Challenges encountered and lessons learnt from venous injuries at Sri Lankan combat theatres

Our experience with blast and gunshot induced traumatic vascular injuries at Somalia's major vascular referral center

Blast and gunshot-induced penetrating traumatic vascular injuries represent a significant portion of patients with vascular trauma in countries where there are higher rates of war-related violence. These injuries are especially challenging in resource-limited countries due to early diagnosis and transfer delays. This report aimed to present our experience regarding the surgical management and outcome of such injuries at a major referral vascular surgery centre in the country. A retrospective descriptive review of 326 patients with blast and gunshot-induced penetrating traumatic vascular injuries managed during a five-year period between April 2018 and April 2023. The demographics, mechanism of injury, type of vascular injury, Anatomical location, time to the operation, length of hospital stay, amount of blood products given, concomitant neuroskeletal injuries, development of Vascular injury associated acute kidney injury, surgical procedures performed and patient outcome were reviewed. In this study, 326 patients with 445 vascular injuries fulfilled the inclusion criteria. Most of the patients were male 92.3%, and the mean age was 28.3 ± 9.9 years. The gunshot mechanism of vascular injury was implicated in 76.1% of the injuries, and explosive-induced injury was 78 (23.9%). 193 (59.2%) of the patients had isolated arterial injuries, 117 (35.9%) patients had combined arterial and venous injuries while 18 (4.9%) patients had isolated venous injuries. The most commonly injured arteries were the femoral artery, followed by Brachial and popliteal artery injuries (26.1%, 23.5% and 19.4%, respectively). The median time to revascularization was 8.8 ± 8.7 h. 46.8% of the patients had Concomitant fractures, while 26.5% had Concomitant nerve injuries. Only three patients had temporary non-heparin-bound shunts during their arrival. The most common surgical intervention in arterial injuries was reversed saphenous vein graft 46.1%. The mortality was 5.8% and 7.7% of the patients needed secondary amputation. The majority of wartime arterial injuries are a result of Blast and gunshot vascular injuries. Frequent need for autologous vein grafts should be considered to manage such injuries. Results are encouraging despite delays in intervention; therefore, all viable limbs should be revascularized, keeping in mind the long-term functionality of the limb.

Treatment of vascular non-iatrogenic injuries of upper and lower extremities in tertiary vascular center

BACKGROUND

The purpose of this study was to examine demographic and baseline characteristics of patients with vascular injuries of extremities and to define the most relevant factors which influenced an early outcome, as well as limb salvage after the management of vascular trauma.

METHODS

This study used the database that included 395 patients with peripheral arterial injuries, who were treated in the tertiary vascular university center in the period between 2005-2020. Exclusion criteria were isolated thoracic, abdominal and neck injuries as well as iatrogenic injuries and injuries of intravenous addicts. Univariate binary logistic regression analysis and multiple logistic regression were used to determine risk factors for lomb loss (after vascular reconstruction) or mortality. Decision to perform primary amputation (without vascular reconstruction) was based on surgeons' preference and experience.

RESULTS

Out of 395 vascular injuries treated in the period 2005-2020, 210 (53.2%) presented with non-iatrogenic vascular injuries of upper and lower extremities were analyzed. According to the univariate regression analysis, hemorrhage as the main clinical manifestation on admission (P=0.035) and early reintervention (P=0.048) increased, while an early patency of repaired artery (0.010) significantly decreased a 30-day amputation rate. Multivariate logistic regression analysis of these three variables showed that only early patency of repaired artery significantly decreased the early amputation rate (P=0.009).

CONCLUSIONS

Based on presented experience, the patency of vascular reconstruction plays a crucial role in limb salvage in patients with non-iatrogenic peripheral vascular injuries. All factors that might influence the patency should be in focus of improvement.

Analysis of Concomitant and Isolated Venous Injury in Military Lower Extremity Trauma

OBJECTIVES

The implications of major venous injury to the lower extremity are not well established. We aimed to determine the significance of concomitant and isolated femoropopliteal venous injury and assess the impact of surgical management strategies on limb outcomes.

METHODS

The Fasciotomy and Vascular Injury Outcomes Database was queried for limbs sustaining femoropopliteal arterial, venous, or concomitant injuries in Iraq or Afghanistan between 2004-2012. Demographics, injury patterns and severity, interventions, and outcomes were compared between patients sustaining isolated arterial injuries (IAI) and concomitant arteriovenous injuries (AVI). In limbs with any venous injury, outcomes were compared between those undergoing venous (VR) and ligation (VL).

RESULTS

330 patients (133 IAI, 135 AVI, 62 isolated venous injuries (IVI)) were included. AVI was associated with greater limb injury severity: median extremity Abbreviated Injury Scale (AVI 4 vs. IAI 3, p=0.01), Mangled Extremity Severity Score >7 (25.9% vs. 13.5%, p= 0.01), multi-level vascular injury (6.7% vs. 0.8%, p=0.01) and with greater fasciotomy use (83.0% vs. 69.2%, p=0.01). No differences were present in tourniquet use/time, shunting, or nature of arterial repair. No differences in vascular or limb complications (71.1% vs. 63.9%, p=0.21) or amputation rate (25.9% vs. 18.8%, p=0.16) were present, though limb DVT rate was 12.6% in AVI vs. 7.5% in IAI (p=0.17). Limbs with IVI had a 12.9% amputation and a 74.2% complication rate. Repair (n=103) versus ligation (n=94) of venous injuries was not associated with a difference in amputation (18.4% vs. 25.5%, p=0.23) or limb complication rates (71.8% vs. 72.3%, p=0.94).

CONCLUSION

Despite higher extremity injury severity and more frequent fasciotomies, concomitant venous injury was not associated with poorer limb salvage or complications. With nontrivial amputation and complication rates, IVI is indicative of severe limb trauma. Repair of femoropopliteal venous injuries does not appear to influence limb outcomes.

A critical appraisal of impact of compounding factors in limb salvage decision making in combat extremity vascular trauma

Objective

For more than half a century, surgeons who managed vascular injuries were guided by a 6-hour maximum ischaemic time dogma in their decision to proceed with vascular reconstruction or not. Contemporary large animal survival model experiments aimed at redefining the critical ischaemic time threshold concluded this to be less than 5 hours. Our clinical experience from recent combat vascular trauma contradicts this dogma with limb salvage following vascular reconstruction with an average ischaemic time of 6 hours.

Methods

During an 8-month period of the Sri Lankan Civil War, all patients with penetrating extremity vascular injuries were prospectively recorded by a single surgeon and retrospectively analysed. A total of 76 arterial injuries was analysed for demography, injury anatomy and physiology, treatment and outcomes. Subsequent statistical analysis was performed to evaluate the impact of independent variables to include; injury anatomy, concomitant venous, skeletal trauma, shock at presentation and time delay from injury to reconstruction.

Results

In this study, the 76 extremity arterial injuries had a median ischaemic time of 290 (IQR 225–375) min. Segmental arterial injury (p=0.02), skeletal trauma (p=0.05) and fasciotomy (p=0.03) were found to have a stronger correlation to subsequent amputation than ischaemic time.

Conclusions

Multiple factors affect limb viability following compromised distal circulation and our data show a trend towards various subsets of limbs that are more vulnerable due to inherent or acquired paucity of collateral circulation. Early identification and prioritisation of these limbs could achieve functional limb salvage if recognised. Further prospective research should look into the clinical, biochemical and morphological markers to facilitate selection and prioritisation of limb revascularisation.