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Layman JR, Benarroch-Gampel J, Sciarretta JD, Rajani RR, Muralidharan VJ, García-Toca M, Ramos C. Identifying Risk Factors for Poor Outcomes Following Popliteal Vascular Injuries. Ann Vasc Surg 2024:S0890-5096(24)00474-6. [PMID: 39067847 DOI: 10.1016/j.avsg.2024.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/02/2024] [Accepted: 06/02/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Popliteal artery injuries may have amputation rates as high as 20%. This study focuses on identifying risk factors associated with major amputations following popliteal artery injuries in a large single-center cohort. Additionally, we assess the impact of repairing or ligating concomitant popliteal vein injuries. METHODS A retrospective chart review encompassing 2011 to 2023 was conducted at a large urban level 1 trauma center. Patients with popliteal artery injuries were included. Demographics and clinical data were analyzed, and univariate and multivariate evaluations identified significant risk factors for amputation. In patients with concomitant popliteal vein injuries, we compared outcomes between those who underwent popliteal vein repair and ligation. RESULTS 188 patients with popliteal artery injuries were identified, 10 underwent index amputation and were excluded. Univariate analysis followed by multivariate analysis revealed that obesity (p= 0.0132) and neurologic deficits on arrival (p=0.0096) were associated with amputation. In the subgroup with popliteal vein injuries (N=93), there was no significant difference in amputation rates between those who had vein repair (p=0.21) and those who underwent ligation (p=0.84) on logistic regression analysis. Likewise, popliteal vein ligation did not impact duration of fasciotomy closure (p=0.20) or skin graft area (p=0.48) based on linear regression analysis. CONCLUSION Our study suggests that major amputations following popliteal artery injuries are more likely in obese patients with neurologic deficits. It also suggests that venous ligation in cases of concomitant popliteal vein injuries does not significantly impact early limb salvage rate. Further research is needed to determine the optimal approach for managing concomitant popliteal vein injuries.
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Affiliation(s)
- John R Layman
- Medical College of Georgia Augusta University/ University of Georgia Medical Partnership, Winnie Davis Hall, Athens, Georgia 30606 United States of America
| | - Jaime Benarroch-Gampel
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, Georgia 30322 United States of America; Division of Vascular Surgery and Endovascular Therapy, Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE, Atlanta, Georgia 30303 United States of America
| | - Jason D Sciarretta
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, Georgia 30322 United States of America; Acute Care and Trauma Surgery, Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE, Atlanta, Georgia 30303 United States of America
| | - Ravi R Rajani
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, Georgia 30322 United States of America; Division of Vascular Surgery and Endovascular Therapy, Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE, Atlanta, Georgia 30303 United States of America
| | | | - Manuel García-Toca
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, Georgia 30322 United States of America; Division of Vascular Surgery and Endovascular Therapy, Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE, Atlanta, Georgia 30303 United States of America
| | - Christopher Ramos
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, Georgia 30322 United States of America; Division of Vascular Surgery and Endovascular Therapy, Grady Memorial Hospital, 80 Jesse Hill Jr Drive SE, Atlanta, Georgia 30303 United States of America.
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Vaidya A, Rilo N, Steigerwald S, Rajani RR. Outcomes of Endovascular and Open Surgical Therapy for Popliteal Artery Injury. Ann Vasc Surg 2024; 104:282-295. [PMID: 38493887 DOI: 10.1016/j.avsg.2023.12.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 03/19/2024]
Abstract
BACKGROUND Popliteal arterial injury carries an appreciable risk of limb loss and, despite advances in stent and stent-graft technology, endovascular therapy for popliteal arterial trauma is infrequently used when compared with traditional open repair. Thus, this study aims to assess outcomes of endovascular management (EM) with open surgery (OS) as a historical reference. METHODS An electronic search was performed (from January 2010 until June 2023) using multiple databases. Initial records were screened against eligibility criteria. Next, the full-text manuscript of articles that passed the title and abstract assessment was reviewed for relevancy of data points. Data from articles passing the inclusion criteria were extracted and tabulated. Comparative analysis was completed by performing chi-square tests and 2-sampled t-tests (Welch's). RESULTS The 24 selected studies described 864 patients (96 EM; 768 OS). In the endovascular group, patients underwent procedures primarily for blunt trauma using covered, self-expanding stents, resulting in universal technical success and patency. Patients had an average length of stay of 7.99 ± 7.5 days and follow-up time of 33.0 ± 7.0 months, with 21% undergoing fasciotomies, 6% undergoing amputation, and 4% having pseudoaneurysms. Patients in the OS group were evenly divided between blunt and penetrating trauma, chiefly undergoing vein graft interposition and exhibiting fasciotomy and amputation rates of 66% and 24%, respectively. Patients had an average length of stay of 5.66 ± 4.6 days and a 96% survival rate at discharge. CONCLUSIONS The current evidence sheds light on the nature of treatment offered by EM and OS treatment and suggests EM is associated with several important positive outcomes. Although it is difficult to directly compare endovascular and open surgical techniques, the data with respect to open surgical management of popliteal artery trauma can still provide a powerful frame of reference for the outcomes of EM to date. However, this claim is weak due to the little published data for EM of popliteal trauma, publication bias accompanying the published studies, and general, selection bias. Additional prospective data are necessary to define patients who specifically benefit from endovascular repair.
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Affiliation(s)
| | - Natalie Rilo
- Emory University School of Medicine, Atlanta, GA
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Qi Y, Wang J, Yuan D, Duan P, Hou L, Wang T. Systematic review and meta-analysis of endovascular therapy versus open surgical repair for the traumatic lower extremity arterial injury. World J Emerg Surg 2024; 19:16. [PMID: 38678282 PMCID: PMC11055329 DOI: 10.1186/s13017-024-00544-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024] Open
Abstract
OBJECTIVE For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury. METHODS The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates. RESULTS A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21-0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20-0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75-1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%-27%). CONCLUSION Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.
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Affiliation(s)
- Yuhan Qi
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jiarong Wang
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China
| | - Ding Yuan
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China
| | - Pengchao Duan
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Li Hou
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Tiehao Wang
- Division of Vascular Surgery Department of General Surgery, West China Hospital, Sichuan University, 37 Guo Xue Alley, Chengdu, Sichuan Province, 610041, China.
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Liu G, Li L, Xu H, Kang B. Five-year outcomes after bypass graft versus Fogarty balloon catheter for the treatment of acute blunt popliteal artery injury. Eur J Trauma Emerg Surg 2023; 49:1989-1996. [PMID: 37039830 DOI: 10.1007/s00068-023-02268-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/02/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE To evaluate long-term clinical outcomes after revascularization by bypass graft versus Fogarty balloon catheter in acute blunt popliteal artery injury and identify risk factors contributing to amputation. METHODS A retrospective review was conducted in patients treated for acute blunt PAI between 2011 and 2019. Inclusion criteria were patients who underwent bypass graft and Fogarty balloon catheter. The cumulative limb salvage rate was calculated by the Kaplan-Meier test and compared with Breslow-Wilcoxon test. Cox proportional hazard model was performed to estimate the potential risk factors for amputation. Receiver operating characteristic (ROC) curve was used to determine the optimal cut-off value for the potential risk factors. RESULTS The overall limb salvage rate was 60.4% (29/48), including 24 patients (66.7%) in bypass graft, and 5 patients (41.7%) in Fogarty balloon catheter with mean follow-up of 5 years (range, 2-10 years). Among amputees, 15 patients (15/19, 78.9%) received primary amputation due to vascular failure or severe soft tissue damage, and 4 received secondary amputation because of chronic bone infection or neurologic deficit. Kaplan-Meier curves showed patients who received Fogarty balloon catheter had significantly higher amputation rate than those received bypass graft, with a hazard ratio of 3.801 (95% CI: 1.162-12.43, p = 0.009). In addition, Cox proportional hazard model revealed that MESS was the only independent risk factor for patients developing amputation, and the optimal cut-off value of MESS was 8. CONCLUSION Five-year outcome demonstrated that Fogarty balloon catheter is not a safe procedure and has significantly higher amputation rate in severe blunt PAI. MESS is the only risk factor for amputation.
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Affiliation(s)
- Gang Liu
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Lin Li
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Han Xu
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China
| | - Bin Kang
- Department of Orthopaedics, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No.12 Changjia Lane, Fucheng District, Mianyang, Sichuan Province, 621000, People's Republic of China.
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Nguyen A, Tiziano T, Beckermann J, Wildenberg J, Carmody T. Endovascular Repair of a Traumatic Popliteal Artery Injury. Cureus 2022; 14:e31100. [DOI: 10.7759/cureus.31100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 11/06/2022] Open
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Abdou H, Edwards J, Stonko D, Elansary N, Ottochian M, DuBose JJ, Scalea TM, Morrison JJ, Kundi R. The Role of Endovascular Repair of Popliteal Arterial Injuries in the Acute Setting. Ann Vasc Surg 2022; 87:522-528. [PMID: 35760265 DOI: 10.1016/j.avsg.2022.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/28/2022] [Accepted: 05/27/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The role of endovascular surgery in the treatment of popliteal arterial injuries is not well established. As with other popliteal pathology, open repair has traditionally been considered the gold standard. As data has accumulated and technology advanced, however, a reassessment of the role of endovascular surgery is warranted. The aim of this study is to perform a noninferiority comparison of open versus endovascular management of traumatic popliteal injuries. Our hypothesis is that endovascular management is noninferior to open management of traumatic popliteal injuries. METHODS The National Trauma Data Bank was searched for adult patients from 2002-2016 for isolated popliteal arterial injury. The study used a standard noninferiority methodology to compare rates of amputation and compartment syndrome between endovascular and open surgery. Margins for noninferiority were established using established published rates of complications: 17.1% for amputations and 23.0% for compartment syndrome. Endovascular intervention would be considered noninferior to open surgery if the lower bound confidence of the complication proportion (endo/open complication rate) was greater than the pre-defined noninferiority margin. RESULTS 3698 patients met inclusion criteria, with blunt injury accounting for 2117 (57%) and penetrating injury accounting for 1581 (43%). Within the blunt group, 1976 (93.3%) underwent open and 141 (6.7%) endovascular surgery. The rate of compartment syndrome (percentage and 95% confidence interval) after surgery for open repair was 9.9 (8.6-11.2) and 6.4 (3.2-11.3) for endovascular repair. The complication proportion is 64.6 (59.7-69.5). The rate of amputation for open repair was 15.7 (14.2-17.4) and 14.2 (9.2-20.6) for endovascular repair. The complication proportion is 90.4 (87.4-93.4). Within the penetrating group, 1525 (96.5%) underwent open repair and 56 (3.5%) endovascular surgery. The rate of compartment syndrome after surgery for open repair was 14.9 (13.2-16.7) and 5.4 (1.5-13.6) for endovascular repair. The complication proportion is 36.2 (31.3-41.1). The rate of amputation for open repair was 4.3 (3.3-5.4) and 3.6 (0.7-11.0) for endovascular repair. The complication proportion is 83.7 (75.3-90.6). CONCLUSION These data suggest that endovascular repair of popliteal artery injury may be noninferior to open repair with respect to limb preservation . Further examination of endovascular repair in popliteal artery injury is warranted.
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Affiliation(s)
- Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph Edwards
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - David Stonko
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Marcus Ottochian
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD.
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
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Liu G, Chen J, Xiang Z. Five-year outcomes of trauma-specific function in patients after acute blunt popliteal artery injury: a matched cohort analysis. J Orthop Surg Res 2022; 17:256. [PMID: 35525991 PMCID: PMC9077808 DOI: 10.1186/s13018-022-03145-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/26/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Few studies focus on the trauma-specific functional outcomes after surgical revascularization and risk factors contributing to poor outcomes in patients with acute blunt popliteal artery injury (PAI). The objective of this study was to investigate the long-term trauma-specific functional outcomes in patients with acute blunt PAI and identify the associated risk factors. METHODS There were 36 patients with acute blunt PAI who require surgical revascularization at a national trauma center of West China Hospital of Sichuan University between March 2010 and April 2019. After propensity matching, each patient was matched to one patient who did not have a concomitant vascular injury in control cohort. Functional outcomes were assessed with trauma-specific functional scores, physical examination of range of motion, nerve functional status and knee stability. A logistics regression model was established to determine the independent risk factors. RESULTS The 5-year (range 2-10 years) follow-up showed that 22 patients (22/36, 61.1%) had functional deficit due to limited activity or chronic neurological symptoms. Patients in vascular cohort had significantly decreased FIM score and AHFS score compared with matched patients without vascular involvement (P = 0.003 and P < 0.001), whereas there was no statistically significant difference in KSS (P = 0.136). Spearman correlation analysis of functional scores in vascular cohort showed that the FIM score was positively correlated with AHFS score (r = 0.926, P < 0.001), but not correlated with the KSS (r = - 0.007, P = 0.967). Additionally, there was significant difference in the range of motion of ankle between two groups (P < 0.001 and P = 0.034). Logistic regression analysis further demonstrated nerve injuries and compartment syndrome were risk factors for poor ankle function after surgery (OR 22.580, P = 0.036 and OR 12.674, P = 0.041). CONCLUSION Most patients who sustained blunt PAI had significant functional deficit associated with limited activity and chronic neurological symptoms of ankle and foot, and poor functional outcomes were related to nerve injury and compartment syndrome. Therefore, early and effective decompression for compartment syndrome remains the only potentially modifiable risk factor for improving functional outcomes following PAI.
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Affiliation(s)
- Gang Liu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Jialei Chen
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Zhou Xiang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China.
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Deng P, Yang J, Hacquebord JH, Qin B, Wang H, Li P, Gu L, Qi J, Zhu Q. Degree of Soft Tissue Injury is a Major Determinant of Successful Arterial Repair in the Extremity: A New Classification of Extremity Arterial Injury? J INVEST SURG 2022; 35:1562-1570. [PMID: 35361053 DOI: 10.1080/08941939.2022.2055237] [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: 10/18/2022]
Abstract
BACKGROUND This study aimed to investigate outcomes after extremity arterial injury repair and examined the association between outcomes and the degree of soft tissue injury and vascular repair methods. METHODS A retrospective study was conducted on 106 patients (108 cases) who underwent emergent microsurgical repair of extremity arterial injury due to trauma and non-perfusion of the affected extremity. The cases were divided into three groups by degree of associated soft tissue injuries: (A) adequate soft tissue coverage over the injured major vessels after radical debridement, (B) inadequate soft tissue coverage over the injured major vessels after radical debridement, and (C) radical debridement was not feasible due to unclear extent of injured soft tissue. Differences in vascular repair methods and outcomes among the three groups were analyzed. RESULTS In Group A (n = 61), microvascular suture and vessel graft achieved 95.1% and 85.0% successful limb reperfusion, respectively. In Group B (n = 31), vessel reconstruction with flap coverage achieved 100% successful reperfusion. Vessel graft achieved 28.6% successful limb reperfusion, while there were no cases of successful reperfusion using microvascular sutures. In Group C (n = 16), no vascular repair method achieved successful reperfusion. There were significant differences among the three groups in successful reperfusion (p < 0.001) and limb salvage (p < 0.001). CONCLUSION The extent of associated soft tissue injury was associated with different vascular repair methods and outcomes. We propose a new system for classifying these injuries according to the degree of associated soft tissue injury.
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Affiliation(s)
- Peijun Deng
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Jiantao Yang
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Jacques Henri Hacquebord
- Department of Orthopedic Surgery and Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, USA
| | - Bengang Qin
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Honggang Wang
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Ping Li
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Liqiang Gu
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Jian Qi
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
| | - Qingtang Zhu
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Orthopaedics and Traumatology, Guangzhou, China
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O'Banion LA, Dirks R, Saldana-Ruiz N, Farooqui E, Yoon WJ, Pozolo C, Fox CJ, Crally A, Siada S, Nehler MR, Brooke BS, Beckstrom JL, Kiang S, Boggs HK, Chandra V, Ho VT, Zhou W, Lee A, Bowens N, Cho Y, Woo K, Ulloa J, Magee GA. Contemporary outcomes of traumatic popliteal artery injury repair from the popliteal scoring assessment for vascular extremity injury in trauma study. J Vasc Surg 2021; 74:1573-1580.e2. [PMID: 34023429 DOI: 10.1016/j.jvs.2021.04.064] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Traumatic popliteal artery injuries are associated with the greatest risk of limb loss of all peripheral vascular injuries, with amputation rates of 10% to 15%. The purpose of the present study was to examine the outcomes of patients who had undergone operative repair for traumatic popliteal arterial injuries and identify the factors independently associated with limb loss. METHODS A multi-institutional retrospective review of all patients with traumatic popliteal artery injuries from 2007 to 2018 was performed. All the patients who had undergone operative repair of popliteal arterial injuries were included in the present analysis. The patients who had required a major lower extremity amputation (transtibial or transfemoral) were compared with those with successful limb salvage at the last follow-up. The significant predictors (P < .05) for amputation on univariate analysis were included in a multivariable analysis. RESULTS A total of 302 patients from 11 institutions were included in the present analysis. The median age was 32 years (interquartile range, 21-40 years), and 79% were men. The median follow-up was 72 days (interquartile range, 20-366 days). The overall major amputation rate was 13%. Primary repair had been performed in 17% of patients, patch repair in 2%, and interposition or bypass in 81%. One patient had undergone endovascular repair with stenting. The overall 1-year primary patency was 89%. Of the patients who had lost primary patency, 46% ultimately required major amputation. Early loss (within 30 days postoperatively) of primary patency was five times more frequent for the patients who had subsequently required amputation. On multivariate regression, the significant perioperative factors independently associated with major amputation included the initial POPSAVEIT (popliteal scoring assessment for vascular extremity injury in trauma) score, loss of primary patency, absence of detectable immediate postoperative pedal Doppler signals, and lack of postoperative antiplatelet therapy. Concomitant popliteal vein injury, popliteal injury location (P1, P2, P3), injury severity score, and tibial vs popliteal distal bypass target were not independently associated with amputation. CONCLUSIONS Traumatic popliteal artery injuries are associated with a significant rate of major amputation. The preoperative POPSAVEIT score remained independently associated with amputation after including the perioperative factors. The lack of postoperative pedal Doppler signals and loss of primary patency were highly associated with major amputation. The use of postoperative antiplatelet therapy was inversely associated with amputation, perhaps indicating a protective effect.
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Affiliation(s)
- Leigh Ann O'Banion
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, Fresno, Calif. leighann.o'
| | - Rachel Dirks
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, Fresno, Calif
| | - Nallely Saldana-Ruiz
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Emaad Farooqui
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, Fresno, Calif; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - William J Yoon
- Division of Vascular Surgery, Department of Surgery, University of California, Davis, Davis, Calif
| | - Cara Pozolo
- Division of Vascular Surgery, Department of Surgery, University of California, Davis, Davis, Calif
| | - Charles J Fox
- Department of Surgery, Denver Health Medical Center, Denver, Colo
| | - Alexis Crally
- Department of Surgery, Denver Health Medical Center, Denver, Colo
| | - Sammy Siada
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, Fresno, Calif; Division of Vascular Surgery, Department of Surgery, University of Colorado Denver, Denver, Colo
| | - Mark R Nehler
- Division of Vascular Surgery, Department of Surgery, University of Colorado Denver, Denver, Colo
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - Julie L Beckstrom
- Division of Vascular Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - Sharon Kiang
- Division of Vascular and Endovascular Surgery, Department of General Surgery, Loma Linda University Medical Center, Loma Linda, Calif
| | - Hans K Boggs
- Division of Vascular and Endovascular Surgery, Department of General Surgery, Loma Linda University Medical Center, Loma Linda, Calif
| | - Venita Chandra
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif
| | - Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, Calif
| | - Wei Zhou
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Ashton Lee
- Division of Vascular Surgery, Department of Surgery, University of Arizona, Tucson, Ariz
| | - Nina Bowens
- Division of Vascular Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif
| | - Yan Cho
- Division of Vascular Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, Calif
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, Calif
| | - Jesus Ulloa
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, Calif
| | - Gregory A Magee
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
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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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Maithel S, Fujitani RM, Grigorian A, Kabutey NK, Gambhir S, Sheehan BM, Nahmias J. Outcomes and Predictors of Popliteal Artery Injury in Pediatric Trauma. Ann Vasc Surg 2020; 66:242-249. [PMID: 31978483 DOI: 10.1016/j.avsg.2020.01.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 12/26/2019] [Accepted: 01/12/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population. METHODS The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI. RESULTS From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001). CONCLUSIONS A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.
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Affiliation(s)
- Shelley Maithel
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA.
| | - Roy M Fujitani
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Areg Grigorian
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Nii-Kabu Kabutey
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Sahil Gambhir
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Brian M Sheehan
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Jeffry Nahmias
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
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Long-term functional outcomes after traumatic popliteal artery injury: A 20-year experience. J Trauma Acute Care Surg 2019; 88:197-206. [DOI: 10.1097/ta.0000000000002548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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