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Vuoncino M, Scheidt J, Kauvar DS. Association between time to revascularization and limb loss in military femoropopliteal arterial injuries. J Vasc Surg 2023; 78:1198-1203. [PMID: 37541556 DOI: 10.1016/j.jvs.2023.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE Expeditious revascularization is key to limb salvage after arterial injuries, but the relationship between time to revascularization and amputation risk is not well-defined. We aimed to explore amputation risk based on time to revascularization in a cohort of military femoropopliteal arterial injuries. METHODS A database of vascular injuries from Iraq and Afghanistan casualties (2004-2012) was queried for femoral (common, superficial, or deep) and/or popliteal arterial injuries that underwent revascularization. Time from injury to initial revascularization (via shunt or reconstruction) was divided into groups of <3 hours, 3 to 6 hours, 6 to 9 hours, and >9 hours, and bivariate comparisons were performed. RESULTS Revascularization times were available for 120 cases. Injury and treatment characteristics by time group were generally similar between time groups. Shunting and vein injuries were more common in limbs revascularized earlier, whereas blast mechanism and fasciotomy were more common with later revascularization. Ten cases (8%) underwent revascularization in less than 3 hours, 63 (53%) were revascularized in 3 to 6 hours, 33 (28%) in 6 to 9 hours, and 14 (12%) after 9 hours. Amputation rates within the cohorts were 10%, 21%, 24%, and 50%, respectively (P = .085, χ2 of amputation rates across time groups). The mean ± standard deviation revascularization time for amputated limbs was 442 ± 348 minutes vs 347 ± 183 minutes for salvaged limbs (P = .057). Amputation was performed in 19% of limbs revascularized in <6 hours and in 32% revascularized >6 hours from injury (P = .112). The >9-hour group, however, had a 50% amputation rate vs 21% for those with revascularization in <9 hours (P = .016). Fractures were more common in >9-hour limbs than <9-hour limbs (79% vs 44%; P = .016), but other limb injury characteristics were similar, with no difference in limb injury severity scores. Among 91 salvaged limbs, neither vascular nor other complications were predicted by time to revascularization. All seven >9-hour limbs had a limb complication, most commonly infection (71%), and three (42%) required a skin graft to close their fasciotomies. CONCLUSIONS Increasing time from injury to initial revascularization was associated with increasing rates of limb loss. Revascularization within 3 hours of injury resulted in a low amputation rate, whereas one-half of limbs treated after 9 hours were amputated. Arterial shunting was associated with earlier revascularization and should be considered a mainstay of combat casualty vascular care. Forward-deployed surgical assets play a pivotal role in providing early revascularization and reducing rates of limb loss in modern combat casualty care.
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Affiliation(s)
- Matthew Vuoncino
- Division of Vascular Surgery, The University of California Davis, Sacramento, CA
| | - Justin Scheidt
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX
| | - David S Kauvar
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA.
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2
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Lauria AL, Hicks CW. Ischemia Duration and Lower Limb Salvage. Adv Surg 2023; 57:59-71. [PMID: 37536862 PMCID: PMC10773526 DOI: 10.1016/j.yasu.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Management of acute limb ischemia is complex and time sensitive, and delays in diagnosis and treatment may lead to irreversible tissue damage. Current data challenge the commonly accepted 6-hour ischemic threshold for acute limb ischemia, although variations in practice remain. Patients with chronic peripheral artery disease may tolerate longer ischemia time due to presence of collateral circulation. Here the authors discuss the presentation, workup, management, and postoperative care of patients with acute limb ischemia, with a focus on how management is altered depending on the duration and degree of ischemia.
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Affiliation(s)
- Alexis L Lauria
- Department of Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 North Wolfe Street - Halsted 668, Baltimore, MD 21287, USA.
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3
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García AM, Gutiérrez J, Villamil E, Sánchez W, Villarreal L, Lozada-Martinez ID, Picón-Jaimes YA, Pérez M, Cabrera-Vargas LF. Predictors for limb amputation in war vascular trauma: A 20-years retrospective analysis from the Colombian armed conflict. Am J Surg 2023; 225:787-792. [PMID: 36220700 DOI: 10.1016/j.amjsurg.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Latin American military vascular trauma is virtually unknown. The aim of this study was to describe severe war vascular trauma during the last 20 years of the Colombian armed conflict, and to identify predictors of limb amputation. METHODS Retrospective analysis of a follow-up cohort from 1999 to 2019 of patients with associated severe vascular injuries (ISS >15) in the Colombian armed conflict treated at the Hospital Militar Central. RESULTS Out of 5948 patients, 243 had military vascular trauma with 430 vascular injuries. The most frequent trauma mechanisms were gunshot wounds (n = 153; 63%). The most common injured vessels were femoral. 24 (10%) patients required amputations. Mortality was 4.1%. Amputation was associated with arteriovenous lesions (RR 4.82, p = 0.025), compartment syndrome (RR 4.2, p = 0.007), arteriovenous femoropopliteal injuries (RR 3.5, p = 0.0026), multiple arterial injuries (RR 3.35, p = 0.0218), associated fractures (RR 3.1, p = 0.0032). CONCLUSIONS Concomitant arteriovenous injuries in popliteal and femoropopliteal lesions, multiple arterial lesions, bone fractures, and compartment syndrome are associated with amputation in severe vascular injury.
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Affiliation(s)
- Ana Maria García
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Jorge Gutiérrez
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia; Department of Surgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Edwin Villamil
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - William Sánchez
- Department of Surgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Laura Villarreal
- Department of Surgery, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Ivan David Lozada-Martinez
- Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia; International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua.
| | | | - Mauricio Pérez
- Department of Surgery, Universidad El Bosque, Bogotá, Colombia
| | - Luis Felipe Cabrera-Vargas
- Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia; Department of Surgery, Universidad El Bosque, Bogotá, Colombia
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Assessment and Interventions for Vascular Injuries Associated With Fractures. J Am Acad Orthop Surg 2022; 30:387-394. [PMID: 35050940 DOI: 10.5435/jaaos-d-21-00660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/23/2021] [Indexed: 02/01/2023] Open
Abstract
Vascular injuries associated with fractures are limb-threatening injuries with notable morbidity. The prompt and thorough evaluation of these patients is imperative to diagnose vascular injuries, and coordinated multidisciplinary care is needed to provide optimal outcomes. The initial assessment includes a detailed physical examination assessing for hard and soft signs of arterial injury, and the arterial pressure index can be used to reliably identify vascular compromise and the need for additional assessment or intervention. Advanced imaging in the form of CT angiography is highly sensitive in additional characterization of the potential injury and can be obtained in an expedient manner. The optimal treatment of fractures with vascular injuries includes providing skeletal stability and confirming or reestablishing adequate distal perfusion as soon as possible. Options for vascular intervention include observation, ligation, direct arterial repair, vascular bypass grafting, endovascular intervention, and staged temporary shunting, followed by bypass grafting. Although the optimal sequence of surgical intervention remains an incompletely answered question, the orthopaedic role in the care of patients with these injuries is to provide mechanical stability to the injured limb to protect the vascular repair and surrounding soft-tissue envelope.
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Laverty RB, Treffalls RN, Kauvar DS. Systematic review of temporary intravascular shunt use in military and civilian extremity trauma. J Trauma Acute Care Surg 2022; 92:232-238. [PMID: 34538830 DOI: 10.1097/ta.0000000000003399] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of temporary intravascular shunts (TIVS) in the setting of military and civilian trauma has grown in recent years, predominantly because of the mounting evidence of improved limb outcomes. We sought to characterize the use and outcomes of TIVS in trauma through a systematic review of military and civilian literature. METHODS The MEDLINE, EBSCO, EMBASE, and Cochrane databases were searched for studies on TIVS use in military and civilian trauma settings published between January 2000 and March 2021. Reports lacking systematic data collection along with those with insufficient TIVS descriptive and outcome data were excluded. Data regarding the characteristics and outcomes of TIVS were assessed and collective syntheses of military and civilian data performed. RESULTS Twenty-one reports were included, 14 from civilian trauma centers or databases and 7 from military field data or databases (total of 1,380 shunts in 1,280 patients). Sixteen were retrospective cohort studies, and four were prospective. Five studies had an unshunted comparison group. Shunts were predominantly used in the lower extremity and most commonly for damage control indications. Dwell times were infrequently reported and were not consistently linked to shunt thrombosis or other complications. Anticoagulation during shunting was sparsely reported and inconsistently applied. Shunted limbs had higher injury severity than unshunted limbs but similar salvage rates. CONCLUSION Temporary intravascular shunts are effective for expeditious restoration of perfusion in severely injured limbs and likely contribute to limb salvage. There is a paucity of comparative TIVS data in the literature and no consistently applied reporting standards, so controversies regarding TIVS use remain. LEVEL OF EVIDENCE Systematic Review, level IV.
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Affiliation(s)
- Robert B Laverty
- From the Department of Surgery (R.B.L.), Brooke Army Medical Center, JBSA Fort Sam Houston; University of the Incarnate Word School of Medicine (R.N.T.), San Antonio; Vascular Surgery Service (D.S.K.), Brooke Army Medical Center, JBSA Fort Sam Houston, Texas; and Department of Surgery (D.S.K.), Uniformed Services University, Bethesda, Maryland
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Combined Orthopaedic and Vascular Injuries With Ischemia: A Multicenter Analysis. J Orthop Trauma 2021; 35:512-516. [PMID: 33512862 DOI: 10.1097/bot.0000000000002067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and, where possible, the variables that predict amputation. DESIGN Retrospective. SETTING Nine trauma centers. PATIENTS This study involved 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage versus amputation. RESULTS We reviewed 199 patients, 17-85 years of age. One hundred seventy-two of the injuries were open. Thirty-eight patients (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 patients who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25 of 27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21 of 48 (44%) required amputation. The ischemia time for successful salvage was significantly less, P = 0.03. One hundred twenty-four patients had their definitive vascular repair before the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed before the definitive osseous repair, although this was not statistically significant. CONCLUSIONS In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury, before vascular repair may benefit limb salvage, although this needs more study. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
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.
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Affiliation(s)
- David V Feliciano
- From the Department of Surgery (D.V.F.), Shock Trauma Center, University of Maryland Medical Center, University of Maryland, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery (M.P.K.), University of Florida Health Jacksonville Medical Center, Jacksonville, Florida; and Division of Acute Care Surgery, Department of Surgery (G.F.R.), John Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Laverty RB, Brock SG, Walters TJ, Kauvar DS. Outcomes of Arterial Grafts for the Reconstruction of Military Lower Extremity Arterial Injuries. Ann Vasc Surg 2021; 76:59-65. [PMID: 33831531 DOI: 10.1016/j.avsg.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/02/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Lower extremity (LE) arterial injuries are common in military casualties and limb salvage is a primary goal. Bypass grafts are the most common reconstructions; however, their specific outcomes are largely unreported. We sought to describe the outcomes of LE arterial grafts among combat casualties and their association with limb loss. METHODS Retrospective cohort study of 2004-2012 Iraq/Afghanistan casualties with LE arterial injury undergoing bypass graft from a database containing follow-up until amputation, death, or military discharge. Primary outcome was composite graft complications (GC-thrombosis, stenosis, pseudoaneurysm, blowout, and/or arteriovenous fistula). RESULTS Two hundred and twenty-two grafts were included (99 femoral, 73 popliteal, 48 tibial). 56 (26%) had at least one GC; thrombosis was most common in femoral, stenosis most common in popliteal and tibial. GC was not associated with graft level but was associated with synthetic conduit (P = 0.01) and trended towards an association with multiple-level arterial injuries (P = 0.07). Four of eight (50%) synthetic grafts had amputations, all within 72h. Two of the eight synthetic grafts thrombosed, and both limbs were amputated. There were 52 total amputations. Amputation was performed in 13 (23%) of limbs with a GC and 24% of those without (P = 0.93) Overall, 24 (11%) of grafts thrombosed, 16 within 48h and 13 (25%) in limbs undergoing amputation (P = 0.001 for association of thrombosis with amputation). CONCLUSION GC are common among LE bypass grafts in combat casualties but are not associated with limb loss. Thrombosis is predominantly early and is associated with amputation. Closer attention to ensuring early patency may improve limb salvage.
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Affiliation(s)
- Robert B Laverty
- Department of Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | | | - Thomas J Walters
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas; Department of Surgery, Uniformed Services University, Bethesda, Maryland.
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9
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Georgakarakos E, Efenti GM, Koutsoumpelis A, Veloglou AM, Mechmet B, Tasopoulou KM, Argyriou C, Georgiadis GS. Five-Year Management of Vascular Injuries of the Extremities in the "Real-World" Setting in Northeastern Greece: The Role of Iatrogenic Traumas. Ann Vasc Surg 2021; 74:264-270. [PMID: 33549784 DOI: 10.1016/j.avsg.2020.12.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/23/2020] [Accepted: 12/26/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Vascular trauma comprises a diagnostic and surgical challenge. Aim of this study was to present the vascular traumas treated in our Tertiary Hospital during the last 5 years. METHODS We retrospectively reviewed the surgical records of our vascular department and documented the site and type of vascular injuries of the extremities along with the concurrence of musculoskeletal injuries. The type and outcome of surgical interventions were also recorded. RESULTS Fifty-eight cases of vascular trauma were recorded (39 in the upper and 19 in the lower extremities). Overall, iatrogenic traumas accounted for 41.3% of cases. The arterial injuries of the upper limb were blunt and penetrating in 27% and 67%, respectively. The most affected artery in the upper limb was the radial artery (37.8%), followed by the ulnar artery (27%) and the brachial artery (24.3%). Orthopedic injuries were recorded in 19% of patients. Management involved simple revascularization, bypass operations, patch arterioplasty and endovascular management in 48.7%, 33.3%, 5.1%, and 5.1%, respectively. The most affected site in the lower extremity was the common femoral artery (36.8%) followed by the popliteal artery (21%). Bone fractures were reported in 5 cases (26.3%). The surgical management involved bypass, simple revascularization, patch arterioplasty in 42.1%, 26.3%, and 21%, respectively. Endovascular management was performed in 10.5%. CONCLUSIONS A considerable percentage of iatrogenic vascular injuries was recorded, affecting both the upper and lower limbs. Despite the trend toward centralization of vascular services, a basic service of vascular surgery should be available in most sites to ensure that patients with vascular injuries receive fast and appropriate care.
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Affiliation(s)
- Efstratios Georgakarakos
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece.
| | | | - Andreas Koutsoumpelis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anna-Maria Veloglou
- School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Birtze Mechmet
- School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Kalliopi-Maria Tasopoulou
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Christos Argyriou
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
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Kochuba M, Rozycki GF, Feliciano D. Outcome after ligation of major veins for trauma. J Trauma Acute Care Surg 2021; 90:e40-e49. [PMID: 33502152 DOI: 10.1097/ta.0000000000003014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew Kochuba
- From the Division of Acute Care Surgery, Department of Surgery, UF Health Jacksonville Medical Center (M.K.), University of Florida-Jacksonville, Jacksonville, Florida; Division of Acute Care and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University School of Medicine (G.F.R.), Johns Hopkins University; and Division of Surgical Critical Care, Department of Shock Trauma Center, Shock Trauma Center (D.F.), University of Maryland Medical Center, University of Maryland, Baltimore, Maryland
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Haney LJ, Bae E, Pugh MJV, Copeland LA, Wang CP, MacCarthy DJ, Amuan ME, Shireman PK. Patency of arterial repairs from wartime extremity vascular injuries. Trauma Surg Acute Care Open 2020; 5:e000616. [PMID: 33409373 PMCID: PMC7768973 DOI: 10.1136/tsaco-2020-000616] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/20/2020] [Accepted: 12/05/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Extremity vascular injury (EVI) causes significant disability in Veterans of the Afghanistan/Iraq conflicts. Advancements in acute trauma care improved survival and decreased amputations. The study of wartime EVI has relied on successful limb salvage as a surrogate for vascular repair. We used imaging studies as a specific measure of arterial repair durability. METHODS Service members with EVI were identified using the Department of Defense Trauma Registry and validated by chart abstraction. Inclusion criteria for the arterial patency subgroup included an initial repair attempt with subsequent imaging reports (duplex ultrasound, CT angiography, and angiogram) documenting initial patency. RESULTS The cohort of 527 included 140 Veterans with available imaging studies for 143 arterial repairs; median follow-up from injury time to last available imaging study was 19 months (Q1-Q3: 3-58; range: 1-175). Injury mechanism was predominantly explosions (52%) and gunshot wounds (42%). Of the 143 arterial repairs, 81% were vein grafts. Eight repairs were occluded, replaced or included in extremity amputations. One upper extremity and three transtibial late amputations were performed for chronic pain and poor function averaging 27 months (SD: 4; range: 24-32). Kaplan-Meier analysis estimated patency rates of 99%, 97%, 95%, 91% and 91% at 3, 6, 12, 24, and 36 months, respectively, with similar results for upper and lower extremity repairs. Explosive and gunshot wound injury mechanisms had similar patency rates and upper extremity injuries repaired with vein grafts had increased patency. CONCLUSIONS Arterial repair mid-term patency in combat-related extremity injuries is excellent based on imaging studies for 143 repairs. Assertive attempts at acute limb salvage and vascular repair are justified with decisions for amputation versus limb salvage based on the overall condition of the patient and degree of concomitant nerve, orthopedic and soft tissue injuries rather than the presence of arterial injuries. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- Lauren J Haney
- Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA,South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Esther Bae
- South Texas Veterans Health Care System, San Antonio, Texas, USA,Surgery, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Mary Jo V Pugh
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA,Internal Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA,Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Chen-Pin Wang
- South Texas Veterans Health Care System, San Antonio, Texas, USA,Population Health Sciences, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Daniel J MacCarthy
- South Texas Veterans Health Care System, San Antonio, Texas, USA,Population Health Sciences, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Megan E Amuan
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Paula K Shireman
- Surgery, Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA,Surgery, South Texas Veterans Health Care System, San Antonio, Texas, USA
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12
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Polcz JE, White JM, Ronaldi AE, Dubose JJ, Grey S, Bell D, White PW, Rasmussen TE. Temporary intravascular shunt use improves early limb salvage after extremity vascular injury. J Vasc Surg 2020; 73:1304-1313. [PMID: 32987146 DOI: 10.1016/j.jvs.2020.08.137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The use of temporary intravascular shunts (TIVSs) allow for restoration of distal perfusion and reduce ischemic time in the setting of arterial injury. As a damage control method, adjunct shunts restore perfusion during treatment of life-threatening injuries, or when patients require evacuation to a higher level of care. Single-center reports and case series have demonstrate that TIVS use can extend the opportunity for limb salvage. However, few multi-institutional studies on the topic have been reported. The objective of the present study was to characterize TIVS use through a multi-institutional registry and define its effects on early limb salvage. METHODS Data from the Prospective Observation Vascular Injury Treatment registry was analyzed. Civilian patients aged ≥18 years who had sustained an extremity vascular injury from September 2012 to November 2018 were included. Patients who had a TIVS used in the management of vascular injury were included in the TIVS group and those who had received treatment without a TIVS served as the control group. An unadjusted comparison of the groups was conducted to evaluate the differences in the baseline and outcome characteristics. Double robust estimation combining logistic regression with propensity score matching was used to evaluate the effect of TIVS usage on the primary end point of limb salvage. RESULTS TIVS use was identified in 78 patients from 24 trauma centers. The control group included 613 patients. Unmatched analysis demonstrated that the TIVS group was more severely injured (mean ± standard deviation injury severity score, 18.83 ± 11.76 for TIVS vs 14.93 ± 10.46 for control; P = .002) and had more severely mangled extremities (mean ± standard deviation abbreviated injury scale, extremity, score 3.23 ± 0.80 for TIVS vs 2.95 ± 0.87 for control; P = .008). Logistic regression demonstrated that propensity-matched control patients had a three times greater likelihood of amputation compared with the TIVS patients (odds ratio, 3.6; 95% confidence interval, 1.2-11.1; P = .026). Concomitant nerve injury and orthopedic fracture were associated with a greater risk of amputation. The median follow-up for the TIVS group was 12 days (interquartile range, 4-25 days) compared with 9 days (interquartile range, 4-18 days) for the control group. CONCLUSIONS To the best of our knowledge, the present study is the first multicenter, matched-cohort study to characterize early limb salvage as a function of TIVS use in the setting of extremity vascular injury. Shunts expedite limb perfusion and resulted in lower rates of amputation during the early phase of care. The use of TIVS should be one part of a more aggressive approach to restore perfusion in the most injured patients and ischemic limbs.
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Affiliation(s)
- Jeanette E Polcz
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Md
| | - Joseph M White
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Md.
| | - Alley E Ronaldi
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Md
| | - Joseph J Dubose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Scott Grey
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Md
| | - Devin Bell
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Md
| | - Paul W White
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Md
| | - Todd E Rasmussen
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Md
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Haney LJ, Pugh MJV, Copeland LA, Wang CP, MacCarthy DJ, Amuan ME, Shireman PK. Persistent Pain, Physical Dysfunction, and Decreased Quality of Life After Combat Extremity Vascular Trauma. Ann Vasc Surg 2020; 71:167-180. [PMID: 32890646 DOI: 10.1016/j.avsg.2020.08.104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/30/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Combat-related extremity vascular injuries (EVI) have long-lasting impact on Iraq/Afghanistan veterans. The purpose of this study is to describe long-term functional outcomes in veterans with EVI using survey measures and identify modifiable factors that may be improved to reduce chronic pain and injury-related dysfunction. METHODS Veterans with upper and lower EVI undergoing an initial limb salvage attempt were identified using the Department of Defense Trauma Registry and validated with chart abstraction. Surveys measured pain; Short Musculoskeletal Function Assessment (SMFA) for self-reported bother and dysfunction; and Veterans RAND 12-Item Health Survey (VR-12) physical and mental component scores (PCS; MCS) for quality of life, depression, post-traumatic stress disorder, and the potentially modifiable factors of reintegration into civilian life, resilient coping, resilience, and family functioning. RESULTS Eighty-one patients responded with an average time since injury of 129 months (SD: 31; range 67-180 months). Mechanism of injury included 64% explosions and 31% gunshot wounds; 16% of the respondents were diagnosed with moderate/severe/penetrating traumatic brain injury. Limb salvage rates were 100% and 77% for upper and lower extremities, respectively (P = 0.004). Respondents screened positive for probable depression (55%) and post-traumatic stress disorder (51%). Compared with population norms, SMFA bother and dysfunction indices were higher (worse), MCS was lower (worse), and PCS was similar. The multivariable models adjusted for age, marital status and pain. The higher SMFA is part of the results of the multivariable models. MCS decreased with difficulty reintegrating into civilian life and was positively correlated with increased resilience and resilient coping. SMFA scores were greater for patients with high pain intensity and increased 6-11 points per point increase in difficulty with civilian-life reintegration. SMFA dysfunction was associated with better family functioning. CONCLUSIONS EVI results in significant long-term disability with lasting deficits in physical function, frequent depressive symptoms, and below average self-reported quality of life. Strengthening modifiable factors including resiliency and resilient coping, and providing ongoing assistance to improve reintegration into civilian life, may ameliorate the functional disabilities and chronic pain experienced by veterans with EVI.
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Affiliation(s)
- Lauren J Haney
- South Texas Veterans Health Care System, San Antonio, TX; Department of Surgery, Division of Vascular and Endovascular Surgery, and the Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX
| | - Mary Jo V Pugh
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT; VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA; Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Chen-Pin Wang
- South Texas Veterans Health Care System, San Antonio, TX; Department of Surgery, Division of Vascular and Endovascular Surgery, and the Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX
| | - Daniel J MacCarthy
- South Texas Veterans Health Care System, San Antonio, TX; Department of Surgery, Division of Vascular and Endovascular Surgery, and the Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX
| | - Megan E Amuan
- VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Paula K Shireman
- South Texas Veterans Health Care System, San Antonio, TX; Department of Surgery, Division of Vascular and Endovascular Surgery, and the Department of Population Health Sciences, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX.
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Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017. J Trauma Acute Care Surg 2020; 88:e53-e76. [PMID: 32150031 DOI: 10.1097/ta.0000000000002407] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. METHODS The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. RESULTS The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. CONCLUSION Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. LEVEL OF EVIDENCE Systematic review of predominantly level II studies, level II.
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The Ethical Triage and Management Guidelines of the Entrapped and Mangled Extremity in Resource Scarce Environments: A Systematic Literature Review. Disaster Med Public Health Prep 2020; 15:389-397. [PMID: 32456743 DOI: 10.1017/dmp.2020.49] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE A systematic literature review (SLR) was performed to elucidate the current triage and treatment of an entrapped or mangled extremity in resource scarce environments (RSEs). METHODS A lead researcher followed the search strategy following inclusion and exclusion criteria. A first reviewer (FR) was randomly assigned sources. One of the 2 lead researchers was the second reviewer (SR). Each determined the level of evidence (LOE) and quality of evidence (QE) from each source. Any differing opinions between the FR and SR were discussed between them, and if differing opinions remained, then a third reviewer (the other lead researcher) discussed the article until a consensus was reached. The final opinion of each article was entered for analysis. RESULTS Fifty-eight (58) articles were entered into the final study. There was 1 study determined to be LOE 1, 29 LOE 2, and 28 LOE 3, with 15 determined to achieve QE 1, 37 QE 2, and 6 QE 3. CONCLUSION This SLR showed that there is a lack of studies producing strong evidence to support the triage and treatment of the mangled extremity in RSE. Therefore, a Delphi process is suggested to adapt and modify current civilian and military triage and treatment guidelines to the RSE.
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Abstract
This article discusses the pathophysiology, presentation, cause, and treatment of ischemic pain in the surgical patient. Causes of ischemic pain vary but all fundamentally cause local acidosis in the peripheral tissues, which causes signals to be passed through ascending pain pathways to the thalamus and eventual cerebral cortex where it is interpreted as ischemic pain. Ischemic pain is classically associated with an insidious onset but can present in the acute or chronic setting. Treatments are aimed at improving perfusion to the affected tissue. Surgical options include repairing damaged vessels, bypassing diseased vessels, performing thrombectomy, or embolectomy. Numerous conservative therapies exist.
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Affiliation(s)
- Michael R Romanelli
- Department of Surgery, Institute for Plastic Surgery, Southern Illinois University School of Medicine, 747 North Rutledge Street, 3rd Floor, PO Box 19653, Springfield, IL 62794-9653, USA
| | - Jacob A Thayer
- Department of Surgery, Institute for Plastic Surgery, Southern Illinois University School of Medicine, 747 North Rutledge Street, 3rd Floor, PO Box 19653, Springfield, IL 62794-9653, USA
| | - Michael W Neumeister
- Department of Surgery, Institute for Plastic Surgery, Southern Illinois University School of Medicine, 747 North Rutledge Street, 3rd Floor, PO Box 19653, Springfield, IL 62794-9653, USA.
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Liu JL, Li JY, Jiang P, Jia W, Tian X, Cheng ZY, Zhang YX. Literature review of peripheral vascular trauma: Is the era of intervention coming? Chin J Traumatol 2020; 23:5-9. [PMID: 32014343 PMCID: PMC7049612 DOI: 10.1016/j.cjtee.2019.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/25/2019] [Accepted: 11/25/2019] [Indexed: 02/04/2023] Open
Abstract
Traumatic peripheral vascular injury is a significant cause of disability and death either in civilian environments or on the battlefield. Penetrating trauma and blunt trauma are the most common forms of vascular injuries. Besides, iatrogenic arterial injury (IAI) is another pattern of vascular trauma. The management of peripheral vascular injuries has been improved in different environments and wars. There are different types of vascular injuries, such as vasospasm, contusion, intimal flaps, intimal disruption or hematoma, external compression, laceration, transection and focal wall defects, etc. The main clinical manifestations of vascular injuries are shock following massive hemorrhage and limb necrosis due to tissue and organ ischemia. Ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are most valuable for assessment of peripheral vascular injuries. Angiography remains the gold standard for diagnosing vascular trauma. Immediate hemorrhage control and rapid restoration of blood flow are the primary goals of vascular trauma treatment. There are many operative treatment methods for vascular injuries, such as vascular suture or ligation, vascular wall repair and vascular reconstruction with blood vessel prostheses or vascular grafts. Embolization, balloon dilation and covered stent implantation are the main endovascular techniques. Surgical operation is still the primary treatment for vascular injuries. Endovascular treatment is a promising alternative, proved to be safe and effective, and preferred selection for patients. In summary, rapid diagnosis and timely surgical intervention remain the mainstays of the treatment. However, many issues need to be resolved by further studies.
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Affiliation(s)
- Jian-Long Liu
- Department of Vascular Surgery, Beijing Jishuitan Hospital, Beijing 100035, China.
| | - Jin-Yong Li
- Department of Vascular Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Peng Jiang
- Department of Vascular Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Wei Jia
- Department of Vascular Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Xuan Tian
- Department of Vascular Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Zhi-Yuan Cheng
- Department of Vascular Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Yun-Xin Zhang
- Department of Vascular Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
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Kauvar DS, Propper BW, Arthurs ZM, Causey MW, Walters TJ. Impact of Staged Vascular Management on Limb Outcomes in Wartime Femoropopliteal Arterial Injury. Ann Vasc Surg 2020; 62:119-127. [DOI: 10.1016/j.avsg.2019.08.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/17/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
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Morrison JJ, McMahon J, DuBose JJ, Scalea TM, Lawson JH, Rasmussen TE. Clinical implementation of the Humacyte human acellular vessel: Implications for military and civilian trauma care. J Trauma Acute Care Surg 2019; 87:S44-S47. [PMID: 31246906 DOI: 10.1097/ta.0000000000002350] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The incidence of wartime vascular injury has increased and is a leading cause of mortality and morbidity. While ligation remains an option, current resuscitation and damage control techniques have resulted in vascular repair being pursued in more than half of wartime injuries. Options for vascular reconstruction are currently limited to autologous vein or synthetic conduits, choices which have not changed in decades, both of which have problems. Autologous vein is preferable but requires time to harvest and may not be available. Synthetic grafts are poorly resistant to infection and associated with thrombotic complications. Recognizing this capability gap, the US Combat Casualty Care Research Program has partnered with academia and industry to support the development and clinical introduction of a bioengineered human acellular vessel. This human acellular vessel has the potential to be an off-the-shelf conduit that is resistant to infection and incorporates well into native tissues. This report reviews the rationale of this military-civilian partnership in medical innovation and provides an update on the clinical use and ongoing study of this new vascular technology. LEVEL OF EVIDENCE: Therapeutic, level III.
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Affiliation(s)
- Jonathan J Morrison
- From the R Adams Cowley Shock Trauma Center (J.J.M., J.J.D., T.M.S.), University of Maryland Medical System, Baltimore, Maryland; Humacyte Inc (J.M., J.H.L.), Research Triangle Park, North Carolina; and Department of Surgery (T.E.R.) at the Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
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Romagnoli A, DuBose J, Brenner M. Damage Control Vascular Surgery. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-00172-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Impact of time to repair on outcomes in patients with lower extremity arterial injuries. J Vasc Surg 2019; 69:1519-1523. [DOI: 10.1016/j.jvs.2018.07.075] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 07/27/2018] [Indexed: 11/22/2022]
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Xu Y, Xu W, Wang A, Meng H, Wang Y, Liu S, Li R, Lu S, Peng J. Diagnosis and treatment of traumatic vascular injury of limbs in military and emergency medicine: A systematic review. Medicine (Baltimore) 2019; 98:e15406. [PMID: 31045795 PMCID: PMC6504268 DOI: 10.1097/md.0000000000015406] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 12/05/2018] [Accepted: 04/03/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Traumatic vascular injury is caused by explosions and projectiles (bullets and shrapnel); it may affect the arteries and veins of the limbs, and is common in wartime, triggering bleeding, and ischemia. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries. METHODS To summarize the current evidence of diagnosis and treatment for traumatic vascular injury of limbs, for saving limbs and lives, and put forward some new insights, we comprehensively consulted literatures and analyzed progress in injury diagnosis and wound treatment, summarized the advanced treatments now available, especially in wartime, and explored the principal factors in play in an effort to optimize clinical outcomes. RESULTS Extremity vascular trauma poses several difficult dilemmas in diagnosis and treatment. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries. Any delay in treatment may lead to loss of limbs or death. The development of diagnose and treat vascular injury of extremities are the clinical significance to the tip of military medicine, such as the use of fast, cheap, low invasive diagnostic methods, repairing severe vascular injury as soon as possible, using related technologies actively (fasciotomy, etc). CONCLUSION We point out the frontier of the diagnosis and treatment of traumatic vascular injury, also with a new model of wartime injury treatment in American (forward surgical teams and combat support hospitals), French military surgeons regarding management of war-related vascular wounds and Chinese military ("3 districts and 7 grades" model). Many issues remain to be resolved by further experience and investigation.
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Kim JY, Jung YJ, Keum MA, Kwon SK, Hong SK. Comparison of Quality of Life among Patients with Mangled Trauma. JOURNAL OF ACUTE CARE SURGERY 2019. [DOI: 10.17479/jacs.2019.9.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Joon-Young Kim
- Department of Surgery, Asan Medical Center, Asan Medical Center, Seoul, Korea
| | - Yooun Joong Jung
- Clinical Nurse Specialist, Critical Care Nursing Team, Asan Medical Center, Seoul, Korea
| | - Min Ae Keum
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Su Kyung Kwon
- Division of Vascular and Transplant Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Suk-Kyung Hong
- Division of Trauma & Surgical Critical Care, Department of Surgery, Asan Medical Center, Seoul, Korea
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Kish AJ, Pensy RA. The Mangled Extremity: An Update. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0226-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Matsumoto S, Jung K, Smith A, Coimbra R. Outcomes Comparison Between Ligation and Repair after Major Lower Extremity Venous Injury. Ann Vasc Surg 2019; 54:152-160. [DOI: 10.1016/j.avsg.2018.05.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/07/2018] [Accepted: 05/18/2018] [Indexed: 10/28/2022]
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Patel JA, White JM, White PW, Rich NM, Rasmussen TE. A contemporary, 7-year analysis of vascular injury from the war in Afghanistan. J Vasc Surg 2018; 68:1872-1879. [DOI: 10.1016/j.jvs.2018.04.038] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/16/2018] [Indexed: 11/29/2022]
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To shunt or not to shunt in combined orthopedic and vascular extremity trauma. J Trauma Acute Care Surg 2018; 85:1038-1042. [DOI: 10.1097/ta.0000000000002065] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Typische Verletzungen durch terrorassoziierte Ereignisse und ihre Implikationen für die Erstversorgung. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s10039-018-0393-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Leclerc B, Boyer E, Menu G, Leclerc G, Sergent P, Ducroux E, Salomon Du Mont L, Garbuio P, Rinckenbach S, Obert L. Two-team management of vascular injuries concomitant with osteo-articular injuries in 36 patients over six years. Orthop Traumatol Surg Res 2018; 104:497-502. [PMID: 29578106 DOI: 10.1016/j.otsr.2018.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 02/02/2018] [Accepted: 02/06/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with both vascular and osteoarticular injuries require multidisciplinary management. Vascular injuries may be function- and/or life-threatening. The lower limbs are predominantly affected. Traffic, domestic, and work-related accidents contribute most of the cases. The primary objective of this study was to describe the management of patients with concomitant vascular and osteo-articular injuries, with special attention to the rates of amputation and fasciotomy. The secondary objective was to suggest a management sequence to optimise our surgical practice. HYPOTHESIS The management sequence is a crucial consideration in patients with both vascular and osteo-articular injuries. MATERIAL AND METHODS A 6-year, retrospective, observational study was conducted in patients with concomitant vascular and osteo-articular injuries. RESULTS The study included 36 patients with a mean age of 40.6±22.1 years. The main sources of injury were traffic accidents (n=19, 52.8%), crush injury (n=8, 22.2%), and falls (n=5, 13.9%). A compound fracture was present in 20 (55.6%) patients. Evidence of ischaemia in 25 (69.4%) patients, and bleeding in 11 (30.6%) patients. Pre-operative imaging, by ultrasonography or computed tomography, was performed in 27 (75.0%) patients. The lower limb was involved in 30 (83.3%) patients, who had osteoarticular injuries to the femur and leg combined with injury to the popliteal artery. Fasciotomy was performed in 11 (30.6%) patients and secondary amputation in 7 (19.4%) patients. The limb salvage rate was 80.6%. Median patient survival was 9.3 [0-74.8] months. DISCUSSION Coordinated work by two surgical teams is crucial to manage concomitant vascular and osteo-articular injuries. The management sequence must be defined clearly. Computed tomography angiography is the investigation of choice and should be performed at the slightest suspicion of vascular injury. LEVEL OF EVIDENCE IV, retrospective observational study.
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Affiliation(s)
- B Leclerc
- Service de chirurgie vasculaire et endovasculaire, hôpital Jean Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA 3920, université de Franche-Comté, 25000 Besançon, France.
| | - E Boyer
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
| | - G Menu
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
| | - G Leclerc
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
| | - P Sergent
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
| | - E Ducroux
- Service de chirurgie vasculaire et endovasculaire, hôpital Jean Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA 3920, université de Franche-Comté, 25000 Besançon, France
| | - L Salomon Du Mont
- Service de chirurgie vasculaire et endovasculaire, hôpital Jean Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA 3920, université de Franche-Comté, 25000 Besançon, France
| | - P Garbuio
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
| | - S Rinckenbach
- Service de chirurgie vasculaire et endovasculaire, hôpital Jean Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA 3920, université de Franche-Comté, 25000 Besançon, France
| | - L Obert
- Service de chirurgie orthopédique , traumatologique, de chirurgie plastique, reconstructrice et assistance main, hôpital Jean-Minjoz, centre hospitalier universitaire, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France; EA Nano Médecine-FEMTO, 25000 Besançon, France
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Affiliation(s)
- Gregory A Magee
- Department of Surgery, University of Southern California, Los Angeles, Calif
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Lebowitz C, Matzon JL. Arterial Injury in the Upper Extremity: Evaluation, Strategies, and Anticoagulation Management. Hand Clin 2018; 34:85-95. [PMID: 29169600 DOI: 10.1016/j.hcl.2017.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Trauma to the upper extremity can present with an associated arterial injury. After patient stabilization, thorough assessment with physical examination and various imaging modalities allows accurate diagnosis of the specific arterial injury. After diagnosis, efficient treatment is necessary to allow limb salvage. Treatment options include ligation, primary repair, graft reconstruction, endovascular repair, and amputation. The final treatment rendered is frequently dependent on injury location and mechanism. With any of the treatment options, complications may occur, including thrombosis. Currently, no validated anticoagulation protocol has been established for managing arterial injuries in the upper extremity.
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Affiliation(s)
- Cory Lebowitz
- Department of Orthopedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, NJ 080084, USA
| | - Jonas L Matzon
- Department of Orthopaedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107, USA.
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Clouse WD. Expert comments on “management of vascular injury in counter insurgency area: A single center study”. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2018. [DOI: 10.4103/0972-0820.224452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Beranger F, Lesquen HD, Aoun O, Roqueplo C, Meyrat L, Natale C, Avaro JP. Management of war-related vascular wounds in French role 3 hospital during the Afghan campaign. Injury 2017. [PMID: 28622832 DOI: 10.1016/j.injury.2017.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To describe the management of war-related vascular injuries in the Kabul French military hospital. METHODS From January 2009 to April 2013, in the Kabul French military hospital, we prospectively included all patients presenting with war-related vascular injuries. We collected the following data: site, type, and mechanism of vascular injury, associated trauma, type of vascular repair, amputation rate and complications. RESULTS Out of the 922 soldiers admitted for emergency surgical care, we recorded 45 (5%) patients presenting with vascular injuries: 30 (67%) gunshot-related, 11 (24%) explosive device-related, and 4 (9%) due to road traffic accident. The majority of injuries (93%) involved limbs. Vascular injuries were associated with fractures in 71% of cases. Twelve (26.7%) had an early amputation performed before evacuation. Twenty (44.4%) patients underwent fasciotomy and three (6.6%) sustained a compartment syndrome. CONCLUSIONS This was the first French reported series of war-related vascular injuries during the last decade's major conflicts. The majority of injuries occurred in the limbs. Autologous vein graft remains the treatment of choice for arterial repair. Functional severity of these injuries justifies specific training for military surgeons.
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Affiliation(s)
- Fabien Beranger
- Department of Vascular and Thoracic Surgery, Sainte-Anne Military Teaching Hospital, Toulon, 83 800, France.
| | - Henri De Lesquen
- Department of Vascular and Thoracic Surgery, Sainte-Anne Military Teaching Hospital, Toulon, 83 800, France
| | - Olivier Aoun
- Strasbourg Armed Forces Medical Center, Strasbourg, 67000, France
| | - Cédric Roqueplo
- Strasbourg Armed Forces Medical Center, Strasbourg, 67000, France
| | - Léon Meyrat
- Department of Vascular and Thoracic Surgery, Sainte-Anne Military Teaching Hospital, Toulon, 83 800, France
| | - Claudia Natale
- Department of Vascular and Thoracic Surgery, Sainte-Anne Military Teaching Hospital, Toulon, 83 800, France
| | - Jean-Philippe Avaro
- Department of Vascular and Thoracic Surgery, Sainte-Anne Military Teaching Hospital, Toulon, 83 800, France
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Giannakopoulos TG, Avgerinos ED. Management of Peripheral and Truncal Venous Injuries. Front Surg 2017; 4:46. [PMID: 28884115 PMCID: PMC5573711 DOI: 10.3389/fsurg.2017.00046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/08/2017] [Indexed: 12/19/2022] Open
Abstract
Civilian injuries are increasing according to the World Health Organization, and this is attributed mainly to road traffic accidents and urban interpersonal violence. Vascular injuries are common in these scenarios and are associated with high morbidity and mortality rates. Associated peripheral venous trauma is less likely to lead to death and controversy remains whether ligation or repair should be the primary approach. Conversely, non-compressible truncal venous insult can be lethal due to exsanguination, thus a high index of suspicion is crucial. Operative management is demanding with fair results but recent endovascular adjuncts demonstrate promising results and seem to be the way forward for these serious conditions.
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Affiliation(s)
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Belfast Limb Arterial and Skeletal Trauma (BLAST): the evolution of punishment shooting in Northern Ireland. Ir J Med Sci 2017; 186:747-752. [PMID: 28110378 PMCID: PMC5550529 DOI: 10.1007/s11845-017-1561-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 01/12/2017] [Indexed: 11/06/2022]
Abstract
Introduction Northern Ireland has developed significant experience in specific punishment injuries due to its unique civil unrest. Simple gunshot wound (GSW) injuries have begun to evolve into more complex injuries. Case presentation We describe three cases of young male victims who suffered from GSW injuries—from a single GSW injury to multiple GSW injuries involving all four limbs; the phenomenon of Belfast Limb Arterial and Skeletal Trauma. We describe the management of these injuries, with a review of current literature. Conclusion Due to the unique political situation of Northern Ireland, there has been significant development of surgical experience in GSW management. Historically, single knee-capping injuries were prevalent. However, these shootings have evolved into targeted injuries resulting in significant trauma as demonstrated by this case series.
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Abou Ali AN, Salem KM, Alarcon LH, Bauza G, Pikoulis E, Chaer RA, Avgerinos ED. Vascular Shunts in Civilian Trauma. Front Surg 2017; 4:39. [PMID: 28775985 PMCID: PMC5517780 DOI: 10.3389/fsurg.2017.00039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/05/2017] [Indexed: 11/25/2022] Open
Abstract
Experience with temporary intravascular shunts (TIVS) for vessel injury comes from the military sector and while the indications might be clear in geographically isolated and under resourced war zones, this may be an uncommon scenario in civilian trauma. Data supporting TIVS use in civilian trauma have been extrapolated from the military literature where it demonstrated improved life and limb salvage. Few non-comparative studies from the civilian literature have also revealed similar favorable outcomes. Still, TIVS placement in civilian vascular injuries is uncommon and by some debatable given the absence of clear indications for placement, the potential for TIVS-related complications, the widespread resources for immediate and definitive vascular repair, and the need for curtailing costs and optimizing resources. This article reviews the current evidence and the role of TIVS in contemporary civilian trauma management.
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Affiliation(s)
- Adham N Abou Ali
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Karim M Salem
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Louis H Alarcon
- Division of Trauma and General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Graciela Bauza
- Division of Trauma and General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Emmanuel Pikoulis
- Uniformed Services University of Health Sciences, Bethesda, MD, United States
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Abstract
BACKGROUND Arterial shunting is a well-described method to control hemorrhage and rapidly reestablish flow, but optimal shunt dwell times remain controversial. We hypothesized that prolonged shunt dwell times of more than 6 hours are related to adverse outcomes after major arterial injury. METHODS A review (2005-2013) of all patients with arterial shunts placed after traumatic injury at our urban Level I trauma center was undertaken. Patients who died prior to shunt removal (n = 7) were excluded. Shunt complications were defined as dislodgement, thrombosis, and distal ischemia. Patients were compared on the basis of shunt complications with respect to clinical parameters. RESULTS The 42 patients who underwent arterial shunting after major vascular injury were primarily young (median, 26 years; interquartile range [IQR], 22-31 years) males (97.6%), severely injured (Injury Severity Score, 17.5 [IQR, 14-29]; shunted vessel Abbreviated Injury Scale score, 4 [IQR, 3-4]) by gunshot (85.7%) requiring neck/torso (33.3%) or upper-extremity (19.1%) or lower-extremity (47.6%) shunts. Thirty-five patients survived until shunt removal, and 5 (14.3%) of 35 developed shunt complications. Demographics and clinical characteristics were compared between those with shunt dwell times of less than 6 hours (n = 19) and more than 6 hours (n = 16). While patients appeared to have a greater injury burden overall in the group with dwell times of more than 6 hours, there were no statistical differences between groups with respect to age, gender, initial systolic blood pressure or hemodynamics during the shunt dwell period, use of vasopressors, Abbreviated Injury Scale score of the shunted vessel, Injury Severity Score, or outcomes including limb amputation or mortality. No patients (0/19) with shunt dwell times of less than 6 hours developed complications, whereas 5 (31.3%) of 16 patients with dwell times of more than 6 hours developed shunt complications (p = 0.05). CONCLUSIONS In this civilian series, 14% of patients with arterial shunts developed shunt complications. Our data suggest that limiting shunt dwell times to less than 6 hours when clinically feasible may decrease adverse outcomes. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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Abstract
Noncompressible torso hemorrhage (NCTH) constitutes a leading cause of potentially preventable trauma mortality. NCTH is defined by high-grade injury present in one or more of the following anatomic domains: pulmonary, solid abdominal organ, major vascular or pelvic trauma; plus hemodynamic instability or the need for immediate hemorrhage control. Rapid operative management, as part of a damage control resuscitation strategy, remains the mainstay of treatment. However, endovascular techniques are evolving and may become more mainstream with the advent of hybrid rooms that can deliver concurrent open and radiologic/endovascular management of traumatic hemorrhage.
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Affiliation(s)
- Jonathan J Morrison
- Department of Vascular Surgery, Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow G51 4TF, UK.
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Şişli E, Kavala AA, Mavi M, Sarıosmanoğlu ON, Oto Ö. Single centre experience of combat-related vascular injury in victims of Syrian conflict: Retrospective evaluation of risk factors associated with amputation. Injury 2016; 47:1945-50. [PMID: 27060019 DOI: 10.1016/j.injury.2016.03.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 03/11/2016] [Accepted: 03/25/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To elucidate the risk factors associated with amputation in cases with combat-related vascular injury (CRVI). MATERIAL AND METHODS This retrospective study included 90 cases with CRVI treated between May 2011 and July 2013. The patients were divided into group I (n=69), in which the limb was salvaged and group II (n=21), in which the patients received amputation. RESULTS The overall and the secondary amputation rates were 23% and 18%, respectively. There were no amputations with the MESS of nine or less, increasing proportions of amputations at 10 and 11, with a level of 12 leading to 100% amputation rate. The mortality rate was 2%. Among the 52 (58%) cases with the mangled extremity severity score (MESS) ≥7, the limb salvage rate was 60%. The patients in group II were more likely to have a combined artery and vein injury (p=0.042). They were also more likely to be injured as a result of an explosion (p=0.004). Along with the MESS (p<0.001), the duration of ischemia (DoI) (p<0.001) were higher in group II. The rate of bony fracture (p<0.001) and wound infection (p=0.011) were higher in group II. For the overall amputation, the odds ratio of the bony fracture (OR: 61.39, p=0.011), nerve injury (OR: 136.23, p=0.004), DoI (OR: 2.03, p=0.003), vascular ligation (OR: 8.65, p=0.040) and explosive device injury (OR: 10.8, p=0.041) were significant. Although the DoI (p<0.001) and the MESS (p=0.004) were higher in whom a temporary vascular shunt (TVS) was applied, the utilisation of a TVS did not influence the amputation rate (p=1.0). CONCLUSIONS The DoI and the variables indicating the extent of tissue disruption were the major determinants of amputation. While statistically non-significant, the benefit of the application of a TVS is non-negligible. MESS is a valid scoring system but should not be the sole foundation for deciding on amputation. Extremities which were doomed to amputation with the MESS>7 seem to benefit from revascularisation with initiation of reperfusion at once. The validity of MESS merits further investigation with regard to the determination of a new cut-off value under ever developing medical management strategies.
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Affiliation(s)
- Emrah Şişli
- Department of Cardiovascular Surgery, Ege University Faculty of Medicine, İzmir, Turkey.
| | - Ali Aycan Kavala
- Department of Cardiovascular Surgery, Dr. Sadi Konuk Education and Research Hospital, İstanbul, Turkey
| | - Mustafa Mavi
- Department of Cardiovascular Surgery, Antakya State Hospital, Hatay, Turkey
| | | | - Öztekin Oto
- Department of Cardiovascular Surgery, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
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42
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Contemporary management of civilian penetrating cervicothoracic arterial injuries. J Trauma Acute Care Surg 2016; 81:302-6. [DOI: 10.1097/ta.0000000000001103] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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43
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Abstract
Ischemia of the upper extremity is uncommon but can be seen with open or closed trauma. Those dealing with traumatic injury of the upper extremity should be conversant with techniques of vascular surgery and microsurgery to address these injuries when they occur. Closed injury can occur as well, and at times these are best managed nonoperatively. This article discusses the management of both in the acute setting.
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Affiliation(s)
- William C Pederson
- Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin, Suite 610, Houston, TX 77030, USA.
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44
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Current concepts in repair of extremity venous injury. J Vasc Surg Venous Lymphat Disord 2016; 4:238-47. [DOI: 10.1016/j.jvsv.2015.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/24/2015] [Indexed: 10/22/2022]
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45
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Gifford SM, Arthurs ZM. Damage Control Vascular Surgery in the Austere Environment. CURRENT TRAUMA REPORTS 2016. [DOI: 10.1007/s40719-016-0036-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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van Dongen TTCF, Idenburg FJ, Tan ECTH, Rasmussen TE, Hamming JF, Leenen LPH, Hoencamp R. Combat related vascular injuries: Dutch experiences from a role 2 MTF in Afghanistan. Injury 2016; 47:94-8. [PMID: 26358515 DOI: 10.1016/j.injury.2015.08.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/25/2015] [Accepted: 08/22/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND In a combat environment, major vascular trauma endures as the leading cause of death. The Dutch role 2 Medical Treatment Facility (MTF), provided supportive care during the mission in Uruzgan, Afghanistan. Aim of this study was to conduct detailed analysis of the admitted major haemorrhages (vascular injuries) and to compare our findings with NATO coalition partners. METHODS Retrospective, descriptive study. Participants eligible for this study came from the role 2 MTF admission database, where they fitted the criteria 'Major haemorrhage (class 2 haemorrhage or more according to the ATLS(®) classification) between 2006 and 2010'. Results were contrasted with studies from coalition partners. RESULTS The query revealed 194 casualties sustaining 208 central (60% abdominal, 40% thoracic/neck), and 99 extremity major haemorrhages leading to 1.6 major haemorrhages per casualty. Survival was significantly better (p<0.05) in the peripheral vascular injuries cohort (96% versus 72%). Primary amputation was needed in 73/84 of lower, and in 8/15 of upper extremity major haemorrhages. Vascular repair or vascular Damage Control Surgery techniques (e.g. shunting) were used in 19/84 cases in the lower, and 7/15 in the upper extremity cohort, with a success rate of 69.2 percent. Amputation rates of coalition partners, using different inclusion and exclusion criteria, ranged from 5 to 60 percent. CONCLUSIONS Only in a few cases genuine peripheral vascular surgery was needed (<1%). This limited number of reconstructions does not demonstrate the need for extensive skills in all areas of vascular surgery. Achieved success rate until discharge was almost 70%. Vascular damage control surgery seems effective as initial limb saving skill in a role 2 MTF. The difference in usage of definitions concerning vascular injuries in current literature warrants further assessment. For optimal analysis there is need for detailed (NATO wide) registration with uniform definitions for vascular injuries. LEVEL OF EVIDENCE Level IV--Epidemiologic study.
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Affiliation(s)
- Thijs T C F van Dongen
- Department of Trauma, Division of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Floris J Idenburg
- The Royal Netherlands Navy (R) and Department of Traumatology, Division of Surgery, Medical Center Haaglanden - Bronovo, The Hague, The Netherlands.
| | - Edward C T H Tan
- Royal Netherlands Army and Department of Surgery-Trauma, Division of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Todd E Rasmussen
- United States Air Force and The Norman M. Rich Department of Surgery, The Uniformed Services University of the Health Science, Bethesda, United States.
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Luke P H Leenen
- The Royal Netherlands Navy (R) and Department of Traumatology, Division of Surgery, Medical Center Haaglanden - Bronovo, The Hague, The Netherlands.
| | - Rigo Hoencamp
- The Royal Netherlands Navy (R) and Department of Traumatology, Division of Surgery, Medical Center Haaglanden - Bronovo, The Hague, The Netherlands.
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Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system. BMC Musculoskelet Disord 2015; 16:372. [PMID: 26796522 PMCID: PMC4722671 DOI: 10.1186/s12891-015-0832-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/27/2015] [Indexed: 11/27/2022] Open
Abstract
Background In the last decades a lot of new reconstructive techniques were developed for the treatment of mangled lower extremity. However failed attempt to limb salvage is related to high risk of mortality for the patient. Several scores were developed to establish guidelines for the decision to amputate or not, however in literature there is no consensus about the reliability of this scores. Methods The authors focused their attention on the most used score system to provide guidance of the management of a mangled lower limb. The search term used included mangled lower extremity, MESS, PSI, LSI and NISSSA. The inclusion criteria were: studies dealing with mangled lower extremity; articles reporting MESS, PSI, LSI or NISSSA scores; articles published in English in PubMed, Cochrane, Scopus and web of science in the last 30 years, minimum number of cases in study of 15, minimum follow up of 1 year. Results According with the criteria described above, we found 134 articles in PubMed, 165 articles in Scopus, 111 articles in the Cochrane Library and 108 articles in Web of Science. The most used score in literature is the MESS. Few results are shown using the other severity scores. There are a lot of controversies in literature about the use of this scale. MESS seems to be more accurate than the LSI in prediction of limb salvage. LSI score shows better results when applied to type III tibial fractures. High sentivity of the PSI score is described when applied to predict successful limb salvage. Low sensitivity and specificity are described for the NISSSA score. The literature is very poor of articles related to mangled lower extremity in children. Higher sensitivity and specificity are described for these scores in children when compared to adult population. Conclusion The mangled lower extremity treatment is a challenge for the surgeon. Many scores were developed to help the surgeon, however they cannot be used as the sole criterion by which amputation decision are made and, in case of succesful limb salvage, they are not predictive of the functional recovery. Moreover, undue enthusiasm for new surgical techniques can lead to increased morbidity and mortality in case of secondary amputation.
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Hornez E, Boddaert G, Ngabou UD, Aguir S, Baudoin Y, Mocellin N, Bonnet S. Temporary vascular shunt for damage control of extremity vascular injury: A toolbox for trauma surgeons. J Visc Surg 2015; 152:363-8. [PMID: 26456452 DOI: 10.1016/j.jviscsurg.2015.09.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
In an emergency, a general surgeon may be faced with the need to treat arterial trauma of the extremities when specialized vascular surgery is not available in their hospital setting, either because an arterial lesion was not diagnosed during pre-admission triage, or because of iatrogenic arterial injury. The need for urgent control of hemorrhage and limb ischemia may contra-indicate immediate transfer to a hospital with a specialized vascular surgery service. For a non-specialized surgeon, hemostasis and revascularization rely largely on damage control techniques and the use of temporary vascular shunts (TVS). Insertion of a TVS is indicated for vascular injuries involving the proximal portion of extremity vessels, while hemorrhage from distal arterial injuries can be treated with simple arterial ligature. Proximal and distal control of the injured vessel must be obtained, followed by proximal and distal Fogarty catheter thrombectomy and lavage with heparinized saline. The diameter of the TVS should be closely approximated to that of the artery; use of an oversized TVS may result in intimal tears. Systematic performance of decompressive fasciotomy is recommended in order to prevent compartment syndrome. In the immediate postoperative period, the need for systematic use of anticoagulant or anti-aggregant medications has not been demonstrated. The patient should be transferred to a specialized center for vascular surgery as soon as possible. The interval before definitive revascularization depends on the overall condition of the patient. The long-term limb conservation results after placement of a TVS are identical to those obtained when initial revascularization is performed.
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Affiliation(s)
- E Hornez
- Hôpital d'Instruction des Armées Percy, Clamart, France.
| | - G Boddaert
- Hôpital d'Instruction des Armées Percy, Clamart, France
| | - U D Ngabou
- Hôpital d'Instruction des Armées Percy, Clamart, France
| | - S Aguir
- Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Y Baudoin
- Hôpital d'Instruction des Armées Percy, Clamart, France
| | - N Mocellin
- Hôpital d'Instruction des Armées Percy, Clamart, France
| | - S Bonnet
- Hôpital d'Instruction des Armées Percy, Clamart, France
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Characteristics and clinical outcome in patients after popliteal artery injury. J Vasc Surg 2015; 61:1495-500. [DOI: 10.1016/j.jvs.2015.01.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
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50
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Watson JDB, Houston R, Morrison JJ, Gifford SM, Rasmussen TE. A Retrospective Cohort Comparison of Expanded Polytetrafluorethylene to Autologous Vein for Vascular Reconstruction in Modern Combat Casualty Care. Ann Vasc Surg 2015; 29:822-9. [DOI: 10.1016/j.avsg.2014.12.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 12/11/2014] [Accepted: 12/29/2014] [Indexed: 11/26/2022]
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