Long-term results with autogenous tissue repair of traumatic extremity vascular injuries

Staged treatment with arterial reconstruction and flap transplantation for ischemic mangled extremity: An observational study

Patients with traumatic ischemic mangled extremities first undergo arterial reconstruction using autogenous vein grafts, followed by flap transplantation as a staged treatment for soft tissue reconstruction. This study aimed to report the outcomes of such a staged treatment. Thirteen patients underwent arterial reconstruction between February 2015 and April 2017 due to damage to the major blood vessels by the traumatic mangled extremities. Of them, 6 patients (5 males and 1 female with a mean age of 51 years, age range: 36-60 years) who underwent soft tissue reconstruction due to necrosis were retrospectively analyzed. The average Mangled Extremity Severity Score was 7.2 (range, 6-8). Injuries were found in the lower leg (4 cases), foot (1 case), and wrist and hand (1 case). Arterial reconstruction was performed using autologous venous grafts. The reconstructed arteries included the posterior tibial artery (3 cases), anterior tibial artery (1 case), dorsalis pedis artery (1 case), and radial artery (1 case). The blood circulation status of the reconstructed blood vessels was assessed using computed tomography angiography at an average of 5 weeks (range, 4-6 weeks) after arterial reconstruction. For some necrotic soft tissues, debridement and flap transplantation were performed an average of 7 weeks (range, 6-8 weeks) after arterial reconstruction. Soft tissue reconstruction was performed with an anterolateral thigh free flap in 4 cases, a local flap in 1 case, and a muscle flap in 1 case. In 5 out of 6 cases, blood circulation was maintained in the reconstructed blood vessels, resulting in the salvaging of the extremities. All the patients who underwent flap surgery survived. Notably, there were no special complications during a follow-up visit conducted at an average of 19 months post-reconstruction. To treat an ischemic mangled extremity, the limbs should first be salvaged with arterial reconstruction, followed by subsequent appropriate flap surgery when soft tissue necrosis occurs at the mangled site as a staged treatment.

Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma

OBJECTIVE

Autologous vein is the preferred bypass conduit for extremity arterial injuries owing to superior patency and low infection risk; however, long-term data on outcomes in civilians are limited. Our goal was to assess short- and long-term outcomes of autologous vein bypass for upper and lower extremity arterial trauma.

METHODS

A retrospective review was performed of patients with major extremity arterial injuries (2001-2019) at a level I trauma center. Demographics, injury and intervention details, and outcomes were recorded. Primary outcomes were primary patency at 1 year and 3 years. Secondary outcomes were limb function at 6 months, major amputation, and mortality. Multivariable analysis determined risk factors for functional impairment.

RESULTS

There were 107 extremity arterial injuries (31.8% upper and 68.2% lower) treated with autologous vein bypass. Mechanism was penetrating in 77% of cases, of which 79.3% were due to firearms. The most frequently injured vessels were the common and superficial femoral (38%), popliteal (30%), and brachial arteries (29%). For upper extremity trauma, concomitant nerve and orthopedic injuries were found in 15 (44.1%) and 11 (32.4%) cases, respectively. For lower extremities, concomitant nerve injuries were found in 10 (13.7%) cases, and orthopedic injuries in 31 (42.5%). Great saphenous vein was the conduit in 96% of cases. Immediate intraoperative bypass revision occurred in 9.3% of patients, most commonly for graft thrombosis. The in-hospital return to operating room rate was 15.9%, with graft thrombosis (47.1%) and wound infections (23.5%) being the most common reasons. The median follow-up was 3.6 years. Kaplan-Meier analysis showed 92% primary patency at 1 year and 90% at 3 years. At 6 months, 36.1% of patients had functional impairment. Of patients with functional impairment at 6 months, 62.9% had concomitant nerve and 60% concomitant orthopedic injuries. Of those with nerve injury, 91.7% had functional impairment, compared with 17.8% without nerve injury (P < .001). Of patients with orthopedic injuries, 51.2% had functional impairment, vs 25% of those without orthopedic injuries (P = .01). On multivariable analysis, concomitant nerve injury (odds ratio, 127.4; 95% confidence interval, 17-957; P <. 001) and immediate intraoperative revision (odds ratio, 11.03; 95% confidence interval, 1.27-95.55; P = .029) were associated with functional impairment.

CONCLUSIONS

Autologous vein bypass for major extremity arterial trauma is durable; however, many patients have long-term limb dysfunction associated with concomitant nerve injury and immediate intraoperative bypass revision. These factors may allow clinicians to identify patients at higher risk for functional impairment, to outline patient expectations and direct rehabilitation efforts toward improving functional outcomes.

Patency of arterial repairs from wartime extremity vascular injuries

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.

Early Outcomes of Vein Grafting for Reconstruction of Brachial Arterial Injuries in Children

PURPOSE

We postulated that, with microsurgical technique, vascular reconstruction with interpositional vein grafts in the pediatric population is safe and results in sustained vascular patency and excellent midterm outcomes.

METHODS

Twenty children with brachial artery injuries were treated with interpositional vein grafting at a tertiary pediatric hospital from 1995 to 2013. Medical records were evaluated for demographic, clinical, and radiographic data. Ten patients were available for longer-term follow-up. Pain at rest, pain with exercise, and temperature intolerance were assessed with visual analog scale (VAS) (range, 0-5). Functional outcomes were assessed using the Pediatric Outcomes Data Collection Instrument (PODCI) and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Graft patency and flow were characterized via duplex sonography. Peak flow velocity and resistive index (RI) were compared with the contralateral extremity. Median patient age at the time of injury was 7.75 years (range, 4.6-11.5 years) and median follow-up was 1.75 years (range, 0.3-6.3 years).

RESULTS

All patients had perfused hands with palpable radial pulses at follow-up. There were no clinically meaningful differences in motion, sensibility, or strength between affected and unaffected limbs. Mean VAS scores for pain at rest, pain with exercise, and temperature intolerance were 0.4, 0.4, and 0.6, respectively. Mean global PODCI and DASH scores were 98.0 and 5.1, respectively. Nine of 10 patients had patent arteries with normal flow patterns. In the patient with graft occlusion, there was collateralization around the elbow with normal reconstitution of the distal vessels. Mean peak flow velocity proximal and distal to the graft were 77.7 cm/s and 66.5 cm/s, respectively. Mean RI of the graft were 0.84 and 0.77, respectively.

CONCLUSIONS

Brachial artery reconstruction using interpositional vein graft and microsurgical technique is safe and effective and results in excellent functional outcomes in children.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Conservative Treatment of Polytetrafluoroethylene Grafts Infection

The treatment of infected syn thetic grafts presents a serious prob lem and there is no single approach to dealing with it.

The authors report on 9 patients who developed infections following bypass operation with a synthetic graft. The infections appeared in var ious places but mainly in the groin. In 2 of the patients who suffered infec tions after implant of dacron grafts, the authors had to remove the graft and then perform an extraanatomic bypass, after conservative treatment had failed. Seven patients, in whom a prosthesis of polytetrafluoroethylene (PTFE) had been implanted, were given conservative treatment that was very successful in dealing with the infection that developed in the wounds.

The treatment included antibiot ics appropriate to the sensitivity of the bacteria, debridement of the wounds, local treatment with wound- cleansing powder and continual irri gation with povidone-iodine. The wounds in these patients healed spon taneously or with the help of second ary closure, and the implants re mained patent.

Management of traumatic popliteal vein injuries

PURPOSE

The aim of this study was to evaluate different repair methods of popliteal vein injuries, and to assess the relationship between early patency and surgical outcome.

METHODS

Thirty patients with popliteal vein injuries underwent surgical repair procedure at our hospital from March 2000 to April 2010. Patients who were haemodynamically unstable and those with massive bleeding from limb wounds were taken directly to the operating room. Stable patients underwent preoperative colour-flow duplex ultrasonography (CFDU).

RESULTS

Our study group consisted of 26 males and 4 females, ranging in age from 17 to 60 years with a mean age of 25.3 ± 5.9 years. The mechanism of trauma was penetrating in 27 patients and blunt in the remaining 3 patients. Treatment included primary venous repair in 11 cases, end-to-end anastomosis in 8, interposition vein graft in 10, and interposition polytetrafluoroethylene (PTFE) graft in 1. There were 26 patients with associated arterial injury, of which 4 cases had primary repair, 9 had end-to-end anastomosis, 11 had saphenous vein graft interposition, and 2 had PTFE graft interposition. Associated bone fracture was seen in 6 patients. There were no deaths. One patient required a below-knee amputation. Postoperative CFDU revealed thrombosed venous repair in 7 cases without any sequelae.

CONCLUSION

Popliteal venous injuries can be repaired with minimal downside and a good early patency rate. Additionally, transient venous patency allows for establishment of venous and lymphatic collateralisation. Alternatively, venous ligation should be considered only in unstable patients who refuse blood transfusion (Jehovah's witnesses). In these victims, adjuvant management may be required such as the use of fasciotomy and anticoagulation treatment.

Proximity arteriography: cost-effectiveness in asymptomatic penetrating extremity trauma

PURPOSE

Many urban trauma centers have abandoned proximity arteriography, which is defined as exclusion arteriography used to evaluate the asymptomatic patient with penetrating extremity trauma near major arteries. However, decision analysis has not been applied to study proximity arteriography.

MATERIALS AND METHODS

The cost-effectiveness of proximity arteriography was examined by creating a decision model that compared arteriography with observation after patient examination in the trauma unit. The model used predominantly literature-derived estimates for input variables and outcomes. The authors retrospectively reviewed arteriograms for 1 year to identify major occult injuries (requiring intervention) at their institution. After a resource-based cost analysis from the taxpayers' perspective, the cost-effectiveness ratio was calculated (incremental cost per quality-adjusted life year [QALY] gained) for proximity arteriography.

RESULTS

For proximity trauma, arteriography is a dominant strategy (more effective and costs less) at a prevalence of major occult injury of 5.5% or more. Observation is a dominant strategy if the prevalence is from 0% to 0.5% or 2.0%, depending on arteriography complication assumptions. In between, arteriography is cost-effective, with a ratio of $12,100 per QALY at 2.5% prevalence (base case). Besides prevalence of occult injury, the model is sensitive to outcome assumptions for occult injuries.

CONCLUSION

Proximity arteriography is a cost-effective procedure if major occult injuries equal or exceed 1.0%.

Late development of renal arteriovenous fistula following gunshot trauma--a case report

A 43-year-old man presenting with symptoms of congestive heart failure, cardiomegaly, and impaired left ventricular (LV) function was diagnosed as having a huge left renal arteriovenous (AV) fistula. The AV fistula might be attributed to a gunshot wound suffered during his military service twenty years ago. Percutaneous transcatheter arterial embolization utilizing multiple spring coils in conjunction with cyanoacrylic glue successfully occluded the fistula, with subsequent improvement of LV function and reduction of LV size on his serial echocardiographic follow-up.

Traumatic arteriovenous fistula: experience with 202 patients

Experience with the management of 202 patients with 210 traumatic arteriovenous fistulas is reported. Penetrating trauma accounted for 98 per cent of injuries caused mainly by stabs (63 per cent) and missile wounds (26 per cent). Seven of 15 patients with shotgun wounds had multiple lesions. Over half of all fistulas occurred in the cervico-mediastinal vessels; abdominal and thoracic vessels were infrequently involved. The upper limbs were involved in 22 per cent and the lower limbs in 20 per cent. Some 133 patients were diagnosed and treated within 1 week of injury; 69 presented 1 week to 12 years later. Machinery murmur was noted in 61 per cent of the early presenters, but was an almost universal finding in those presenting late. Only three patients had cardiac failure and all had underlying cardiomyopathy. Active overt haemorrhage was not common. Arterial continuity was restored in 80 per cent of cases, usually by autogenous reconstruction. Venous injury was usually treated by ligation or lateral suture. Patients treated within 1 week of injury had a lower rate of perioperative mortality and morbidity than those treated late, due mainly to technical difficulties in controlling the vessels caused by fibrosis and massive venous dilatation. If a policy of selective exploration of penetrating trauma is to be followed, careful assessment for arteriovenous fistula must be made and the patient evaluated at regular intervals for several months. Shotgun injuries require routine angiography at the time of presentation. The earlier treatment is instituted, the better the results.

Management of major arterial injuries of the limbs in 166 cases

The charts of 166 patients with major arterial injuries (175 arterial repairs) inflicted during periods of peace and war time were reviewed. One hundred and sixty-seven (95%) of the arteries repaired remained patent. Nine patients had limbs which developed ischemic contracture. Nine patients required amputations. Follow-up data was obtained from seventy-five patients with an average follow-up of five years and one month (six months to thirty years). Early diagnosis, prompt treatment including fasciotomies when indicated, complete debridement, appropriate coverage, meticulous surgical technique, and simultaneous treatment of concomitant injuries are all crucial factors in successful limb salvage. Major arterial injuries of the limb occur frequently in our patient population, especially in time of war. Successful treatment of major arterial injuries may be life-saving, as well as allowing limb salvage and restoration of limb function. The purpose of this study is to review our experience with repair of major arterial injuries.