artery Injuries

BACKGROUND

Popliteal artery injuries are uncommon and often result in limb loss or long-term limb dysfunction. The aims of this study were (1) to evaluate the association between predictors and outcomes and (2) to validate the rational of systematic early fasciotomy.

METHODS

This retrospective cohort study included 122 patients (80% men, n = 100) who underwent surgery for popliteal artery injuries from October 2018 to March 2021 in southern Vietnam. Primary outcomes included primary and secondary amputation. The associations between predictors and primary amputation were analyzed using logistic regression models.

RESULTS

Among the 122 patients, 11 (9%) underwent primary amputation, while 2 (1.6%) had secondary amputation. Longer time to surgery was associated with increased odds of amputation (odds ratio = 1.65; 95% confidence interval, 1.2 to 2.2 for every 6 hr). Severe limb ischemia was also associated with a 50-fold increase in the risk of primary amputation (adjusted odds ratio = 49.9; 95% confidence interval, 6 to 418, P = 0.001). Furthermore, 11 patients (9%) without signs of severe limb ischemia and acute compartment syndrome on admission were found to have myonecrosis of at least one muscle compartment during fasciotomy.

CONCLUSIONS

The data suggest that among patients with popliteal artery injuries, prolonged time before surgery and severe limb ischemia are associated with increased risk of primary amputation, whereas early fasciotomy may lead to improved outcomes.

Review article: History of venous trauma

ABSTRACT

This is a literature review on the history of venous trauma since the 1800s, especially that to the common femoral, femoral and popliteal veins, with focus on the early 1900s, World War I, World War II, Korean War, Vietnam War, and then civilian and military reviews (1960-2020). In the latter two groups, tables were used to summarize the following: incidence of venous repair versus ligation, management of popliteal venous injuries, patency of venous repairs when assessed <30 days from operation, patency of venous repairs when assessed >30 days from operation, clinical assessment (edema or not) after ligation versus repair, incidence of deep venous thrombosis after ligation versus repair, and incidence of pulmonary embolism after ligation versus repair.There is a lack of the following in the literature on the management of venous injuries over the past 80 years: standard definition of magnitude of venous injury in operative reports, accepted indications for venous repair, standard postoperative management, and timing and mode of early and later postoperative assessment.Multiple factors have entered into the decision on venous ligation versus repair after trauma for the past 60 years, but a surgeon's training and local management protocols have the most influence in both civilian and military centers. Ligation of venous injuries, particularly those in the lower extremities, is well tolerated in civilian trauma, although there is the usual lack of short- and long-term follow-up as noted in many of the articles reviewed.

LEVEL OF EVIDENCE

Review article, levels IV and V.

Damage control of peripheral vascular trauma - Don't be afraid of axillary or popliteal fosses

Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient’s life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries

The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

A critical appraisal of impact of compounding factors in limb salvage decision making in combat extremity vascular trauma

Objective

For more than half a century, surgeons who managed vascular injuries were guided by a 6-hour maximum ischaemic time dogma in their decision to proceed with vascular reconstruction or not. Contemporary large animal survival model experiments aimed at redefining the critical ischaemic time threshold concluded this to be less than 5 hours. Our clinical experience from recent combat vascular trauma contradicts this dogma with limb salvage following vascular reconstruction with an average ischaemic time of 6 hours.

Methods

During an 8-month period of the Sri Lankan Civil War, all patients with penetrating extremity vascular injuries were prospectively recorded by a single surgeon and retrospectively analysed. A total of 76 arterial injuries was analysed for demography, injury anatomy and physiology, treatment and outcomes. Subsequent statistical analysis was performed to evaluate the impact of independent variables to include; injury anatomy, concomitant venous, skeletal trauma, shock at presentation and time delay from injury to reconstruction.

Results

In this study, the 76 extremity arterial injuries had a median ischaemic time of 290 (IQR 225–375) min. Segmental arterial injury (p=0.02), skeletal trauma (p=0.05) and fasciotomy (p=0.03) were found to have a stronger correlation to subsequent amputation than ischaemic time.

Conclusions

Multiple factors affect limb viability following compromised distal circulation and our data show a trend towards various subsets of limbs that are more vulnerable due to inherent or acquired paucity of collateral circulation. Early identification and prioritisation of these limbs could achieve functional limb salvage if recognised. Further prospective research should look into the clinical, biochemical and morphological markers to facilitate selection and prioritisation of limb revascularisation.

Do Antiplatelet and Anticoagulation Agents Matter after Repair of Traumatic Arterial Injuries?

Thrombosis is a devastating complication after repair of traumatic vascular injury. Although thrombosis rates have been described, the value of anticoagulation in preventing postrepair thrombosis is unknown. We hypothesize that postoperative anticoagulation reduces thrombosis rates. A total of 1524 consecutive patients with traumatic arterial injuries from January 2005 to June 2015 were identified, and 381 patients underwent the following repair types: direct suture of vessel wall, primary anastomosis, extra-anatomic reconstruction, tissue and synthetic interposition reconstruction. Twenty six patients received postoperative heparin at therapeutic levels, and 29 patients received postoperative aspirin for five consecutive days. The heparin and aspirin groups were matched with patients without postoperative anticoagulation by the following variables: anatomic arterial injury, type of vascular repair, and age. These groups were then compared using the following outcome measures: mortality, thrombosis of repaired vessel, amputation, hemorrhage, cerebral vascular accident, and extremity compartment syndrome. The demographics between the heparin, aspirin, and respectively matched groups were not statistically different. There was no statistically significant difference in the rate of thrombosis, bleeding, compartment syndrome, cerebral vascular accident, limb amputation, or mortality. Although there was no increase in bleeding complications with the use of heparin or aspirin, there was also no impact on the rate of thrombosis.

Retrospective analysis of case series of patients with vascular war injury treated in a district hospital

INTRODUCTION

As the Syrian civil war continues, medical care of the injured remains a priority for health facilities receiving casualties. Ziv Medical Centre, the closest hospital in Israel to the Syrian border, has received 500 casualties since February 2013. Seventeen of these patients had vascular injuries. This research reports the care of these seventeen patients and explores the challenges of treatment in patients with little antecedent clinical history and improvised initial care that may be complicated by delay to definitive care, sepsis and limb ischaemia.

METHOD

Electronic and paper patient records were examined. Descriptive case series data are presented.

RESULTS

Fifteen of the 17 patients were male. The mean age was 20 years (range 8-30 years). Causes of injury included gunshot wounds (4 patients), shrapnel (multi-fragment) injury (12 patients), and 1 patient was run over and dragged behind a car. The time from injury to transfer to definitive care ranged from 5h to 7 days (mean 43 h). All but one patient had associated non-vascular multiple-trauma. Thirteen patients presented with limb ischaemia. Four patients had arterio-venous fistula (AVF) or pseudoaneurysm. There were 5 upper and 10 lower limb major vascular injuries. Three patients had neck vessel injuries. All patients were investigated with CT angiography and underwent surgical or endovascular intervention. In 12 patients, 4 vessels were debrided and re-anastomosed and 13 vessels bypassed. Endovascular repair was performed in 4 patients. After initial revascularisation, 4 patients went on to amputation. There were no deaths.

CONCLUSIONS

The injuries treated are heterogeneous, and reflect the range of high energy vascular trauma expected in conflict. The broad range of vascular solutions required to optimise outcomes, in particular, limb salvage, in turn, reflect the challenges of dealing with such injuries, especially within the context of sepsis, ischaemia and delay. As war continues, there is a pressing need to address the needs of patients with high energy injuries in austere environments where there is a dearth of health resources and where definitive care may be days away.