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Stonko DP, Betzold RD, Azar FK, Edwards J, Abdou H, Elansary NN, Gerling KA, White J, Feliciano DV, DuBose JJ, Morrison JJ. Postoperative antiplatelet and/or anticoagulation use does not impact complication or reintervention rates after vein repair of arterial injury: A PROOVIT study. Vascular 2023; 31:777-783. [PMID: 35430941 DOI: 10.1177/17085381221082371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The use of antiplatelet (AP) and anticoagulation (AC) therapy after autogenous vein repair of traumatic arterial injury is controversial. The hypothesis in this study was that there is no difference in early postoperative outcomes regardless of whether AC, AP, both, or neither are used. METHODS The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November, 2013, to January, 2019, for arterial injuries repaired with a vein graft. Demographics and injury characteristics were compared. Need for in-hospital reoperation was the primary outcome in this four-arm study, assessed with two ordinal logistic regression models (1. no therapy vs. AC only vs. AC and AP; 2. no therapy vs. AP only vs. AC and AP). RESULTS 373 patients (52 no therapy, 88 AP only, 77 AC only, 156 both) from 19 centers with recorded Injury Severity Scores (ISS) were identified. Patients who received no therapy were younger than those who received AP (27.0 vs. 34.2, p = 0.02), had higher transfusion requirement (p < 0.01 between all groups) and a different distribution of anatomic injury (p < 0.01). After controlling for age, sex, ISS, platelet count, hemoglobin, pH, lactate, INR, transfusion requirement and anatomic location, there was no association with postoperative medical therapy and in-hospital operative reintervention, or any secondary outcome, including thrombosis (p = 0.67, p = 0.22). CONCLUSIONS Neither AC nor AP alone, nor in combination, impact complication rate after arterial repair with autologous vein. These patients can be safely treated with or without antithrombotics, recognizing that this study did not demonstrate a beneficial effect.
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Affiliation(s)
- David P Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Richard D Betzold
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Faris K Azar
- St Mary's Medical Center, West Palm Beach, Florida Atlantic University, Boca Raton, FL USA
| | - Joseph Edwards
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Hossam Abdou
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Noha N Elansary
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | | | - Joseph White
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - David V Feliciano
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Joseph J DuBose
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jonathan J Morrison
- University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Wang J, Blalock SK, Levitan GS, Prichard HL, Niklason LE, Kirkton RD. Biological mechanisms of infection resistance in tissue engineered blood vessels compared to synthetic expanded polytetrafluoroethylene grafts. JVS Vasc Sci 2023; 4:100120. [PMID: 37662589 PMCID: PMC10474492 DOI: 10.1016/j.jvssci.2023.100120] [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: 04/18/2023] [Accepted: 06/24/2023] [Indexed: 09/05/2023] Open
Abstract
Objective Synthetic expanded polytetrafluoroethylene (ePTFE) grafts are known to be susceptible to bacterial infection. Results from preclinical and clinical studies of bioengineered human acellular vessels (HAVs) have shown relatively low rates of infection. This study evaluates the interactions of human neutrophils and bacteria with ePTFE and HAV vascular conduits to determine whether there is a correlation between neutrophil-conduit interactions and observed differences of their infectivity in vivo. Methods A phase III comparative clinical study between investigational HAVs (n = 177) and commercial ePTFE grafts (n = 178) used for hemodialysis access (ClinicalTrials.gov Identifier: NCT02644941) was evaluated for conduit infection rates followed by histological analyses of HAV and ePTFE tissue explants. The clinical histopathology of HAV and ePTFE conduits reported to be infected was compared with immunohistochemistry of explanted materials from a preclinical model of bacterial contamination. Mechanistic in vitro studies were then conducted using isolated human neutrophils seeded directly onto HAV and ePTFE materials to analyze neutrophil viability, morphology, and function. Results Clinical trial results showed that the HAV had a significantly lower (0.93%; P = .0413) infection rate than that of ePTFE (4.54%). Histological analysis of sections from infected grafts explanted approximately 1 year after implantation revealed gram-positive bacteria near cannulation sites. Immunohistochemistry of HAV and ePTFE implanted in a well-controlled rodent infection model suggested that the ePTFE matrix permitted bacterial infiltration and colonization but may be inaccessible to neutrophils. In the same model, the HAV showed host recellularization and lacked detectable bacteria at the 2-week explant. In vitro results demonstrated that the viability of human neutrophils decreased significantly upon exposure to ePTFE, which was associated with neutrophil elastase release in the absence of bacteria. In contrast, neutrophils exposed to the HAV material retained high viability and native morphology. Cocultures of neutrophils and Staphylococcus aureus on the conduit materials demonstrated that neutrophils were more effective at ensnaring and degrading bacteria on the HAV than on ePTFE. Conclusions The HAV material seems to demonstrate a resistance to bacterial infection. This infection resistance is likely due to the HAV's native-like material composition, which may be more biocompatible with host neutrophils than synthetic vascular graft material.
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Figueras JH, Johnson BM, Thomson C, Dailey SW, Betz BE, Grawe BM. Team Approach: Treatment of Traumatic Dislocations of the Knee. JBJS Rev 2023; 11:01874474-202304000-00004. [PMID: 37058579 DOI: 10.2106/jbjs.rvw.22.00188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
» Traumatic knee dislocations are complex injuries that can be associated with compromise of the neurovascular structures about the knee. » Various classification systems for knee dislocations exist in the literature but should be used with caution as a prognostic tool because many knee dislocations fit into more than 1 category. » Special populations of knee dislocations, such as obese patients and high-velocity mechanism injuries, require additional caution during the initial evaluation for possible vascular injuries.
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Affiliation(s)
- Jorge H Figueras
- Department of Orthopaedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
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Ben Romdhane M, Boufi M, Dona B, Hartung O, Alimi Y. Predictive factors of amputation in infra-inguinal vascular trauma: a monocentric experience. Ann Vasc Surg 2023:S0890-5096(23)00150-4. [PMID: 36906127 DOI: 10.1016/j.avsg.2023.02.035] [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: 12/14/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVES Infra-inguinal vascular injuries (IIVI) are emergencies involving both functional and vital prognosis. The choice between saving the limb or doing a first-line amputation is difficult even for an experienced surgeon. The aims of this work are to analyze early outcomes in our center and to identify predictive factors for amputation. M METHODS Between 2010 and 2017, we reviewed retrospectively patients with IIVI. The main criteria for judgement were: primary, secondary and overall amputation. Two groups of potential risk factors of amputation were analyzed: Those related to the patient: age, shock, ISS score; those related to the lesion: mechanism, above or below the knee, bone lesions, venous lesions and skin decay. A univariate and multivariate analysis were performed to determine the risk factor(s) independently associated with the occurrence of amputation. RESULTS 57 IIVI were found in 54 patients. The mean ISS was 32,3 ± 21. A primary amputation was performed in 19%, and secondary in 14% of cases. Overall amputation rate was 35% (n=19). Multivariate analysis reveals that the ISS is the only predictor of primary (p=0.009; OR:1.07; CI:1.01-1.12) and global (p=0.04; OR:1.07; IC:1.02-1.13) amputation. A threshold value of 41 was selected as a primary amputation risk factor with a negative predictive value of 97%. CONCLUSIONS The ISS is a good predictor of the risk of amputation in IIVI. A threshold of 41 is an objective criterion helping to decide for a first-line amputation. Advanced age and hemodynamic instability should not be important in the decision tree.
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Affiliation(s)
| | | | - Bianca Dona
- Vascular Surgery Department, Marseille, France
| | | | - Yves Alimi
- Vascular Surgery Department, Marseille, France
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Shahat M, Abdelmonem M. Lower extremity vascular trauma assiut university hospital experience. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_127_21] [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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American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries. J Trauma Acute Care Surg 2021; 89:1183-1196. [PMID: 33230048 DOI: 10.1097/ta.0000000000002967] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Franklin BR, Dyke C, Durning SJ, Artino AR, Bowyer MW, Nealeigh MD, Kucera WB, Ritter EM. Piloting the FIRE: A Novel Error Management Training Simulation Curriculum for Fasciotomy Instruction. JOURNAL OF SURGICAL EDUCATION 2021; 78:655-664. [PMID: 32873508 DOI: 10.1016/j.jsurg.2020.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Multiple studies have demonstrated poor performance of lower extremity fasciotomy (LEF), highlighted by missed and/or inadequately released compartments. Incorporating error management training (EMT) into surgical simulation has been promoted as a way to gain deeper understanding of procedural errors and overall performance. The purpose of this study was to evaluate LEF performance using a Fasciotomy Improvement through Recognition of Errors (FIRE) simulation training curriculum to train novice surgical trainees. METHODS A mastery learning-based EMT curriculum was developed, and surgical residents were enrolled and pretested with a multiple-choice question (MCQ) written test, and a simulated fasciotomy using a lower leg model. Each trainee then watched a 15-minute narrated presentation followed by 2 rounds of fasciotomy error recognition and management training exercises to a mastery standard. During each round, trainees performed hands-on assessment of unique premade fasciotomy leg models containing a variable number of procedural errors. They were required to identify and propose corrective action for all errors. Serial rounds of remediation were implemented until the mastery standard was attained on both error identification rounds. All trainees were post-tested with the same MCQ and another simulated fasciotomy. RESULTS All 14 residents had minimal experience with only 0.3 ± 0.6 fasciotomies performed prior to instruction. There were 3 ± 1.6 missed or inadequately released compartments on the pretest. Residents examined 14 ± 2.5 legs, including 2 ± 2.5 legs during remediation to attain mastery. All residents demonstrated significant improvement following the FIRE of Error curriculum for the MCQ (57% ± 16% vs 78% ± 13%; p = 0.01; Cohen's d = 1.4), fasciotomy score (10 ± 7.1 vs 28 ± 1.9; p < 0.001; Cohen's d = 3.6), and achieving a complete fasciotomy (14% ± 36% vs 93% ± 27%; p < 0.001; Cohen's d = 2.5). Only a single cumulative compartment was missed on post-testing. CONCLUSIONS Implementation of a mastery learning-based EMT curriculum for fasciotomy simulation training results in significant improvement in fasciotomy technique without reliance on repeated procedure performance nor clinical fasciotomy exposure. This curriculum is a highly effective option for surgical trainees lacking fasciotomy training during residency.
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Affiliation(s)
- Brenton R Franklin
- Department of Surgery, Walter Reed National Military Medical Center/Uniformed Services University of the Health Sciences, Bethesda, Maryland; Center for Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
| | - Christopher Dyke
- Department of Surgery, Walter Reed National Military Medical Center/Uniformed Services University of the Health Sciences, Bethesda, Maryland; Center for Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Steven J Durning
- Center for Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Anthony R Artino
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Mark W Bowyer
- Department of Surgery, Walter Reed National Military Medical Center/Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Matthew D Nealeigh
- Department of Surgery, Walter Reed National Military Medical Center/Uniformed Services University of the Health Sciences, Bethesda, Maryland; Center for Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Walter B Kucera
- Department of Surgery, Walter Reed National Military Medical Center/Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - E Matthew Ritter
- Department of Surgery, Walter Reed National Military Medical Center/Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Asensio JA, Dabestani PJ, Miljkovic SS, Kotaru TR, Kessler JJ, Kalamchi LD, Wenzl FA, Sanford AP, Rowe VL. Popliteal artery injuries. Less ischemic time may lead to improved outcomes. Injury 2020; 51:2524-2531. [PMID: 32732120 DOI: 10.1016/j.injury.2020.07.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/11/2020] [Accepted: 07/20/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Popliteal artery injuries are rare. They have high amputation rates. OBJECTIVES To report our experience, identify predictors of outcome; mechanism of injury (MOI), Mangled Extremity Severity Score (MESS) score and length of ischemic time. We hypothesized that ischemic time as close to six hours results in improved outcomes. METHODS Retrospective 132-month study. All popliteal artery injuries. Urban Level I Trauma Center. OUTCOME MEASURES MOI, ISS, MESS, ischemic time, risk factors for amputation, role of popliteal venous injuries, and limb salvage. STATISTICAL ANALYSIS univariate and multivariate. RESULTS 76 patients - 59 (76.1%) males and 17 (22.4%) females. MOI: penetrating - 54 (71%). MESS for penetrating injuries - 5.8 ± 1.5, blunt injuries - 5.6 ± 1.8. Admission-perfusion restoration (n = 76) - 5.97 hours (358 minutes). Ischemic time was not predictive of outcome (p = 0.79). Ischemic time penetrating (n = 58) 5.9 hours (354 ± 209 minutes), blunt 6.1 hours (371 ± 201 minutes). Popliteal arterial repairs: RSVG 44 (58%), primary repair 21 (26%), PTFE 3 (4%), vein patch 2 (2%), ligation 2 (3%), exsanguinated 4 (6%). No patients underwent stenting. Popliteal Vein: Repair 19 (65%), ligation 10 (35%). Fasciotomies 45 patients (59%). OUTCOMES Limb salvage - 90% (68/76). Adjusted limb salvage excluding intraoperative deaths - 94% (68/72). Selected patient characteristics; MOI: penetrating vs. blunt - age (p <0.0005). Amputated vs. non-amputated patients, age (p < 0.05). ISS (p < 0.005) predicted amputation, MESS (p = 0.98) did not. Mean ischemic time (p = 0.79) did not predict amputation. Relative risk of amputation, MOI - blunt (p = 0.26, RR 4.67, 95% CI: 1.11 - 14.1), popliteal artery ligation (p = 0.06, RR 3.965, 95% CI: 1.11 - 14.1) as predictors of outcome. Combined artery and vein injuries (p = 0.25) did not predict amputation. CONCLUSIONS Decreasing ischemic time from arrival to restoration of perfusion may lead to improved outcomes and increased limb salvage. MESS is not predictive for amputation. Blunt MOI is a risk factor for amputation. Maintaining ischemic times as close to six hours as possible may lead to improved outcomes.
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Affiliation(s)
- Juan A Asensio
- Department of Surgery, Creighton University School of Medicine, Omaha, United States.
| | - Parinaz J Dabestani
- Department of Surgery, Creighton University School of Medicine, Omaha, United States.
| | - Stephanie S Miljkovic
- Department of Surgery, Creighton University School of Medicine, Omaha, United States.
| | - Tharun R Kotaru
- Department of Surgery, Creighton University School of Medicine, Omaha, United States.
| | - John J Kessler
- Department of Surgery, Creighton University School of Medicine, Omaha, United States.
| | - Louay D Kalamchi
- Department of Surgery, Creighton University School of Medicine, Omaha, United States.
| | - Florian A Wenzl
- Department of Surgery, Creighton University School of Medicine, Omaha, United States.
| | - Arthur P Sanford
- Department of Surgery, Loyola University Stritch School of Medicine, IL, United States.
| | - Vincent L Rowe
- Department of Surgery, University of Southern California Keck School of Medicine, CA, United States.
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Masood A, Danawar NA, Mekaiel A, Raut S, Malik BH. The Utility of Therapeutic Anticoagulation in the Perioperative Period in Patients Presenting in Emergency Surgical Department With Extremity Vascular Injuries. Cureus 2020; 12:e8473. [PMID: 32642377 PMCID: PMC7336685 DOI: 10.7759/cureus.8473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Extremity vascular trauma is a challenging surgical emergency in both civilian population and combat environment. It requires vigilant diagnosis and prompt treatment to minimize limb loss and mortality. A multidisciplinary team approach is required to deal with shock states, concomitant abdominal injuries, head injuries, and fractures with significant tissue loss and psychological stress. Anticoagulation is frequently used during traumatic vascular repair to avoid repair site thrombosis, postoperative deep venous thrombosis, and pulmonary embolism (PE). In this review article, we are going to search about how frequent is the use of anticoagulation in terms of limb salvage rates, and mortality rates or side effects of anticoagulation in terms of risk of bleeding episodes, and the need for future prospective studies. Extremity vascular trauma is managed by a variety of methods including open repairs, endovascular repairs, and nonoperative management. Most of the literature demonstrates the use of systemic or regional anticoagulation in the management of vascular injuries with the improvement in limb salvage rates and reduced morbidities but confounding factors lead to variable results. Some studies show an increased risk of bleeding in trauma patients with the use of anticoagulants in trauma settings without any significant effect on repair site thrombosis. More comprehensive studies and randomized controlled trials are needed to confirm the importance of perioperative anticoagulation while avoiding the confounding factors in terms of injury severity scores, ischemia time, demographics of patients, modes of injury, comorbidities, grades of shock, concomitant injuries that need anticoagulation like venous injuries or intracranial injuries that are contraindications to the use of anticoagulation, type of anticoagulation and expertise available as well as the experience level of the operating surgeon. Literature also reveals the use of new oral anticoagulants (e.g., dabigatran) to be associated with lesser bleeding episodes when compared to warfarin, so in future, we can check the feasibility of these agents to reduce the bleeding episodes and at the same time improve the limb salvage rates.
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Affiliation(s)
- Ayesha Masood
- General Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Nuaman A Danawar
- General Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Andrew Mekaiel
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Sumit Raut
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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A meta-analysis on anticoagulation after vascular trauma. Eur J Trauma Emerg Surg 2020; 46:1291-1299. [PMID: 32067052 PMCID: PMC7691301 DOI: 10.1007/s00068-020-01321-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/04/2020] [Indexed: 11/05/2022]
Abstract
Purpose There is much debate regarding the use of anticoagulation following vascular trauma. The aim of this meta-analysis was to compare the outcome of trauma following administration of anticoagulation medication. Methods The literature search was carried out using Ovid MEDLINE and PubMed databases to search for keywords and MeSH terms including “Anticoagulation”, “Vascular Surgery”, “Vascular Trauma”, “Vascular Repair”, “Repair” and “Wounds and Injuries”. Results Use of anticoagulation was associated with a better prognosis for overall vascular trauma outcomes (weighted OR 0.46; 95% CI 0.34–0.64; P < 0.00001), as well as reduced risk of amputation for both lower and upper limb vascular trauma (weighted OR 0.42; 95% CI 0.22–0.78; P = 0.007), and reduced occurrence of reoperation events and amputations in isolated lower limb vascular trauma (weighted OR 0.27; 95% CI 0.14–0.52; P < 0.0001). Conclusion There was a statistically significant correlation between the use of anticoagulation and vascular trauma outcome. A major limitation with many of the studies includes a lack of prospective analysis and therefore we recommend prospective studies to properly elucidate prognostic outcomes following use of these anticoagulants. Further studies need to be conducted to assess the effects of timing of anticoagulant delivery, dosages and severity of traumatic injury. Thus, this would prove to be very useful in the formation of guidelines.
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Dauer E, Yamaguchi S, Yu D, Lu X, Kelley K, Sharpe J, Manley N, Harvin JA, Taub EA, Goldenberg-Sandau A, Patel K, Omi E, Mashbari H, Hartwell J, Brocker J. Major venous injury and large volume crystalloid resuscitation: A limb threatening combination. Am J Surg 2019; 219:38-42. [PMID: 31604488 DOI: 10.1016/j.amjsurg.2019.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Major venous injury (MVI) affecting the lower extremity can result in subsequent amputation. The contribution of intraoperative resuscitation efforts on the need for amputation is not well defined. We hypothesized that intraoperative large volume crystalloid resuscitation (LVCR) increases the risk of amputation after MVI, while massive transfusion (MT) does not. METHODS We performed a retrospective review of patients with infrarenal MVI from 2005 to 2015 at seven urban level I trauma centers. The outcome of interest was the need for secondary amputation. RESULTS 478 patients were included. 31 (6.5%) patients with MVI required amputation. LVCR(p < 0.001), combined arterial/venous injury (p = 0.001), and associated fracture (p = 0.001) were significant risk factors for amputation. MT did not significantly increase amputation risk (p = 0.44). Multivariable logistic regression model demonstrated that patients receiving ≥5L LVCR(aOR (95% CI): 9.7 (2.9, 33.0); p < 0.001), with combined arterial/venous injury (aOR (95% CI):3.6 (1.5, 8.5); p = 0.004), and with an associated fracture (aOR (95% CI):3.2 (1.5, 7.1); p = 0.004) were more likely to require amputation. CONCLUSION Patients with MVI who receive LVCR, have combined arterial/venous injuries and have associated fractures are more likely to require amputation. MT was not associated with delayed amputation.
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Affiliation(s)
- Elizabeth Dauer
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA, 19140, USA.
| | - Seiji Yamaguchi
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA, 19140, USA.
| | - Daohai Yu
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA, 19140, USA.
| | - Xiaoning Lu
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA, 19140, USA.
| | - Kathyrn Kelley
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA, 19140, USA.
| | - John Sharpe
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN 38163, USA.
| | - Nathan Manley
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN 38163, USA.
| | - John A Harvin
- Department of Surgery, University of Texas at Houston Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX, 77030, USA.
| | - Ethan A Taub
- Department of Surgery, University of Texas at Houston Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX, 77030, USA.
| | - Anna Goldenberg-Sandau
- Department of Surgery, Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ, 08103, USA.
| | - Krishan Patel
- Department of Surgery, Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ, 08103, USA.
| | - Ellen Omi
- Advocate Christ Medical Center, 4440 95th St, Oak Lawn, IL, 60453, USA.
| | - Hassan Mashbari
- Advocate Christ Medical Center, 4440 95th St, Oak Lawn, IL, 60453, USA.
| | - Jennifer Hartwell
- Department of Surgery, Indiana University School of Medicine, 1604 N. Capitol Ave, B232, Indianapolis, IN, 46202, USA.
| | - Jason Brocker
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S. Greene Street, Baltimore, MD, 21201, USA.
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D'Alessio I, Domanin M, Bissacco D, Romagnoli S, Rimoldi P, Sammartano F, Chiara O. Operative Treatment and Clinical Outcomes in Peripheral Vascular Trauma: The Combined Experience of Two Centers in the Endovascular Era. Ann Vasc Surg 2019; 62:342-348. [PMID: 31449953 DOI: 10.1016/j.avsg.2019.06.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Arterial traumas of the extremities are quite rare in civilian records; nevertheless, patients with trauma of limbs are admitted daily in emergency departments worldwide. The up-to-date information about epidemiology and treatment (open vs. endovascular surgery) comes from war records and it is not always easy getting data on mortality and morbidity in these patients. The aim of this study is to analyze the approach (open or endovascular) and the outcome of patients with vascular trauma of upper limbs (from the subclavian artery) and/or lower limbs (distal to the inguinal ligament), in the greater Milan area. METHODS A retrospective analysis was conducted on data recorded by the emergency departments of two hospitals of the greater Milan between 2009 and 2017. We collected all patients with arterial injuries of the limbs in terms of demography, injury patterns, clinical status at admission, therapy (open or endovascular approach), and outcomes in terms of limb salvage and survival. RESULTS We studied 52 patients with vascular trauma of extremities. The main mechanism of trauma was road accident (48.1%), followed by criminal acts (32.7%), self-endangering behavior (13.5%), work (3.8%), and sport accidents (1.9%). Associated lesions (orthopedic, neurological, and/or venous lesions of the limbs) were present in 39 patients (75%). All patients underwent emergency surgery, forty-six patients (88.5%) by open repair (polytetrafluoroethylene or greater saphenous vein bypass grafts, arterial suture or ligation), whereas endovascular approach was used only in 6 patients (11.5%), all treated with embolization. The overall postoperative mortality rate was 5.7% (3 patients). Among survivors, we report 5 major amputations of the lower limbs, 3 of them after bypass graft infection, and 2 after graft failure. The rate of limb salvage was 90.4%. CONCLUSIONS Isolated arterial trauma of the extremities are rare, usually they occur in the setting of multiple trauma patients. Despite progresses in surgical techniques, there are still controversies in diagnosis and treatment of these patients. We treated most cases with open surgery (n = 46), choosing endovascular approach (embolization performed mainly by interventional radiologists) in difficult anatomic districts. We believe that, during decision-making of the surgical strategy, it is important to consider the anatomical site of lesions and the general condition of the patients. Moreover, in case of multiple trauma, we suggest a multidisciplinary approach to provide the best medical care to the victims.
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Affiliation(s)
| | - Maurizio Domanin
- Department of Clinical Sciences and Community Health, University of Milan, Milano, Italy; Operative Unit of Vascular Surgery, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Silvia Romagnoli
- Operative Unit of Vascular Surgery, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Pierantonio Rimoldi
- Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Fabrizio Sammartano
- DEA-EAS, General and Trauma Surgery Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Osvaldo Chiara
- DEA-EAS, General and Trauma Surgery Department, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
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Lower extremity cooling reduces ischemia-reperfusion injury following Zone 3 REBOA in a porcine hemorrhage model. J Trauma Acute Care Surg 2019; 85:512-518. [PMID: 29847535 DOI: 10.1097/ta.0000000000001990] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND New strategies to mitigate ischemia during REBOA and to prolong its maximal duration are needed. We hypothesized that simple external cooling of the hind limbs would decrease ischemia-reperfusion injury following prolonged Zone 3 REBOA. METHODS Twelve swine were anesthetized, instrumented, splenectomized, and then underwent 15% total blood volume hemorrhage. Animals were randomized to hypothermia or control followed by 4 hours of Zone 3 REBOA, resuscitation with shed blood, and 3 hours of critical care. Physiologic parameters were continuously recorded, and laboratory specimens were obtained at regular intervals. Baseline and end-of-study muscle biopsies were obtained for histologic analysis. RESULTS There were no significant differences between groups at baseline or after hemorrhage. Maximum creatine kinase was significantly lower in the hypothermia group compared with the normothermia group (median [interquartile range] = 3,445 U/mL [3,380-4,402 U/mL] vs. 22,544 U/mL [17,030-24,981 U/mL]; p < 0.01). Maximum serum myoglobin was also significantly lower in the hypothermia group (1,792 ng/mL [1,250-3,668 ng/mL] vs. 21,186 ng/mL [14,181-24,779 ng/mL]; p < 0.01). Fascial compartment pressures were significantly lower during critical care in the hypothermia group (p = 0.03). No histologic differences were observed in hind limb skeletal muscle. CONCLUSIONS External cooling during prolonged Zone 3 REBOA decreased ischemic muscle injury and resulted in lower compartment pressures following reperfusion. Hypothermia may be a viable option to extend the tolerable duration of Zone 3 occlusion, beyond what is currently achievable. Future survival studies are required to assess functional outcomes.
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Mansor S, Bendardaf R, Issa Y, Moftah M. The impact of urgent computed tomography angiography for gunshot wounds in extremities with concomitant vascular injuries on diagnosis and postoperative outcomes. Vascular 2018; 26:600-607. [PMID: 30041567 DOI: 10.1177/1708538118777445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Computed tomography angiography represents one of the most important investigation modalities in the diagnosis and follow-up of vascular diseases. We prospectively compare between patients who have had preoperative computed tomography (CT) angiography and others who had not, to analyze the influence of CT angiography on the diagnosis and postoperative outcomes in gunshot cases. METHODS A Cohort study to compare between patients who underwent preoperative CT angiography and others who had not, to analyze the influence of CT angiography on the diagnosis and postoperative outcomes in patients who suffer from urgent vascular reconstruction due to gunshot wounds in extremities with concomitant vascular injuries, in the time period from 17 February 2011 to 31 December 2011 in Al-Jalaa Hospital, Benghazi, Libya. RESULTS During the study period, 89 patients were included, of whom 88 (99%) were males and 1 (1%) was female; the mean age was 29.5 years. Patients were arranged into two groups. The first group of 38 patients (43%) were operated urgently without preoperative CT angiographic evaluation. The second group of 51 patients (57%) have had a preoperative CT angiographic evaluation. CONCLUSION In the light of our study, we favor the immediate operative exploration of gunshot wounds in extremities with concomitant hard signs of vascular injuries without waiting for preoperative CT angiography, thereby minimizing the shock state and ischemic interval. CT angiography may be required for a more stable patient to avoid unnecessary surgical exploration.
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Affiliation(s)
- Salah Mansor
- 1 Department of General Surgery, Al-Jalaa Hospital, Benghazi University, Benghazi, Libya.,2 Department of General Surgery, Libyan International Medical University, Benghazi, Libya
| | - Rashid Bendardaf
- 1 Department of General Surgery, Al-Jalaa Hospital, Benghazi University, Benghazi, Libya
| | - Youssef Issa
- 1 Department of General Surgery, Al-Jalaa Hospital, Benghazi University, Benghazi, Libya
| | - Muad Moftah
- 1 Department of General Surgery, Al-Jalaa Hospital, Benghazi University, Benghazi, Libya
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Systemic anticoagulation in the setting of vascular extremity trauma. Injury 2017; 48:1911-1916. [PMID: 28377263 DOI: 10.1016/j.injury.2017.03.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/05/2017] [Accepted: 03/17/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is conflicting data regarding if patients with vascular extremity trauma who undergo surgical treatment need to be systematically anticoagulated. We hypothesized that intraoperative systemic anticoagulation (ISA) decreased the risk of repair thrombosis or limb amputation after traumatic vascular injury of the extremities. METHODS We analyzed a composite risk of repair thrombosis and/or limb amputation (RTLA) between patients who did and did not undergo ISA during arterial injury repair. Patient data was collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry. This registry contains demographic, diagnostic, treatment, and outcome data. RESULTS Between February 2013 and August 2015, 193 patients with upper or lower extremity arterial injuries who underwent open operative repair were entered into the PROOVIT registry. The majority were male (87%) with a mean age of 32.6 years (range 4-91) and 74% injured by penetrating mechanism. 63% of the injuries were described as arterial transection and 37% had concomitant venous injury. 62% of patients underwent ISA. RTLA occurred in 22 patients (11%) overall, with no significant difference in these outcomes between patients who received ISA and those that did not (10% vs. 14%, p=0.6). There was, however, significantly higher total blood product use noted among patients treated with ISA versus those that did not receive ISA (median 3 units vs. 1 unit, p=0.002). Patients treated with ISA also stayed longer in the ICU (median 3days vs. 1day, p=0.001) and hospital (median 9.5days vs. 6days, p=0.01). DISCUSSION In this multicenter prospective cohort, intraoperative systemic anticoagulation was not associated with a difference in rate of repair thrombosis or limb loss; but was associated with an increase in blood product requirements and prolonged hospital stay. Our data suggest there is no significant difference in outcome to support use of ISA for repair of traumatic arterial injuries.
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Systemic intraoperative anticoagulation during arterial injury repair. J Trauma Acute Care Surg 2017; 82:680-686. [DOI: 10.1097/ta.0000000000001384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gustilo type IIIC open tibia fractures with vascular repair: minimum 2-year follow-up. Eur J Trauma Emerg Surg 2016; 43:505-512. [PMID: 27273011 DOI: 10.1007/s00068-016-0689-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 05/28/2016] [Indexed: 01/06/2023]
Abstract
PURPOSE Salvage or amputation for grade 3C open fracture of tibia is not well responded question universally because of surgical innovations, cultural believes, difficulties in estimate the outcome, coasts, and different results in the literature. The aim of this study was to evaluate the surgical outcomes of Gustilo grade 3C open tibia fractures with at least two years follow-up in non-military adults. METHODS Twenty-two non-military patients with a mean age of 31.1 were operated with grade 3c open fractures at tibia level in last 10 years in our clinic. We evaluated them retrospectively and asked about their daily life, pain, and if present, about the wish for secondary amputation. We also asked if they would prefer a first day amputation rather than their present status. RESULTS Mean operation time after the injury was 13 h. Seven patients had nerve injury. Mean operation number was 3.5. Eight patients (%36) (all due to circulatory problem) had to have amputation. All patients treated with temporary unilateral external fixation than converted to circular external fixators when soft tissue healing was completed. Two patients were reoperated because of deformity. Four patients needed revision surgery because of non-union. At long term follow, we had osteomyelitis in one patient. CONCLUSIONS Scoring systems and the ischemic time are not the only predictors of amputation. The decision of the treatment mode should be made by the patient and the care team after discussing the options and outcomes rather than relying on a scoring system.
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He JC, Clancy K, Schechtman D, Conrad-Schnetz KJ, Claridge JA. Traumatic vascular injuries: who are repairing them and what are the outcomes? Am J Surg 2016; 211:619-25. [DOI: 10.1016/j.amjsurg.2015.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 11/28/2022]
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Tien H, Beckett A, Garraway N, Talbot M, Pannell D, Alabbasi T. Advances in damage control resuscitation and surgery: implications on the organization of future military field forces. Can J Surg 2015; 58:S91-S97. [PMID: 26100784 DOI: 10.1503/cjs.001815] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Medical support to deployed field forces is increasingly becoming a shared responsibility among allied nations. National military medical planners face several key challenges, including fiscal restraints, raised expectations of standards of care in the field and a shortage of appropriately trained specialists. Even so, medical services are now in high demand, and the availability of medical support may become the limiting factor that determines how and where combat units can deploy. The influence of medical factors on operational decisions is therefore leading to an increasing requirement for multinational medical solutions. Nations must agree on the common standards that govern the care of the wounded. These standards will always need to take into account increased public expectations regarding the quality of care. The purpose of this article is to both review North Atlantic Treaty Organization (NATO) policies that govern multinational medical missions and to discuss how recent scientific advances in prehospital battlefield care, damage control resuscitation and damage control surgery may inform how countries within NATO choose to organize and deploy their field forces in the future.
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Affiliation(s)
- Homer Tien
- The Canadian Forces Health Services, the 1 Canadian Field Hospital, Petawawa, Ont., the Trauma Services and the Department of Surgery, Sunnybrook Medical Centre, Toronto, Ont
| | - Andrew Beckett
- The 1 Canadian Field Hospital, Petawawa, Ont. and the Trauma Program, McGill University Health Centre, Montréal, Que
| | | | - Max Talbot
- The 1 Canadian Field Hospital, Petawawa, Ont. and McGill University, Montréal, Que
| | - Dylan Pannell
- The 1 Canadian Field Hospital, Petawawa, Ont. and the Sunnybrook Health Sciences Centre, Toronto, Ont
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Stein MJ, Kang C, Ball V. Emergency department evaluation and treatment of acute hip and thigh pain. Emerg Med Clin North Am 2015; 33:327-43. [PMID: 25892725 DOI: 10.1016/j.emc.2014.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Although the incidence of hip fractures is decreasing, the overall prevalence continues to increase because of an aging population. People older than 65 suffer fractures at a rate of 0.6% per year--2% per year for persons older than 85. One in 5 patients suffering a hip fracture will die within a year. Additionally, the emergency physician must consider entities such as avascular necrosis, compartment syndrome, and muscular disruption. This article reviews patterns and complications of acute hip and thigh injuries and clinically relevant diagnostic, anesthetic, and treatment options that facilitate timely, appropriate, and effective emergency department management.
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Affiliation(s)
- Matthew Jamieson Stein
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 94804, USA.
| | - Christopher Kang
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 94804, USA
| | - Vincent Ball
- Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA 94804, USA.
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Yan H, Zhao B, Kolkin J, Li Z, Chen X, Chu T, Gao W. The management of lower extremity multilevel arterial injuries: a 10-year experience. PLoS One 2015; 10:e0121769. [PMID: 25793506 PMCID: PMC4368051 DOI: 10.1371/journal.pone.0121769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 02/05/2015] [Indexed: 11/18/2022] Open
Abstract
Background Limb amputation due to lower extremity arterial injury is not uncommon and multilevel arterial injury is even more limb-threatening and easily missed with potentially devastating consequences. There is limited information on multilevel arterial injuries. Purpose We undertook a review of our experience to gain insight on multilevel arterial injury patterns associated with lower extremity trauma and to analyze the results of management of such injuries with a special focus on the influence of initial diagnosis on limb salvage. Patients and Methods Between August 2002 and September 2012, 38 patients with lower extremity multilevel arterial injuries were reviewed, retrospectively. The injury patterns and amputation rates associated with initial diagnosis or misdiagnosis were analyzed. Results According to their injury levels, three multilevel arterial injury patterns were seen in this series: arterial injuries with the involvement of femoral artery and popliteal artery (pattern A), femoral artery and anterior or (and) posterior artery (pattern B), and popliteal artery and anterior or (and) posterior artery (pattern C). The general missed diagnosis rate was 31.6%. Pattern B had a much higher missed diagnosis rate than the other two patterns. The missed diagnosis rate was significantly correlated with the amputation rates (Odds Ratio =10.7, 95% CI: 2.04-56.61). The definite diagnosis rate was only 14.8% using duplex ultrasonography examination. Conclusions Diagnosis of pattern B injury is more prone to be missed. DUS has low specificity in the detection of multilevel arterial injuries. Aggressive intraoperative exploration is considered to be valuable in the definitive diagnosis of highly suspected cases when other diagnostic tools are unavailable.
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Affiliation(s)
- Hede Yan
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bin Zhao
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - John Kolkin
- Department of Plastic and Hand Surgery, Duke Raleigh Hospital, Raleigh, North Carolina, United States of America
| | - Zhijie Li
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xinglong Chen
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Tinggang Chu
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Weiyang Gao
- Department of Orthopaedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- * E-mail:
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Perkins ZB, Yet B, Glasgow S, Cole E, Marsh W, Brohi K, Rasmussen TE, Tai NRM. Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma. Br J Surg 2015; 102:436-50. [DOI: 10.1002/bjs.9689] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/16/2014] [Accepted: 09/29/2014] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Lower extremity vascular trauma (LEVT) is a major cause of amputation. A clear understanding of prognostic factors for amputation is important to inform surgical decision-making, patient counselling and risk stratification. The aim was to develop an understanding of prognostic factors for amputation following surgical repair of LEVT.
Methods
A systematic review was conducted to identify potential prognostic factors. Bayesian meta-analysis was used to calculate an absolute (pooled proportion) and relative (pooled odds ratio, OR) measure of the amputation risk for each factor.
Results
Forty-five studies, totalling 3187 discrete LEVT repairs, were included. The overall amputation rate was 10·0 (95 per cent credible interval 7·4 to 13·1) per cent. Significant prognostic factors for secondary amputation included: associated major soft tissue injury (26 versus 8 per cent for no soft tissue injury; OR 5·80), compartment syndrome (28 versus 6 per cent; OR 5·11), multiple arterial injuries (18 versus 9 per cent; OR 4·85), duration of ischaemia exceeding 6 h (24 versus 5 per cent; OR 4·40), associated fracture (14 versus 2 per cent; OR 4·30), mechanism of injury (blast 19 per cent, blunt 16 per cent, penetrating 5 per cent), anatomical site of injury (iliac 18 per cent, popliteal 14 per cent, tibial 10 per cent, femoral 4 per cent), age over 55 years (16 versus 9 per cent; OR 3·03) and sex (men 7 per cent versus women 8 per cent; OR 0·64). Shock and nerve or venous injuries were not significant prognostic factors for secondary amputation.
Conclusion
A significant proportion of patients who undergo lower extremity vascular trauma repair will require secondary amputation. This meta-analysis describes significant prognostic factors needed to inform surgical judgement, risk assessment and patient counselling.
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Affiliation(s)
- Z B Perkins
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
| | - B Yet
- Department of Computer Science, Queen Mary, University of London, London, UK
| | - S Glasgow
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
| | - E Cole
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
| | - W Marsh
- Department of Computer Science, Queen Mary, University of London, London, UK
| | - K Brohi
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
| | - T E Rasmussen
- US Army Medical Research and Materiel Command, Fort Detrick, Maryland, USA
| | - N R M Tai
- Centre for Trauma Sciences, Queen Mary, University of London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Rehman S, Salari N, Codjoe P, Rehman M, Gaughan J. Gunshot femoral fractures with vascular injury: a retrospective analysis. Orthop Surg 2013; 4:166-71. [PMID: 22927150 DOI: 10.1111/j.1757-7861.2012.00186.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To retrospectively investigate the experience at one urban level one trauma center with gunshot femoral fractures with vascular injury and to examine the implication of surgical sequence with regards to short-term complications and ischaemia time. METHODS We performed a retrospective study of 24 patients treated at an urban level one trauma center over a 10-year period with low velocity gunshot wounds resulting in femur fractures and major vascular injury. Data were stratified according to sequence of surgical intervention. RESULTS The mean age was 31.3 years. Mean time to revascularization was highest in patients undergoing definitive orthopaedic fixation first (660 min) and lowest in patient undergoing shunting first (210 min). Most complications in patients undergoing vascular repair first, included two disrupted repairs requiring immediate revision after subsequent orthopaedic fixation. Other complications included compartment syndrome and one amputation. CONCLUSION Surgical sequence did not appear to impact the outcome with regard to limb loss, compartment syndrome, or mortality. Orthopaedic repair following vascular repair, however, is a risk for disruption of the vascular repair. We suggest that close and early direct communication between the orthopaedic and vascular surgeons take place in order to facilitate a satisfactory outcome.
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Affiliation(s)
- Saqib Rehman
- Department of Orthopaedic Surgery, Temple University Hospital, Philadelphia, PA 19140, USA.
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Ganie FA, Lone H, Wani ML, Wani NUD, Ahangar AG, Ganie SA. The increasing rate of secondary amputation in popliteal arterial injury associated with multi-organ injuries and hypotension. Int Cardiovasc Res J 2012; 6:124-7. [PMID: 24757606 PMCID: PMC3987417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 11/20/2012] [Accepted: 11/27/2012] [Indexed: 11/01/2022] Open
Abstract
OBEJECTIVES To study the role of hypotension and associated injuries in increasing the chances of secondary amputation in lower limb with vascular injuries. METHODS This study was conducted in the Department of cardiovascular and thoracic surgery( CVTS ), Sher-i- Kashmir Institute of Medical Sciences, ( SKIMS ) Srinagar Kashmir India and comprised all patients sustaining vascular injury due to different causes like road traffic accident, fire arm and blast injuries or falling from height during the last five years. Following admission to our Department, the patients were divided into two groups. The first group with associated injuries was hemodynamically unstable during vascular repair or in post-operative period and the second group had no associated injuries and was hemodynamically stable during vascular repair and in post-operative period. RESULTS During the past five years, 95 patients were operated for lower limb vascular injury in our department. Of these 25 patients had associated multi-organ injuries and were hemodynamically unstable and needed intensive care monitoring after surgical intervention. Additionally, 10 patients died due to associated multiple organ injuries, 10 needed amputation due to recurrent thrombosis of their anastomosis, and in five patients limb salvage was achieved. Seventy patients who had isolated limb vascular injuries with no associated injuries or hypotension were hemodynamically stable and were kept in low dependency unit after vascular repair. Only Four patients from this group needed amputation for thrombosis of the anastomosis. CONCLUSION [corrected] Patients with shock and related injuries face significant rate of amputation. These patients whether with multi-organ injuries or isolated vascular injuries need judicious treatment for hypovolumic shock during surgical intervention and in post-operative period.
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Affiliation(s)
- Farooq Ahmad Ganie
- Department of Cardiovascular and Thoracic Surgery1 SKIMS, Soura, Kashmir, India
| | - Hafeezulla Lone
- Department of Cardiovascular and Thoracic Surgery1 SKIMS, Soura, Kashmir, India
| | - Mohd Lateef Wani
- Department of Cardiovascular and Thoracic Surgery1 SKIMS, Soura, Kashmir, India
| | - Nasir-u-din Wani
- Department of Cardiovascular and Thoracic Surgery1 SKIMS, Soura, Kashmir, India
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Farber A, Tan TW, Hamburg NM, Kalish JA, Joglar F, Onigman T, Rybin D, Doros G, Eberhardt RT. Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: a review of the National Trauma Data Bank. Injury 2012; 43:1486-91. [PMID: 21719009 PMCID: PMC3777619 DOI: 10.1016/j.injury.2011.06.006] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 06/03/2011] [Accepted: 06/03/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION AND OBJECTIVES Lower extremity (LE) arterial trauma and its treatment may lead to extremity compartment syndrome (ECS). In that setting, the decision to perform fasciotomies is multifactoral and is not well delineated. We evaluated the outcomes of patients with surgically treated LE arterial injury who underwent early or delayed fasciotomies. METHODS The National Trauma Data Bank (NTDB) was retrospectively reviewed for patients who had LE arterial trauma and underwent both open vascular repair and fasciotomies. Exclusion criteria were additional non-LE vascular trauma, head or spinal cord injuries, crush injuries, burn injuries, and declaration of death on arrival. Patients were divided into those who had fasciotomies performed within 8h (early group) or >8h after open vascular repair (late group). Comparative analyses of demographics, injury characteristics, complications, and outcomes were performed. RESULTS Of the 1469 patient admissions with lower extremity arterial trauma that met inclusion criteria there were 612 patients (41.7%) who underwent fasciotomies. There were 543 and 69 patients in the early and late fasciotomy groups, respectively. There was no significant difference in age, injury severity, mechanism of injury, associated injuries, and type of vascular repair between the groups. A higher rate of iliac artery injury was observed in the late fasciotomy group (23.2% vs. 5.9%, P<.001). Patients in the early fasciotomy group had lower amputation rate (8.5% vs. 24.6%, P<.001), lower infection rate (6.6% vs. 14.5%, P = .028) and shorter total hospital stay (18.5 ± 20.7 days vs. 24.2 ± 14.7 days, P = .007) than those in the late fasciotomy group. On multivariable analysis, early fasciotomy was associated with a 4-fold lower risk of amputation (Odds Ratio 0.26, 95% CI 0.14-0.50, P<.0001) and 23% shorter hospital LOS (Means Ratio 0.77, 95% CI 0.64-0.94, P = .01). CONCLUSION Early fasciotomy is associated with improved outcomes in patients with lower extremity vascular trauma treated with surgical intervention. Our findings suggest that appropriate implementation of early fasciotomy may reduce amputation rates in extremity arterial injury.
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Affiliation(s)
| | - Tze-Woei Tan
- Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, MA
| | - Naomi M Hamburg
- Section of Cardiovascular Medicine, Boston University Medical Center, Boston, MA
| | - Jeffrey A Kalish
- Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, MA
| | - Fernando Joglar
- Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, MA
| | - Timna Onigman
- Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, MA
| | - Denis Rybin
- Department of Public Health, Boston University, Boston, MA
| | - Gheorghe Doros
- Department of Public Health, Boston University, Boston, MA
| | - Robert T Eberhardt
- Section of Cardiovascular Medicine, Boston University Medical Center, Boston, MA
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Ganie FA, Lone H, Wani ML, Ahmad Dar F, Wani NUD, Wani SN. Role of liberal primary fasciotomy in traumatic vascular injury. Trauma Mon 2012; 17:287-90. [PMID: 24350108 PMCID: PMC3860637 DOI: 10.5812/traumamon.5368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 06/05/2012] [Accepted: 06/09/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Vascular injury represents less than 1% of all injuries, but deserves special attention because of its severe complications. Amputation or retention of a painful functionless limb is the most untoward result of severe vascular injury or inadequate treatmet. Thus, vascular injury needs a judicious and multidimensional approach. OBJECTIVES This retrospective study was done to asess the outcome of minor modifications of the methodology of extremity fasciotomy by making it liberal with respect to incision and definition. MATERIALS AND METHODS Out of 55 patients in 2008, 45 patients (Group A) had either no fasciotomy or limited primary fasciotomy, 10 patients (Group B) had primary liberal fasciotomy. Another group from 2008 onwards had undergone primary liberal fasciotomy in all the 45 patients (Group C). RESULTS In group A, we had 5 amputations and one death. In group B, there were no amputations or deaths and from group C, we had one amputation and no deaths. CONCLUSIONS Blunt and distal traumatic vascular injury of the extremities and its repair should always combined with primary liberal fasciotomy, which although increases manageable morbidity, avoids disability (functional as well as anatomical).
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Affiliation(s)
- Farooq Ahmad Ganie
- Department of Resident Cardiovascular and thoracic surgery, SKIMS Soura, Srinagar, India
- Corresponding author: Farooq Ahmad Ganie, Department of Resident Cardiovascular and thoracic surgery, SKIMS Soura, Srinagar, India. Tel/Fax: +9469064259,
| | - Hafeezulla Lone
- Department of Resident Cardiovascular and thoracic surgery, SKIMS Soura, Srinagar, India
| | - Mohd Lateef Wani
- Department of Resident Cardiovascular and thoracic surgery, SKIMS Soura, Srinagar, India
| | - Farooq Ahmad Dar
- Department of Resident Cardiovascular and thoracic surgery, SKIMS Soura, Srinagar, India
| | - Nasir-u-din Wani
- Department of Resident Cardiovascular and thoracic surgery, SKIMS Soura, Srinagar, India
| | - Shadab Nabi Wani
- Department of Resident Cardiovascular and thoracic surgery, SKIMS Soura, Srinagar, India
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García AF, Sánchez ÁI, Millán M, Carbonell JP, Ferrada R, Gutíerrez MI, Peitzman AB, Puyana JC. Limb amputation among patients with surgically treated popliteal arterial injury: analysis of 15 years of experience in an urban trauma center in Cali, Colombia. Eur J Trauma Emerg Surg 2011; 38:281-93. [DOI: 10.1007/s00068-011-0158-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 09/21/2011] [Indexed: 10/16/2022]
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Topal AE, Eren MN, Celik Y. Lower extremity arterial injuries over a six-year period: outcomes, risk factors, and management. Vasc Health Risk Manag 2010; 6:1103-10. [PMID: 21191430 PMCID: PMC3004513 DOI: 10.2147/vhrm.s15316] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Limb loss following lower extremity arterial injury is not uncommon and has serious implications on the patient's life and functionality. This retrospective study was performed to analyze the results of lower extremity arterial injuries and to identify the risk factors associated with amputation. METHODS Between 2002 and 2009, retrospectively collected data on 140 patients with 173 lower extremity arterial injuries were analyzed. RESULTS There were 133 males (95%) and 7 females (5%). The mechanism of injuries was gunshot wounds in 56.4% of cases, stab wounds in 30%, and blunt trauma in 13.4%. Associated injuries included vein injury in 45% of cases, nerve injury in 16.4%, and bone fracture in 31.4%. The most frequently injured artery was superficial femoral artery (31.2%). More than 1 artery was injured in 18.6% of patients. Surgery was carried out, with a limb salvage rate of 90.4% and a survival of 97.1%. Amputation was performed in 75% of patients in whom only 1 artery was repaired, although all crural arteries were injured. Multivariate logistic regression analysis showed that significant risk factors of outcome were below-knee multiple arterial injuries (odds ratio [OR] 6.62, P < 0.001), associated 2-bone fractures (OR 2.71, P = 0.003), development of compartment syndrome (OR 1.94, P = 0.042), and great soft tissue disruption (OR 1.74, P = 0.010). CONCLUSIONS Limb loss may be decreased by performing prophylactic fasciotomy more often and by repairing at least 2 crural arteries.
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Affiliation(s)
- Aşkin Ender Topal
- Cardiovascular Surgery Department, Dicle University Medicine Faculty, Diyarbakir, Turkey.
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Impact of Intraoperative Arteriography on Limb Salvage for Traumatic Popliteal Artery Injury. ACTA ACUST UNITED AC 2009; 67:252-7; discussion 257-8. [DOI: 10.1097/ta.0b013e31819ea796] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Complications After Fasciotomy Revision and Delayed Compartment Release in Combat Patients. ACTA ACUST UNITED AC 2008; 64:S153-61; discussion S161-2. [PMID: 18376159 DOI: 10.1097/ta.0b013e3181607750] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Kosir R, Moore FA, Selby JH, Cocanour CS, Kozar RA, Gonzalez EA, Todd SR. Acute lower extremity compartment syndrome (ALECS) screening protocol in critically ill trauma patients. ACTA ACUST UNITED AC 2007; 63:268-75. [PMID: 17693823 DOI: 10.1097/ta.0b013e318074fe15] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute lower extremity compartment syndrome (ALECS) is a devastating complication that often presents silently in critically injured patients; therefore, we developed a protocol to screen high-risk patients. METHODS This prospective observational study included all Shock Trauma intensive care unit patients who met specific high-risk criteria including pulmonary artery catheter-directed shock resuscitation, open or closed tibial shaft fracture, major vascular injury below the aortic bifurcation, abdominal compartment syndrome, or pelvic or lower extremity crush injury. Patients were screened at admission and every 4 hours thereafter for the first 48 hours of admission. Screening included physical examination (PE) and anterior or deep posterior calf compartment pressure measurements when PE was suspicious or unreliable. A positive screening, defined as a DeltaP <30 mm Hg (where DeltaP is the difference between the diastolic blood pressure and the compartment pressure), mandated a four-compartment fasciotomy. RESULTS During a 6-month period, the incidence of ALECS in screened patients was surprisingly high at 20% (9 patients). With diligent screening, it was diagnosed early in the patient's Shock Trauma intensive care unit course. These were patients with severe injuries with an Injury Severity Score of 32.0 +/- 12.5 who exhibited significant volume depletion, with a base deficit of 12.9 +/- 5.9 mEq/L and a lactate level of 13.0 +/- 5.2 mmol/L, requiring large volume resuscitation. Although aggressive fasciotomy resulted in no limb loss, ALECS was associated with an exceedingly high mortality rate at 67%. CONCLUSIONS ALECS is an important clinical entity in critically injured patients with trauma associated with significant mortality. Aggressive screening may provide some diagnostic insight to those at risk.
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Affiliation(s)
- Roman Kosir
- Department of Surgery, General and Teaching Hospital, Maribor, Slovenia
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Rai KM, Mohanty SK, Kale R, Chakrabarty A, Prasad D. Management of Vascular Injuries in a Forward Hospital. Med J Armed Forces India 2006; 62:246-51. [PMID: 27365688 PMCID: PMC4922881 DOI: 10.1016/s0377-1237(06)80012-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2001] [Accepted: 05/05/2006] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Management of vascular injuries poses a challenging problem under warlike conditions. Several authorities recommend limb revascularisation only within first 6-8 hours, as the outcome after delayed revascularisation is poor. METHODS A retrospective analysis of 61 consecutive patients with vascular injury in a forward hospital over a 25- month period was carried out. RESULTS Vascular injuries constituted 3.1% of all injuries. The mean injury to treatment delay (lag time) was 11 hours, and 10 patients received treatment after 12 hours. The overall amputation rate was 15%, but only 6.5% for those revascularised within 12 hours and 44% for those undergoing surgery after 12 hours (Chi-square 4.59, p < 0.05). Presence of associated fractures was associated with an adverse outcome (Chi-square 4.24, p < 0.05), as was ligation in comparison to revascularisation (Chi-square 7.86, p < 0.005). Popliteal injuries were associated with a high amputation rate. CONCLUSIONS Failure to revascularise (ligation of artery), presence of associated fracture, and restoration of circulation beyond 12 hours are associated with a high amputation rate.
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Affiliation(s)
- K M Rai
- Assoc Prof (Surgery), Armed Forces Medical College, Pune-411040
| | | | - R Kale
- Senior Adviser (Surgery & Paediatric Surgery), AH (RR), Delhi Cantt
| | | | - D Prasad
- Formerly Commandant, 92 BH, C/o 56 APO
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Ruppert V, Sadeghi-Azandaryani M, Mutschler W, Steckmeier B. [Vascular injuries in extremities]. Chirurg 2005; 75:1229-38; quiz 1239-40. [PMID: 15536512 DOI: 10.1007/s00104-004-0965-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Vascular injuries of the extremities account for most instances of vascular trauma (ca. 70%), and they entail a risk of amputation about 10-20%. According to the kind of force that has acted, arterial trauma is classified as direct or indirect. The scale of hemorrhage and peripheral ischemia depend on the nature and severity of the arterial lesion. In patients with multiple injuries, routine use of Doppler sonography and duplex sonography can facilitate early diagnosis and treatment of vascular injuries. With great certainty, clinical examination and an AB or WB index of >1.0 can rule out the presence of vascular injury that requires treatment. After excluding further life-threatening injuries, surgery should be performed immediately when there is critical ischemia, squirting hemorrhage, or a rapidly expanding hematoma. Angiography or duplex sonography findings determine the further procedure in vascular injuries that do not require immediate treatment. Occlusion of a reconstructed artery, manifestation of a compartment syndrome, and insufficient anticoagulation are the main factors affecting the risk of amputation.
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Affiliation(s)
- V Ruppert
- Gefässchirurgie Chirurgische Klinik und Poliklinik, Klinikum der LMU München
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