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Tamteki̇n B, Gülsen Ersoy G. Our Surgical Results in Popliteal and Infrapopliteal Artery Injuries: 21 Cases without Amputation. Emerg Med Int 2024; 2024:1721047. [PMID: 38298963 PMCID: PMC10830198 DOI: 10.1155/2024/1721047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/07/2024] [Accepted: 01/17/2024] [Indexed: 02/02/2024] Open
Abstract
Objectives Popliteal and infrapopliteal artery injuries have significant morbidity and mortality rates, especially in terms of amputation. In our study, we aimed to evaluate patients who operated due to popliteal and infrapopliteal vascular injuries in our clinic. Patients and Methods. Between 2016 and 2023; 21 patients who were operated in our clinic due to popliteal and infrapopliteal artery injuries were retrospectively evaluated. Results 2 of the patients were female (9.5%) and 19 were male (90.5%). Age ranges were 21-78. The causes of injury were gunshot wounds in 9 patients (42.86%), blunt trauma in 7 patients (33.33%), and sharp object injuries in 5 patients (23.80%). Reversed saphenous vein interposition in 7 patients (33.33%), primary repair in 6 patients (28.57%), 6 mm polytetrafluoroethylene graft (PTFE) interposition in 3 patients (14.28%), end-to-end anastomosis in 2 patients (9.52%), saphenous-PTFE composite graft interposition in 2 patients (9.52%), and embolectomy in 1 patient (4.76%) were performed. Arterial ligation was not performed. Simultaneous orthopedic intervention was performed in 8 patients. Fasciotomy was performed in 3 patients. Venous repair was performed in 5 patients with venous injuries. Vein ligation was not performed. Mortality was observed postoperatively in 1 patient. No patient developed amputation. Foot drop developed with nerve damage in 2 patients. Conclusion Mortality and morbidity rates may increase in popliteal and infrapopliteal artery injuries in cases of hemodynamic disorder, simultaneous bone fracture, multivessel injury, and nerve transection. These rates can be reduced by appropriate surgical repair and ensuring hemodynamic stability.
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Affiliation(s)
- Burak Tamteki̇n
- Department of Cardiovascular Surgery, Faculty of Medicine, Kastamonu University, Kastamonu, Türkiye
| | - Güler Gülsen Ersoy
- Department of Cardiovascular Surgery, Faculty of Medicine, Kastamonu University, Kastamonu, Türkiye
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2
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Nguyen TT, Huynh ST, Lam NV, Phan HQ, Le PT. Reduced Time to Surgery and Prophylactic Fasciotomy May Result in Improved Outcomes in Popliteal Artery Injuries. Ann Vasc Surg 2023; 96:292-300. [PMID: 37003357 DOI: 10.1016/j.avsg.2023.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 02/25/2023] [Accepted: 03/18/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Popliteal artery injuries are uncommon and often result in limb loss or long-term limb dysfunction. The aims of this study were (1) to evaluate the association between predictors and outcomes and (2) to validate the rational of systematic early fasciotomy. METHODS This retrospective cohort study included 122 patients (80% men, n = 100) who underwent surgery for popliteal artery injuries from October 2018 to March 2021 in southern Vietnam. Primary outcomes included primary and secondary amputation. The associations between predictors and primary amputation were analyzed using logistic regression models. RESULTS Among the 122 patients, 11 (9%) underwent primary amputation, while 2 (1.6%) had secondary amputation. Longer time to surgery was associated with increased odds of amputation (odds ratio = 1.65; 95% confidence interval, 1.2 to 2.2 for every 6 hr). Severe limb ischemia was also associated with a 50-fold increase in the risk of primary amputation (adjusted odds ratio = 49.9; 95% confidence interval, 6 to 418, P = 0.001). Furthermore, 11 patients (9%) without signs of severe limb ischemia and acute compartment syndrome on admission were found to have myonecrosis of at least one muscle compartment during fasciotomy. CONCLUSIONS The data suggest that among patients with popliteal artery injuries, prolonged time before surgery and severe limb ischemia are associated with increased risk of primary amputation, whereas early fasciotomy may lead to improved outcomes.
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Affiliation(s)
- Thuc T Nguyen
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Son T Huynh
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Nut V Lam
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Hung Q Phan
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Phong T Le
- Department of Vascular Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam.
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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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Popliteal scoring assessment for vascular extremity injuries in trauma study. J Vasc Surg 2021; 74:804-813.e3. [PMID: 33639233 DOI: 10.1016/j.jvs.2021.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/06/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Traumatic popliteal vascular injuries are associated with the highest risk of limb loss of all peripheral vascular injuries. A method to evaluate the predictors of amputation is needed because previous scores could not be validated. In the present study, we aimed to provide a simplified scoring system (POPSAVEIT [popliteal scoring assessment for vascular extremity injuries in trauma]) that could be used preoperatively to risk stratify patients with traumatic popliteal vascular injuries for amputation. METHODS A review of patients sustaining traumatic popliteal artery injuries was performed. Patients requiring amputation were compared with those with limb salvage at the last follow-up. Of these patients, 80% were randomly assigned to a training group for score generation and 20% to a testing group for validation. Significant predictors of amputation (P < .1) on univariate analysis were included in a multivariable analysis. Those with P < .05 on multivariable analysis were assigned points according to the relative value of their odds ratios (ORs). Receiver operating characteristic curves were generated to determine low- vs high-risk scores. An area under the curve of >0.65 was considered adequate for validation. RESULTS A total of 355 patients were included, with an overall amputation rate of 16%. On multivariate regression analysis, the risk factors independently associated with amputation in the final model were as follows: systolic blood pressure <90 mm Hg (OR, 3.2; P = .027; 1 point), associated orthopedic injury (OR, 4.9; P = .014; 2 points), and a lack of preoperative pedal Doppler signals (OR, 5.5; P = .002; 2 points [or 1 point for a lack of palpable pedal pulses if Doppler signal data were unavailable]). A score of ≥3 was found to maximize the sensitivity (85%) and specificity (49%) for a high risk of amputation. The receiver operating characteristic curve for the validation group had an area under the curve of 0.750, meeting the threshold for score validation. CONCLUSIONS The POPSAVEIT score provides a simple and practical method to effectively stratify patients preoperatively into low- and high-risk major amputation categories.
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Kochuba M, Rozycki GF, Feliciano D. Outcome after ligation of major veins for trauma. J Trauma Acute Care Surg 2021; 90:e40-e49. [PMID: 33502152 DOI: 10.1097/ta.0000000000003014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew Kochuba
- From the Division of Acute Care Surgery, Department of Surgery, UF Health Jacksonville Medical Center (M.K.), University of Florida-Jacksonville, Jacksonville, Florida; Division of Acute Care and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University School of Medicine (G.F.R.), Johns Hopkins University; and Division of Surgical Critical Care, Department of Shock Trauma Center, Shock Trauma Center (D.F.), University of Maryland Medical Center, University of Maryland, Baltimore, Maryland
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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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Romagnoli A, Dubose J, Feliciano D. Through Thick or Thin: Disparities in Perioperative Anticoagulant Use in Trauma Patients. Am Surg 2020. [DOI: 10.1177/000313481908500950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although vascular surgery guidelines recommend immediate anticoagulation for acute occlusion of a peripheral artery, it is unclear whether trauma surgeons follow this practice. A survey regarding the use of perioperative anticoagulation was sent to surgeons who perform their own peripheral arterial repairs after traumatic injury to define contemporary practice patterns. This survey demonstrated minimal consensus opinion regarding the management of extremity vascular injuries, strongly suggesting the need for a consensus conference, meta-analysis, and prospective studies to guide further care.
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Affiliation(s)
- Anna Romagnoli
- From the Division of Trauma/Critical Care, RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph Dubose
- From the Division of Trauma/Critical Care, RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - David Feliciano
- From the Division of Trauma/Critical Care, RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
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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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Bedi V, Agrawal V, Anand V, Garg M. Management of vascular injury in counter insurgency area: A single-center study. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2018. [DOI: 10.4103/ijves.ijves_65_17] [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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11
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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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12
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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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13
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Wang E, Inaba K, Cho J, Byerly S, Rowe V, Benjamin E, Lam L, Demetriades D. Do Antiplatelet and Anticoagulation Agents Matter after Repair of Traumatic Arterial Injuries? Am Surg 2016. [DOI: 10.1177/000313481608201024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Thrombosis is a devastating complication after repair of traumatic vascular injury. Although thrombosis rates have been described, the value of anticoagulation in preventing postrepair thrombosis is unknown. We hypothesize that postoperative anticoagulation reduces thrombosis rates. A total of 1524 consecutive patients with traumatic arterial injuries from January 2005 to June 2015 were identified, and 381 patients underwent the following repair types: direct suture of vessel wall, primary anastomosis, extra-anatomic reconstruction, tissue and synthetic interposition reconstruction. Twenty six patients received postoperative heparin at therapeutic levels, and 29 patients received postoperative aspirin for five consecutive days. The heparin and aspirin groups were matched with patients without postoperative anticoagulation by the following variables: anatomic arterial injury, type of vascular repair, and age. These groups were then compared using the following outcome measures: mortality, thrombosis of repaired vessel, amputation, hemorrhage, cerebral vascular accident, and extremity compartment syndrome. The demographics between the heparin, aspirin, and respectively matched groups were not statistically different. There was no statistically significant difference in the rate of thrombosis, bleeding, compartment syndrome, cerebral vascular accident, limb amputation, or mortality. Although there was no increase in bleeding complications with the use of heparin or aspirin, there was also no impact on the rate of thrombosis.
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Affiliation(s)
- Eugene Wang
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Kenji Inaba
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Jayun Cho
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Saskya Byerly
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Vincent Rowe
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Elizabeth Benjamin
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Lydia Lam
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Demetrios Demetriades
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
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14
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Current concepts in repair of extremity venous injury. J Vasc Surg Venous Lymphat Disord 2016; 4:238-47. [DOI: 10.1016/j.jvsv.2015.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/24/2015] [Indexed: 10/22/2022]
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15
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Rattan R, Jones KM, Namias N. Management of Lower Extremity Vascular Injuries: State of the Art. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0118-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Dua A, Patel B, Desai SS, Holcomb JB, Wade CE, Coogan S, Fox CJ. Comparison of military and civilian popliteal artery trauma outcomes. J Vasc Surg 2014; 59:1628-32. [DOI: 10.1016/j.jvs.2013.12.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/18/2013] [Accepted: 12/18/2013] [Indexed: 11/30/2022]
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17
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Shi L. The delayed management of main arterial injuries in extremity trauma: Surgical challenges and outcomes. Pak J Med Sci 2013; 29:64-7. [PMID: 24353509 PMCID: PMC3809202 DOI: 10.12669/pjms.291.2619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 10/18/2012] [Accepted: 10/20/2012] [Indexed: 12/02/2022] Open
Abstract
Objective: To analyse the early outcome of main arterial injuries with delayed treatment in extremity trauma and help vascular surgeons in determining proper treatment strategy for such injuries. Methodology: Forty-three patients with delayed treatment of main arterial injuries during May 2003 and January 2008 were reviewed retrospectively. Results: In 43 patients, injuries were caused by blunt trauma in 26 cases and penetrating trauma in 17 cases. The maximum ischaemia time was 38 hours and the minimum was 13 hours. Eight patients underwent primary amputations and four patients underwent secondary amputation. There was no perioperative mortality, while wound infection occurred in five patients, followed by graft occlusion in four patients, arteriovenous fistulae in two patients and pseudoaneurysm in one patient. Conclusion: The delayed intervention in main arterial injuries is associated with higher risk of amputation, while the suitable surgical techniques may decrease the risk of limb loss. Viable limbs should be revascularized in otherwise stable patients even with long periods of ischaemia.
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Affiliation(s)
- Liguo Shi
- Liguo Shi, MD, Department of Surgery Emergency, Tianjin 4 Centre Hospital, Tianjin, 300140, China
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Muscle is a target for preservation in a rat limb replantation model. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2013; 1:e70. [PMID: 25289265 PMCID: PMC4186297 DOI: 10.1097/gox.0000000000000017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 09/26/2013] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Ischemia exceeding 6 hours makes clinical limb replantation difficult and places the patient at risk of functional deficit or limb loss. We investigated the preservation of muscle function and morphology with solutions in rat hindlimb in vivo and in vitro. Methods: Quadriceps femoris muscles from luciferase transgenic rats were preserved for 24 hours at 4°C in extracellular-type trehalose containing Kyoto (ETK), University of Wisconsin (UW), or lactated Ringer’s (LR) solution (control). Muscle luminescence was measured with a bioimaging system. Amputated limbs of Lewis rats preserved with ETK, UW, or LR for 6 or 24 hours at 4°C were transplanted orthotopically. At week 8, terminal latency and amplitude were measured in the tibialis anterior muscle. The muscles were also analyzed histologically. Results: Isolated muscles preserved in ETK or UW had significantly higher luminescence than did muscles immersed in LR (P < 0.05). In the 6-hour-preserved limb transplantation model, although the 3 groups had almost the same terminal latency, electrical amplitude was significantly lower in the LR group. Histologically, muscles preserved with LR showed the most atrophic changes. In the 24-hour-preserved model, the survival rate of the LR group was 37.5% in contrast to 80% in the ETK and UW groups. Electrical signals were not detected in the LR group owing to severe muscle atrophy and fibrosis. The ETK and UW groups showed good muscle function electrophysiologically. Conclusions: Preservation solutions can protect muscle function and morphology in ischemia–reperfusion limbs and improve recipient survival rates after transplantation of long-term-preserved limbs.
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Epidemiology of vascular injuries in modern wars. Ann Surg 2013; 259:e91. [PMID: 24169186 DOI: 10.1097/sla.0000000000000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vascular complications and special problems in vascular trauma. Eur J Trauma Emerg Surg 2013; 39:569-89. [DOI: 10.1007/s00068-013-0336-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 09/30/2013] [Indexed: 12/17/2022]
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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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Sciarretta JD, Perez-Alonso AJ, Ebler DJ, Mazzini FN, Petrone P, Asensio-Gonzalez JA. Popliteal vessel injuries: complex anatomy, difficult problems and surgical challenges. Eur J Trauma Emerg Surg 2012; 38:373-91. [PMID: 26816119 DOI: 10.1007/s00068-012-0217-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 07/03/2012] [Indexed: 11/30/2022]
Abstract
The incidence of popliteal vessel injuries is low, even in busy urban trauma centers. As a result of this fact, few trauma centers and trauma surgeons have developed extensive experience in the management of these injuries. Popliteal vessel injuries in both civilian and military arenas incur significant morbidity. These injuries present a difficult challenge, and, although the overall incidence of these injuries remains low, the sequelae can be devastating. Successful outcomes for limb salvage and survival result from early recognition and rapid surgical intervention by a multidisciplinary approach with a great participation of different surgical specialties. From the historical perspective, anatomy, incidence and associated injuries, to the clinical presentation, diagnosis, management, and morbidity and mortality, the aim of this article is to review the various aspects of these complex injuries.
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Affiliation(s)
- J D Sciarretta
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - A J Perez-Alonso
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - D J Ebler
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - F N Mazzini
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - P Petrone
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - Juan A Asensio-Gonzalez
- Division of Trauma Surgery and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, Education and Training International Medicine Institute, Miller School of Medicine, University of Miami, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA. .,Westchester University Medical Center, New York Medical College, Trauma Department of Surgery, 100 Woods Road Taylor Pavilion, Suite E137, Valhalla, NY, 10595, USA.
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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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Franz RW, Shah KJ, Halaharvi D, Franz ET, Hartman JF, Wright ML. A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center. J Vasc Surg 2011; 53:1604-10. [DOI: 10.1016/j.jvs.2011.01.052] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 01/20/2011] [Accepted: 01/21/2011] [Indexed: 10/18/2022]
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Acute ischemia of the lower limb after injury by gunshot: case report and review of literature. Eur J Trauma Emerg Surg 2011; 37:53-9. [PMID: 26814751 DOI: 10.1007/s00068-010-0035-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Accepted: 06/06/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Civilian and military vascular trauma has evolved dramatically. It is estimated that 80% of all cases of vascular injuries are due to peripheral vascular trauma, most involving the lower extremities. Arterial below-knee injuries by gunshot still remain a challenge, with an associated rate of amputation of 20-54%. MATERIAL AND METHODS This case reports a 48 year-old male patient who sustained a gunshot below his left knee. At hospital admission, loss of substance and hemorrhage at the medial and lateral faces of the upper third of his left leg were present with signs of distal ischemia. Arteriography revealed infra-popliteal arterial lesions of the three arterial axes. Two reversed great saphenous vein interposition grafts were performed into the anterior and posterior tibial arteries with immediate revascularization of the left leg and foot. Later, soft tissue reconstruction was accomplished by a split-thickness skin graft. RESULTS At the fifth month of follow-up, the left leg and foot were viable with good healing, without limitations and with controlled pain. Posterior tibial and dorsalis pedis pulses were palpable. CONCLUSION This case report shows the importance of an adequate team approach for treatment of a gunshot extremity injury with vascular lesion. The authors want to highlight the scientific background evidence and the value of comparing worldwide civilian trauma center outcomes, mostly reported previously from the military field.
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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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Pourzand A, Fakhri BA, Azhough R, Hassanzadeh MA, Hashemzadeh S, Bayat AM. Management of high-risk popliteal vascular blunt trauma: clinical experience with 62 cases. Vasc Health Risk Manag 2010; 6:613-8. [PMID: 20730017 PMCID: PMC2922322 DOI: 10.2147/vhrm.s11733] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Indexed: 11/29/2022] Open
Abstract
Purpose: The purpose of this study is to report the clinical and functional outcomes of patients, treated between 2004 and 2009, with high-risk popliteal vascular injuries due to compound fractures about the knee. Patients and methods: A retrospective analysis was conducted of prospectively collected data from Tabriz Medical Trauma Center. Our aim was to perform surgical revascularization as soon as the arterial injury was recognized. The mechanism of injury was blunt in the entire cohort of patients, and all of them had bone fractures about the knee. The treatment of arterial injury included vein graft interposition in 39 (63%), primary anastomosis in 20 (32.3%), and lateral repair in 3 (4.8%) patients. The patients were divided into 2 study groups: limb salvage group (group 1) and amputation group (group 2). Subgroup analysis consisted of univariate analysis comparing the 2 groups and multivariate analysis examining the factors associated negatively and positively with the primary endpoint, limb salvage. Results: In the entire cohort of patients, 60 patients (97%) were male and 2 were female (3%); the mean age was 34.1 years (16–49 years). The overall amputation rate in this study was 37.1% (23 amputations). Significant (P < 0.05) independent factors associated negatively with limb salvage were combined tibia and fibula fracture, concomitant artery and vein injury, ligation of venous injury, and lack of backflow after Fogarty catheter thrombectomy, while repair of popliteal artery and vein injury, when present, was associated with improved early limb salvage. For 40 patients, we adopt a liberal attitude toward open 4-compartment fasciotomy through both medially and laterally placed incisions. Conclusion: Expeditious recognition of vascular injury, transport to repair, and repair of associated venous injury when possible are necessary to optimize limb salvage. The importance of a high level of suspicion and low threshold for timely amputation has been emphasized when limb salvage was deemed impossible to prevent life-threatening complication. Delays in surgery, extensive soft tissue defect, compound tibia–fibula fracture, and other factors are associated with high amputation rate following popliteal artery injury.
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Affiliation(s)
- Ali Pourzand
- Department of General Surgery, Tabriz University of Medical Sciences, Tabriz, East Azarbaijan Province, Iran
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Nicandri GT, Dunbar RP, Wahl CJ. Are evidence-based protocols which identify vascular injury associated with knee dislocation underutilized? Knee Surg Sports Traumatol Arthrosc 2010; 18:1005-12. [PMID: 19779891 DOI: 10.1007/s00167-009-0918-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2009] [Accepted: 09/01/2009] [Indexed: 11/29/2022]
Abstract
A concerning number of patients referred to our clinic with knee dislocations have not been thoroughly evaluated for popliteal injury. The objective of this study is to present our experience and attempt to identify possible causes for this trend. Thirty-one consecutive patients with knee dislocations referred over a 1-year period were evaluated. Patients were assigned to either of two groups: Group I included all patients initially evaluated with an evidence-based protocol for identifying clinically significant vascular injury associated with knee dislocation, and Group II included all patients who had not received an evidence-based evaluation. The main outcome measure was delay in the diagnosis of a limb threatening vascular injury (>8 h) within each group. Six out of the 31 patients referred, were evaluated for vascular injury without an evidence-based protocol. These patients were significantly more likely to have had a delay in the diagnosis of their vascular injury beyond 8 h (P = 0.032) and were less likely to have been evaluated at a level I trauma center (P < 0.001). As expected, evidence-based protocols are superior when compared to initial pedal pulse examination alone for identifying surgically significant vascular injury within 8 h. The consequences of a delay in diagnosis beyond 8 h can be catastrophic and one patient in this series required an above-knee amputation. This is not new information, however, a significant number of patients with knee dislocations continue to be evaluated solely by initial pedal pulse examination. Though effective protocols exist, orthopedic surgeons must work to facilitate the implementation of these protocols at their referring institutions.
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Affiliation(s)
- Gregg T Nicandri
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
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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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Moini M, Takyar MA, Rasouli MR. Revascularisation later than 24h after popliteal artery trauma: is it worthwhile? Injury 2007; 38:1098-101. [PMID: 17697677 DOI: 10.1016/j.injury.2007.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 03/19/2007] [Accepted: 05/03/2007] [Indexed: 02/02/2023]
Abstract
BACKGROUND Traumatic popliteal artery injury carries heavy morbidity. Ischaemic time is an important factor affecting limb survival. In developing countries most patients present late for repair and there are no distinct guidelines in deciding for revascularisation. PATIENTS AND METHODS Patients with popliteal artery trauma who had presented at least 24h after injury were included in the study. Individuals with dead foot were excluded; participants underwent either amputation or revascularisation. RESULTS Among 30 patients entered in the study, 3 underwent amputation; of these, 2 had complete paralysis with partial sensory loss and 1 had complete sensory and motor loss. The rate of amputation was significantly higher among patients with motor deficit (p=0.008) but not among those with sensory deficit. CONCLUSIONS Revascularisation can be successful for patients who retain only one foot movement. We recommend revascularisation also for cases presenting late and with complete motor deficit below the knee, but without mottling.
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Affiliation(s)
- Majid Moini
- Division of Vascular Surgery, Sina Hospital, Tehran University of Medical Sciences, Iran.
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Yahya MM, Mwipatayi BP, Abbas M, Rao S, Sieunarine K. Popliteal artery injury: Royal Perth experience and literature review. ANZ J Surg 2006; 75:882-6. [PMID: 16176232 DOI: 10.1111/j.1445-2197.2005.03550.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Popliteal artery injury is uncommon but poses a significant challenge in Australian trauma care. Blunt trauma and knee dislocations appear to be associated with higher amputation rates. The aim of the present study was to review the authors' experience with this condition and discuss the best approach to investigation and management. METHODS The medical records of all patients with popliteal artery injury (n = 19) who were entered prospectively onto the Royal Perth Hospital Trauma Registry from 1995 to 2003 were reviewed. Their demographic data, investigations, primary operative procedures, fasciotomy, primary and secondary amputation rates and mortality were determined. RESULTS There were 17 male and two female patients with a median age of 34 years (range 17-62 years). Most patients (84%) were under 40 years in age. Blunt trauma was the commonest cause of popliteal artery injury (68.4%), and 84.6% of the patients had associated skeletal injury. The amputation rate in the present study was 26.3% (5/19). There were no intraoperative or in-hospital deaths. Three of 13 patients (23%) with blunt trauma underwent amputation, compared to two of six (33.3%) with penetrating injury. Two of three amputee patients in the blunt trauma group had dislocated knees. CONCLUSION Despite technical improvements in management of popliteal artery injury, a high amputation rate is still seen, especially in patients with one or more of the following factors: extensive soft-issue injury, associated skeletal trauma, knee dislocation, and prolonged ischaemia time. Measures to reduce the amputation rate, ranging from more prompt diagnosis to modified surgical treatment techniques, are discussed.
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Affiliation(s)
- Mazri M Yahya
- Department of Vascular Surgery and General Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
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Elsharawy MA. Arterial reconstruction after mangled extremity: injury severity scoring systems are not predictive of limb salvage. Vascular 2005; 13:114-9. [PMID: 15996366 DOI: 10.1258/rsmvasc.13.2.114] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Vascular Unit at Suez Canal University Hospital in Egypt covers a wide area with high rates of severe injuries. This is a prospective study of mangled extremities to identify risk factors associated with limb loss in these patients. Between December 2000 and August 2003, a prospective study on all patients with arterial injuries in mangled extremities was undertaken. All patients were scored using the Mangled Extremity Severity Score (MESS) and the Mangled Extremity Severity Index (MESI). During this period, arterial reconstruction was performed in 62 patients. Primary patency, secondary patency, and limb salvage rates were 81%, 85.5%, and 93.5%, respectively. The only factor affecting limb salvage (statistical trend) was the site of trauma (upper limb 100% vs lower limb 89%; p = .08%). There was no significant effect related to the mechanism of trauma (blunt 90% vs stab 100%; p = .125), MESS (< 7, 100% vs > 7, 91%; p = .22), and MESI (< 20, 100% vs > 20, 90.5%; p = .154). Upper limb injuries were the least likely to lead to amputation. We recommend that all injuries, whatever their score, should be surgically explored before treatment decisions are made.
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Davidovic LB, Cinara IS, Ille T, Kostic DM, Dragas MV, Markovic DM. Civil and war peripheral arterial trauma: review of risk factors associated with limb loss. Vascular 2005; 13:141-7. [PMID: 15996371 DOI: 10.1258/rsmvasc.13.3.141] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We sought to analyze the early results of civil and war peripheral arterial injury treatment and to identify risk factors associated with limb loss. Between 1992 and 2001, data collected retrospectively and prospectively on 413 patients with 448 peripheral arterial injuries were analyzed. Of these, there were 140 patients with war injuries and 273 patients with civil injuries. The mechanism of injury was gunshot in 40%, blunt injury in 24%, explosive trauma in 20.3%, and stabbing in 15.7% of the cases. The most frequently injured vessels were the femoral arteries (37.3%), followed by the popliteal (27.8%), axillary and brachial (23.5%), and crural arteries (6.5%). Associated injuries, which included bone, nerve, and remote injuries affecting the head, chest, or abdomen, were present in 60.8% of the cases. Surgery was carried out on all patients, with a limb salvage rate of 89.1% and a survival rate of 97.3%. In spite of a rising trend in peripheral arterial injuries, our total and delayed amputation rates remained stable. On statistical analysis, significant risk factors for amputation were found to be failed revascularization, associated injuries, secondary operation, explosive injury, war injury (p < .01) and arterial contusion with consecutive thrombosis, popliteal artery injury, and late surgery (p < .05). Peripheral arterial injuries, if inadequately treated, carry a high amputation rate. Explosive injuries are the most likely to lead to amputations, whereas stab injuries are the least likely to do so. The most significant independent risk factor for limb loss was failed revascularization.
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Affiliation(s)
- Lazar B Davidovic
- Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, Serbia.
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Affiliation(s)
- Bradford Glenn Scott
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas 77030, USA.
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Armstrong PJ, Franklin DP. Treatment of vascular injuries in themultiple-ligament-injured knee. OPER TECHN SPORT MED 2003. [DOI: 10.1053/otsm.2003.35919] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Guerrero A, Gibson K, Kralovich KA, Pipinos I, Agnostopolous P, Carter Y, Bulger E, Meissner M, Karmy-Jones R. Limb loss following lower extremity arterial trauma: what can be done proactively? Injury 2002; 33:765-9. [PMID: 12379385 DOI: 10.1016/s0020-1383(01)00175-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We performed a retrospective review of patients admitted to two Level I trauma centres over a 15-year period with arterial injuries (excluding primary amputations). Preoperative factors analysed included mechanism of injury, site and type of arterial and venous injury and repair, time to operating room, initial blood pressure, evidence of ipsilateral limb fracture and/or extensive tissue damage, status of preoperative pulses and angiographic data. One hundred and fifty-one arterial injuries were treated (80 penetrating). Overall mortality was 10 (6.6%) and limb loss 16 (10.6%). Only two factors that might possibly be modified by specific interventions were noted. The incidence of limb loss was higher in patients who developed compartment syndrome (41% versus 7% without, P=0.003) and in those who did not receive intra- or immediately postoperative anticoagulation (15% without versus 3% with, P=0.02). Unfortunately, no factor was found that reliably predicted the risk of compartment syndrome. In addition, patients who did not receive peri-operative anticoagulation were more severely injured than those that did were. Despite this, there were no bleeding complications associated with anticoagulation. These findings suggest that the primary interventions that may improve limb salvage include liberal use of fasciotomy (recognising that any patient may require this) as well as early use of anticoagulation.
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Affiliation(s)
- Alejandro Guerrero
- Department of Surgery, Harborview Medical Centre, 352 Ninth Avenue, Box 359796, Seattle, WA 98104, USA
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Miranda FE, Dennis JW, Veldenz HC, Dovgan PS, Frykberg ER. Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study. THE JOURNAL OF TRAUMA 2002; 52:247-51; discussion 251-2. [PMID: 11834983 DOI: 10.1097/00005373-200202000-00008] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Knee dislocation, which poses a significant risk for injury of the popliteal artery, prompts many surgeons to evaluate these patients with arteriography routinely. Our hypothesis was that physical examination alone (without arteriography) accurately confirms or excludes surgically significant vascular injuries associated with knee dislocation. METHODS All patients diagnosed with a knee dislocation by an attending orthopedic surgeon between January 1990 and January 2000 were prospectively managed by protocol at our Level I trauma center according to their physical examination. Those with hard signs (active hemorrhage, expanding hematoma, absent pulse, distal ischemia, bruit/thrill) underwent arteriography followed immediately by surgical repair if indicated. Patients with no hard signs (negative physical examination) were admitted for 23 hours, underwent serial physical examination, and then followed as outpatients. RESULTS There were 35 knee dislocations in 35 patients during this 10-year period. The average age was 31 years; 18 dislocations were on the right knee and 17 were on the left. Two patients died from closed head injuries and multisystem trauma. Eight patients were found to have hard signs (positive physical examination) either at presentation (six patients) or during their hospitalization after reduction of their dislocation (two patients). All eight patients demonstrated a loss of pulses only. Six of these patients showed occlusion of the popliteal artery on arteriography and underwent surgical repair without complication (five vein grafts, one primary repair), one demonstrated spasm of the popliteal artery, and one showed a normal artery that required no treatment. None of the 27 patients with negative physical examination during their hospitalization ever developed limb ischemia, needed an operation for vascular injury, or experienced limb loss. Sixteen patients were available for follow-up (46%). Twelve patients with negative physical examination (44%) were contacted (mean, 13 months; range, 2-35 months), and four of the eight patients with positive physical examination (50%) and surgical repair were contacted (mean, 19 months; range, 6-49 months). None of the patients in either group developed any vascular-related symptoms or suffered from a vascular repair complication over the follow-up interval. CONCLUSION This limited series suggests that the presence or absence of an injury of the popliteal artery after knee dislocation can be safely and reliably predicted, with a 94.3% positive predictive value and 100% negative predictive value. Arteriography appears to be unnecessary when physical examination is negative but may avert negative vascular exploration when physical examination is positive. This approach substantially reduces cost and resource use without adverse impact on the patient.
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Affiliation(s)
- Fernando E Miranda
- Department of Surgery, University of Florida Health Science Center, Jacksonville, Florida 32209, USA
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Abstract
Popliteal vascular injury remains one of the most difficult diagnostic and therapeutic challenges for trauma surgeons. Only with strict attention to rapid diagnosis; early surgical treatment with meticulous technical skill; and aggressive use of various adjunctive measures, such as completion arteriography, anticoagulation, fasciotomy, and proper prioritization of management of multiple injuries, can limb salvage be optimized.
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Affiliation(s)
- Eric R Frykberg
- Department of Surgery, University of Florida College of Medicine, Jacksonville 32209, USA.
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Abstract
Although popliteal artery injuries are uncommon, the consequent lack of management protocols may contribute to an already high level of outcome morbidity. We critically reviewed all nine cases of popliteal artery trauma treated at our institution in the last 5 years. The main findings were that blunt trauma was predominant and most patients presented with severe signs of ischaemia. Long delays occurred between injury and treatment, mostly due to the tyranny of distance. Nevertheless, most patients were subjected to further delay whilst undergoing unnecessary formal angiography. Interposition vein graft using contralateral long saphenous vein was the predominant procedure for arterial injury. Most patients did not receive systemic anticoagulation or fasciotomy, and none received intra-operative thrombolysis. Our limb salvage rate was 7/9, although two of these had persistent neurological disability. We criticise our shortcomings in the light of the current literature.
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Affiliation(s)
- R Gupta
- Department of General Surgery, Royal Perth Hospital, Wellington Street Campus, Box X2213 GPO, Perth, WA 6847, Australia.
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Hafez HM, Woolgar J, Robbs JV. Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. J Vasc Surg 2001; 33:1212-9. [PMID: 11389420 DOI: 10.1067/mva.2001.113982] [Citation(s) in RCA: 179] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We sought to analyze the results of lower limb arterial injury (LLAI) management in a busy metropolitan vascular unit and to identify risk factors associated with limb loss. PATIENTS AND METHODS Between 1987 and 1997, prospectively collected data on 550 patients with 641 lower limb arterial injuries were analyzed. RESULTS The mechanism of LLAI was gunshot wounds in 46.1%, blunt in 19%, stabbing in 11.8%, and shotgun in 9.1%. The most frequently injured vessel was the superficial femoral artery (37.2%), followed by the popliteal (30.7%), crural (11%), common femoral (8.7%), and deep femoral (5.3%) arteries. In 3.4% of cases, there was a combined injury on either side of the knee (ipsilaterally). Associated injuries included bony injury in 35.1% of cases, nerve injury in 7.6%, and remote affecting the head, chest, or abdomen in 3.6%. Surgery was carried out on 96.2% of cases with a limb salvage rate of 83.8% and a survival of 98.5%. In spite of a rising trend in LLAI, our total and delayed amputation rates remained stable. On stepwise logistic regression analysis, significant (P <.01) independent risk factors for amputation were occluded graft (odds ratio [OR] 16.7), combined above- and below-knee injury (OR 4.4), tense compartment (OR 4.2), arterial transsection (OR 2.8), and associated compound fracture (OR 2.7). CONCLUSION LLAI carries a high amputation rate. Stab injuries are the least likely to lead to amputations, whereas high-velocity firearm injuries are the most likely to do so. The most significant independent risk factor for limb loss was failed revascularization.
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Affiliation(s)
- H M Hafez
- Regional Vascular Unit, St Mary's Hospital, London, United Kingdom.
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Starnes BW, Bruce JM. Popliteal artery trauma in a forward deployed Mobile Army Surgical Hospital: lessons learned from the war in Kosovo. THE JOURNAL OF TRAUMA 2000; 48:1144-7. [PMID: 10866263 DOI: 10.1097/00005373-200006000-00022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- B W Starnes
- Department of Surgery, HMEDDAC, Heidelberg, Weisbaden, Germany
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Plaza Martínez Á, Coraminas Roura C, Artigues Sánchez de Rojas I, Díaz López M, Lozano Vilardell P, Juliá Montoya J, Manuel-Rimbau Muñoz E, Gómez Ruíz F. Pronóstico funcional del traumatismo de arteria poplítea. ANGIOLOGIA 2000. [DOI: 10.1016/s0003-3170(00)76133-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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