Civil and war peripheral arterial trauma: review of risk factors associated with limb loss

CTA Imaging of Peripheral Arterial Injuries

Traumatic vascular injuries consist of direct or indirect damage to arteries and/or veins and account for 3% of all traumatic injuries. Typical consequences are hemorrhage and ischemia. Vascular injuries of the extremities can occur isolated or in association with major trauma and other organ injuries. They account for 1-2% of patients admitted to emergency departments and for approximately 50% of all arterial injuries. Lower extremities are more frequently injured than upper ones in the adult population. The outcome of vascular injuries is strictly correlated to the environment and the time background. Treatment can be challenging, notably in polytrauma because of the dilemma of which injury should be prioritized, and treatment delay can cause disability or even death, especially for limb vascular injury. Our purposes are to discuss the role of computed tomography angiography (CTA) in the diagnosis of vascular trauma and its optimized protocol to achieve a definitive diagnosis and to assess the radiological signs of vascular injuries and the possible pitfalls.

The Mangled Extremity Severity Score (MESS) does not predict amputation in popliteal artery injury

PURPOSE

Vascular injuries in lower extremity trauma, especially with involvement of the popliteal artery, are associated with considerably high rates of limb loss, especially with blunt trauma mechanisms. The aim of this study was to evaluate the risk of amputation in patients with traumatic popliteal artery lesions with special focus on the validity of the Mangled Extremity Severity Score (MESS).

METHODS

In this retrospective study, all patients treated for isolated lesions of the popliteal artery following trauma between January 1990 and December 2020 at a high-volume level I trauma center were included. Primary outcome was limb salvage dependent on MESS and the influence of defined parameters on limb salvage was defined as secondary outcome. The extent of trauma was assessed by the MESS.

RESULTS

A total of 50 patients (age 39.2 ± 18.6 years, 76% male) with most blunt injuries (n = 47, 94%) were included. None of the patients died within 30 days and revascularization was attempted in all patients with no primary amputation and the overall limb salvage rate was 88% (44 patients). A MESS ≥ 7 was observed in 28 patients (56%) with significantly higher rates of performed fasciotomies (92.9% vs. 59.1%; p < 0.01) in those patients. MESS did not predict delayed amputation within our patient cohort (MESS 8.4 ± 4.1 in the amputation group vs. 8.1 ± 3.8 in the limb salvage group; p = 0.765).

CONCLUSION

Revascularization of limbs with isolated popliteal artery injuries should always be attempted. MESS did not predict delayed amputation in our cohort with fasciotomy being an important measure to increase limb salvage rates.

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.

Vascular injuries: Aetiology, presentation and management outcomes at a tertiary hospital in Lagos, Nigeria

Vascular injuries lead to haemorrhagic shock and distal limb ischaemia, especially with an arterial injury. This life-threatening state mandates urgent evaluation and intervention to save life and limbs. The treatment aims to restore blood flow and replace lost blood within the golden hours, stabilising cardiovascular haemodynamics and averting irreversible ischaemic damage. The aim of this study was to analyse the clinical profile of vascular injuries, management and outcomes in our institution.

MATERIALS AND METHODS

This retrospective study covered the period from January 2015 to December 2021. Information of interest were extracted from the medical records of each participant. The results from the data analysis were presented in charts and tables.

RESULTS

Seventy-four patients aged 15-78 years (mean 32.30 ± 13.75 years) were included in this study. The male-to-female ratio was 3.6:1. The most common causes were gunshot injury, road traffic accident and iatrogenic injuries. The mean duration from injury to presentation was 9.85 h and mean duration from presentation to restoration of flow was 7.3 h. The most common injured artery was the femoral artery, whereas the most common vein was inferior vena cava. Primary vascular repair was done in majority of the cases. Amputation was performed in 18.9% with loss of viability of the limb.

CONCLUSION

Vascular injury though relatively uncommon remains a challenging and life-threatening disease predominantly in young adult males. Urgent intervention prevents limb loss and mortality. Favourable outcome is accomplished by improving emergency healthcare delivery and well-equipped vascular centres with adequately trained personnel in the nation's hospitals.

Predicting surgical resource consumption and in-hospital mortality in resource-scarce conflict settings: a retrospective study

Background

In armed conflicts, civilian health care struggles to cope. Being able to predict what resources are needed is therefore vital. The International Committee of the Red Cross (ICRC) implemented in the 1990s the Red Cross Wound Score (RCWS) for assessment of penetrating injuries. It is unknown to what extent RCWS or the established trauma scores Kampala trauma Score (KTS) and revised trauma score (RTS) can be used to predict surgical resource consumption and in-hospital mortality in resource-scarce conflict settings.

Methods

A retrospective study of routinely collected data on weapon-injured adults admitted to ICRC’s hospitals in Peshawar, 2009–2012 and Goma, 2012–2014. High resource consumption was defined as ≥3 surgical procedures or ≥ 3 blood-transfusions or amputation. The relationship between RCWS, KTS, RTS and resource consumption, in-hospital mortality was evaluated with logistic regression and adjusted area under receiver operating characteristic curves (AUC). The impact of missing data was assessed with imputation. Model fit was compared with Akaike Information Criterion (AIC).

Results

A total of 1564 patients were included, of these 834 patients had complete data. For high surgical resource consumption AUC was significantly higher for RCWS (0.76, 95% CI 0.74–0.78) than for KTS (0.53, 95% CI 0.50–0.56) and RTS (0.51, 95% CI 0.48–0.54) for all patients. Additionally, RCWS had lower AIC, indicating a better model fit. For in-hospital mortality AUC was significantly higher for RCWS (0.83, 95% CI 0.79–0.88) than for KTS (0.71, 95% CI 0.65–0.76) and RTS (0.70, 95% CI 0.63–0.76) for all patients, but not for patients with complete data.

Conclusion

RCWS appears to predict surgical resource consumption better than KTS and RTS. RCWS may be a promising tool for planning and monitoring surgical care in resource-scarce conflict settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00488-2.

Predictive Factors for Failure of Limb Salvage in Blunt Leg Trauma Associated with Vascular Injuries

Introduction:

Blunt leg trauma is common; however, it is rarely associated with significant vascular injury. This study was undertaken to determine the risk factors attributed to failure of limb salvage in acute postoperative period in blunt leg trauma with vascular injuries after revascularization.

Methods:

A retrospective analysis was conducted of all patients with blunt leg trauma involving bone and soft tissue associated with vascular injuries. They were studied in terms of demographic data, associated comorbidities, mechanism of trauma, associated extra leg injuries, type and nature of bone fractures, soft-tissue injuries, nerve injuries, time of ischemia, Injury Severity Score (ISS), Mangled Extremity Severity Score (MESS), injured vascular segments, modality of vascular repair, modality of bone fixation, thrombosis at the site of vascular repair, complications, limb salvage failure, and mortality.

Results:

Vascular injuries were identified in 45 arterial segments and 9 popliteal veins among 31 patients. The patients were 93% male, with a mean age of 31 years. The MESS ranged from 6 to 11, and the ISS ranged from 9 to 41. The main pathology of the injured vessels was contusion/thrombosis in 28 legs, which were repaired by interposition-reversed long saphenous vein graft. Seven patients developed postoperative thrombosis and underwent thrombectomy/embolectomy. Failure of limb salvage occurred in seven limbs with no mortality.

Conclusions:

Severe multi-segmental bone fractures, prolong ischemic time of >10 h, and MESS of ≥9 are significant predictors of limb loss in patients with blunt leg trauma in association with vascular injuries.

Ordinary injury, big surprise - Traumatic false aneurysm and arteriovenous fistula of the posterior tibial artery after civilian trauma: A case report

Introduction

False traumatic aneurysm (FTA) or pseudoaneurysm and traumatic arteriovenous fistulas (TAVF) are rare pathologies in civilian trauma and mainly result from stabs or gunshot wounds. The posterior tibial artery as site of trauma is very rare.

Presentation of case

We report on a 39-year old female patient who was suffering from combined FTA and TAVF of the posterior tibial artery after falling into a wine glass. CT-imaging as well as duplex ultrasound and selective arteriography were performed, and two stent-grafts were inserted.

Discussion

Based on the presented case, incidence of the described pathology, treatment options and outcomes are discussed.

Conclusion

Adequate imaging in penetrating wounds to the extremities is crucial in order to provide diagnosis and treatment of concomitant lesions.

Outcome Predictors in Civilian and Iatrogenic Arterial Trauma

BACKGROUND

Our aim was to identify predictors of mortality and limb loss in iatrogenic and civilian arterial trauma.

METHODS

Cases were identified by searching prospectively maintained registries. Multivariable logistic regression was used to identify independent outcome predictors.

RESULTS

During the study period, 285 patients with arterial trauma were managed with endovascular (n = 20) or open (n = 265) repair. Iatrogenic injuries increased in frequency during the course of the study, from 23.9% during the first decade to 35.9 and 55.7% during the second and third decade, respectively (p < 0.001). Endovascular management increased in frequency during the course of the study, from 0% during the first decade to 5.1 and 11.1% during the second and third decade, respectively (p = 0.005). Mortality was 9.8%, and limb loss (in cases with injury of the aorta or limb arteries, n = 259) was 6.2%. Independent predictors of mortality included increased age (odds ratio, 95% confidence interval [OR, 95% CI] 1.05 (1.02-1.07), p < 0.001), blunt trauma (OR [95% CI] 4.8 (1.9-12.2), p = 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.25 (1.1-1.4), p = 0.001). Independent predictors of limb loss included the first half of the study period (OR [95% CI] 3.9 (1.1-14.1), p = 0.04), lower extremity arterial trauma (vs upper extremity, aortic, common or external iliac artery trauma, OR [95% CI] 8.3 (1.9-35.7), p = 0.004), bone fracture (OR [95% CI] 16.9 (4.7-62.5), p < 0.001) and the number of RBC units transfused intraoperatively (OR [95% CI] 1.16 (1.02-1.33), p = 0.024).

CONCLUSION

Increasingly iatrogenic in cause and managed by endovascular methods, arterial trauma remains a problem associated with significant mortality and limb loss. Identification of unfavourable outcome predictors may help clinicians involved with arterial trauma to escalate the level of care.

Trends in Demographics and Surgical Treatment of Weapon-Related Limb Injuries Over Two Decades in a Resource-Scarce Setting

BACKGROUND

In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings.

METHODS

Retrospective cohort study using routinely collected patient data from the International Committee of the Red Cross hospitals in Pakistan was conducted. Consecutive data from 2009 to 2012 (535 patients) and randomly selected data from 1992 to 1995 (463 patients) were used. Only patients with weapon-related limb injuries were included. Differences in surgical procedures were assessed with logistic regression to adjust for confounding factors.

RESULTS

Less injuries were related to mines in 2009-2012 than in 1992-1995 (3.7% vs. 20.3%, p < 0.0001), but injuries from bombs, shells and fragments were more frequent (38.5% vs. 19.4%, p  < 0.0001) as were injuries with only a small degree of tissue damage (42.0% vs. 31.1%, p  = 0.0004). In the logistic regression, the time period did not affect the risk of amputation, debridement, length of hospital stay or in-hospital mortality. The use of external fixation (OR 0.56, 95% CI 0.33-0.96, p  = 0.04), split skin grafts (OR 0.31, 95% CI 0.21-0.45, p  < 0.0001) and blood transfusion (OR 0.43, 95% CI 0.28-0.66, p  = 0.0001) was less frequent in 2009-2012.

CONCLUSION

In this resource-scarce conflict setting, the risk of amputation appears unchanged over time, while the use of external fixation and split skin grafts was less common in 2009-2012 than in 1992-1995. These results contrast with the improved limb salvage results seen in high-resource settings. It likely reflects the challenges of providing advanced limb-preserving techniques in a resource-scarce setting.

Vascular Injuries in Intravenous Drug Addicts-A Single-Center Experience

BACKGROUND

Infected false aneurysms (IFA) caused by intravenous drug abuse are uncommon but challenging lesions. The best approach for the surgical management of this condition is still unknown. The aim is to present a single-center 14-year experience in the IFA treatment in intravenous drug abusers, thus providing additional data regarding the treatment options and outcome in these patients.

METHODS

A retrospective analysis of 32 consecutive patients with vascular injuries secondary to intravenous drug abuse, during the period from January 2004 to April 2018, was performed. Data of interest were extracted from patients' medical history records, anesthesia charts, and database implemented in daily practice, or were obtained by personal contact. The diagnosis was set based on history, physical examination and/or color Doppler sonography, multidetector computed tomographic angiography, and digital subtraction angiography. The outcome included graft patency, limb amputation, and mortality.

RESULTS

During study period, 32 heroin abusers, predominantly males (81%), were surgically treated due to vascular injuries, with mean age of 35.2 years. The vast majority of patients have had an injury of the lower extremity blood vessels (84.3%) and the common femoral artery was the most common site of injury (59.4%). Three-quarters of patients underwent resection of the false aneurysm and ligation of the artery without reconstruction of the blood vessel. In 7 cases (21.9%), arterial reconstruction was performed with overall failure rate of 42.86%. The overall mortality rate was 6.25% and the rate of extremity salvage was 96.7%.

CONCLUSIONS

The best treatment option is yet to be found, but based on the results of the present study, ligation of affected artery without revascularization seems to be an efficient, safe, and optimal treatment method, with minor risk of the extremity loss.

Comparison of traditional vascular reconstruction with covered stent in the treatment of subclavian artery injury

PURPOSE

To explore the significance of traditional vascular reconstruction and covered stent for limb salvage after subclavian artery injury.

METHODS

Patients with subclavian artery injury admitted to Beijing Jishuitan Hospital from January 2010 to December 2018 were retrospectively analyzed. All the injuries have been confirmed by intraoperative exploration, computed tomography angiography or digital subtraction angiography. Complete or partial amputation injuries were excluded. Mild artery defect or partial intimal damage was treated by interventional implantation, while other patients received open surgeries, including direct suture of small defect less than 2 cm and transplantation with autologous vein or artificial blood when the defect was more than 2 cm. Patients were divided into open surgery group and stent implantation group based on the treatment they received. Patients were followed up at 2 weeks (first stage) and 6 months (second stage) after operation to investigate limb salvage. Student's t-test was used to compare the general data between two groups and Chi-square test to analyze the rate of limb salvage.

RESULTS

Altogether 50 cases of subclavian artery injury were treated, including 36 cases of open surgery and 14 cases of stent implantation. Combination of nerve injury was observed in 27 cases (75.0%) in open surgery group and 12 cases (85.7%) in stent implantation group. Amputation developed in 3 cases with open surgery and 1 case with stent implantation. Consequently the rate of successful limb salvage was respectively 91.7% (33/36) and 92.9% (13/14), revealing no significant difference (p > 0.05).

CONCLUSION

Rapid reconstruction of blood circulation is crucial following subclavian artery injury, no matter what kinds of treatment strategies have been adopted. Interventional stent implantation can achieve a good effect for limb salvage.

The impact of urgent computed tomography angiography for gunshot wounds in extremities with concomitant vascular injuries on diagnosis and postoperative outcomes

BACKGROUND AND OBJECTIVES

Computed tomography angiography represents one of the most important investigation modalities in the diagnosis and follow-up of vascular diseases. We prospectively compare between patients who have had preoperative computed tomography (CT) angiography and others who had not, to analyze the influence of CT angiography on the diagnosis and postoperative outcomes in gunshot cases.

METHODS

A Cohort study to compare between patients who underwent preoperative CT angiography and others who had not, to analyze the influence of CT angiography on the diagnosis and postoperative outcomes in patients who suffer from urgent vascular reconstruction due to gunshot wounds in extremities with concomitant vascular injuries, in the time period from 17 February 2011 to 31 December 2011 in Al-Jalaa Hospital, Benghazi, Libya.

RESULTS

During the study period, 89 patients were included, of whom 88 (99%) were males and 1 (1%) was female; the mean age was 29.5 years. Patients were arranged into two groups. The first group of 38 patients (43%) were operated urgently without preoperative CT angiographic evaluation. The second group of 51 patients (57%) have had a preoperative CT angiographic evaluation.

CONCLUSION

In the light of our study, we favor the immediate operative exploration of gunshot wounds in extremities with concomitant hard signs of vascular injuries without waiting for preoperative CT angiography, thereby minimizing the shock state and ischemic interval. CT angiography may be required for a more stable patient to avoid unnecessary surgical exploration.

USE of arterialized saphenous vein venous flow-through flaps as a temporizing measure for hand salvage in contaminated wounds presenting with limb ischemia: A case series

BACKGROUND

Vascular injuries resulting in limb ischemia are traditionally treated acutely with autologous or prosthetic bypass grafts. Traumatic contaminated injuries with soft tissue and vascular segmental loss are challenging as prosthetic bypasses are at risk of erosion, infection, and occlusion; and autologous bypasses are at risk of desiccation, blow-out, infection, and clotting. We propose a novel approach to these injuries by using arterialized saphenous vein venous flow-through free flaps (S-VFTF) as an autologous bypass, and present the results of its application in a series of cases.

METHODS

Spanning 2008 to 2015, four patients presenting with large contaminated crush/avulsion wounds with vascular injury underwent hand revascularization with S-VFTF, allowing the contaminated wounds to be serially debrided. Definitive soft tissue reconstruction was performed once the wound was considered clean. The S-VFTF skin paddle was de-epithelialized and the soft tissue defect covered with a free latissimus dorsi flap or a rectus abdominis myocutaneous flap.

RESULTS

All ischemic limbs were successfully reperfused and there were no take backs for perfusion issues. All S-VFTF remained patent at discharge and final follow-up. No partial or complete finger/hand amputations were required. All definitive coverage free flap survived with no complications.

CONCLUSION

The two-stage reconstruction presented may help reconstructive and vascular surgeons consider alternatives to traditional vascular reconstruction methods. This technique avoids an exposed vascular graft in an extensively contaminated open wound. It allows the surgeon to perform thorough and sufficient debridement of the wound, preventing definitive reconstruction in a not yet declared zone of injury.

Assessment of Vascular Injuries and Reconstruction

BACKGROUND

Trauma is the third leading cause of death. In this regard, vascular injury plays a leading role in of morbidity and mortality rates.

OBJECTIVES

The present study aimed to assess the prevalence of vascular injuries and results of vascular reconstruction at a referral hospital in northern Iran.

PATIENTS AND METHODS

A retrospective observational study assessed 88 consecutive patients with vascular injury admitted to Poursina Hospital, Rasht in northern Iran, from October 2007 to October 2009. All study information was collected retrospectively from hospital charts.

RESULTS

Most of the affected patients (87/88) were male with a mean age of 29.12 ± 11.20 years. The mechanism of injury in 39.8% was blunt trauma and penetrating trauma in the rest. Of the 53 injured by penetrating trauma (60.2%), the most common cause was stabbing (94.3%). The most common cause of blunt trauma was road traffic accidents (93.1%). The most common mechanism for vascular injuries in upper extremities was penetrating trauma (86.0%) and in lower extremities was blunt trauma (60.0%). Fasciotomy was performed in 16 patients (18.2%) mostly in the lower extremities. Major amputation was required in 10% of the patients. In upper extremities, the most common type of revascularization was end to end anastomosis, followed by inter-position graft. The most common type of reconstruction in the lower extremity was bypass graft. All patients who underwent major amputation were admitted to the center with a delay of more than 6 hours after injury.

CONCLUSIONS

Major vascular injuries in our center occurred in young men, frequently because of stab wounds. Popliteal injuries mostly caused by motor vehicle accidents was the second most common arterial injury, followed by combined ulnar and radial injuries. Vascular reconstruction in the first hours after trauma may prevent many unnecessary and preventable amputation procedures.

The management of lower extremity multilevel arterial injuries: a 10-year experience

Background

Limb amputation due to lower extremity arterial injury is not uncommon and multilevel arterial injury is even more limb-threatening and easily missed with potentially devastating consequences. There is limited information on multilevel arterial injuries.

Purpose

We undertook a review of our experience to gain insight on multilevel arterial injury patterns associated with lower extremity trauma and to analyze the results of management of such injuries with a special focus on the influence of initial diagnosis on limb salvage.

Patients and Methods

Between August 2002 and September 2012, 38 patients with lower extremity multilevel arterial injuries were reviewed, retrospectively. The injury patterns and amputation rates associated with initial diagnosis or misdiagnosis were analyzed.

Results

According to their injury levels, three multilevel arterial injury patterns were seen in this series: arterial injuries with the involvement of femoral artery and popliteal artery (pattern A), femoral artery and anterior or (and) posterior artery (pattern B), and popliteal artery and anterior or (and) posterior artery (pattern C). The general missed diagnosis rate was 31.6%. Pattern B had a much higher missed diagnosis rate than the other two patterns. The missed diagnosis rate was significantly correlated with the amputation rates (Odds Ratio =10.7, 95% CI: 2.04-56.61). The definite diagnosis rate was only 14.8% using duplex ultrasonography examination.

Conclusions

Diagnosis of pattern B injury is more prone to be missed. DUS has low specificity in the detection of multilevel arterial injuries. Aggressive intraoperative exploration is considered to be valuable in the definitive diagnosis of highly suspected cases when other diagnostic tools are unavailable.

Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma

Background

Lower extremity vascular trauma (LEVT) is a major cause of amputation. A clear understanding of prognostic factors for amputation is important to inform surgical decision-making, patient counselling and risk stratification. The aim was to develop an understanding of prognostic factors for amputation following surgical repair of LEVT.

Methods

A systematic review was conducted to identify potential prognostic factors. Bayesian meta-analysis was used to calculate an absolute (pooled proportion) and relative (pooled odds ratio, OR) measure of the amputation risk for each factor.

Results

Forty-five studies, totalling 3187 discrete LEVT repairs, were included. The overall amputation rate was 10·0 (95 per cent credible interval 7·4 to 13·1) per cent. Significant prognostic factors for secondary amputation included: associated major soft tissue injury (26 versus 8 per cent for no soft tissue injury; OR 5·80), compartment syndrome (28 versus 6 per cent; OR 5·11), multiple arterial injuries (18 versus 9 per cent; OR 4·85), duration of ischaemia exceeding 6 h (24 versus 5 per cent; OR 4·40), associated fracture (14 versus 2 per cent; OR 4·30), mechanism of injury (blast 19 per cent, blunt 16 per cent, penetrating 5 per cent), anatomical site of injury (iliac 18 per cent, popliteal 14 per cent, tibial 10 per cent, femoral 4 per cent), age over 55 years (16 versus 9 per cent; OR 3·03) and sex (men 7 per cent versus women 8 per cent; OR 0·64). Shock and nerve or venous injuries were not significant prognostic factors for secondary amputation.

Conclusion

A significant proportion of patients who undergo lower extremity vascular trauma repair will require secondary amputation. This meta-analysis describes significant prognostic factors needed to inform surgical judgement, risk assessment and patient counselling.

False traumatic aneurysms and arteriovenous fistulas: retrospective analysis

BACKGROUND

The purpose of this study was to analyze the incidence, clinical presentation, diagnosis, and treatment of false traumatic aneurysms and arteriovenous fistulas as well as the outcomes of the patients.

METHODS

A retrospective, 16-year survey has been conducted regarding the cases of patients who underwent surgery for false traumatic aneurysms (FTA) of arteries and traumatic arteriovenous fistulas (TAVF). Patients with iatrogenic AV fistulas and iatrogenic false aneurysms were excluded from the study. There were 36 patients with TAVF and 47 with FTA. In all, 73 (87.95%) were male, and 10 (12.05%) were female, with an average age of 36.93 years (13-82 years).

RESULTS

In 25 (29.76%) cases TAVF and FTA appeared combat-related, and 59 (70.24%) were in noncombatants. The average of all intervals between the injury and surgery was 919. 8 days (1 day to 41 years) for FTA and 396.6 days (1 day to 9 years) for TAVF. Most of the patients in both groups were surgically treated during the first 30 days after injury. One patient died on the fourth postoperative day. There were two early complications. The early patency rate was 83.34%, and limb salvage was 100%. There were no recurrent AV fistulas that required additional operations.

CONCLUSIONS

Because of their history of severe complications, FTA and TAV fistulas require prompt treatment. The treatment is simpler if there is only a short interval between the injury and the operation. Surgical endovascular repair is mostly indicated.

Lower extremity arterial injuries over a six-year period: outcomes, risk factors, and management

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.

[How much competence in emergency vascular surgery does a modern trauma surgeon need?: experiences regarding deployment as a military surgeon]

Management of combat-related major vascular injuries is a challenge to all surgeons and a vascular specialist will not always be available in a wartime setting; therefore, every surgeon deployed to a war setting must be able to cope with these life and limb-threatening injuries. Data obtained from searching Medline and Google on the localization and treatment of combat-related vascular injuries of the USA strike forces in Afghanistan and Iraq were analyzed and adjusted to the requirements of the German Armed Forces. A total of 5-7% of casualties sustained major vascular injuries. After initial treatment using damage control measures to control the bleeding and restore perfusion definitive repair with vascular reconstruction must be performed in a facility with a higher level of care. Basic vascular surgical techniques which all military surgeons need to know are presented taking the austere conditions of a wartime environment into consideration. Preparation of all surgeons for deployment to a wartime situation must include basic knowledge and skills in vascular surgery including emergency and vascular reconstruction techniques.

Kriegschirurgische Verletzungsmuster

BACKGROUND

Epidemiological analysis of injury patterns and mechanisms help in identifying the expertise that military surgeons need in a combat setting and also in adjusting training requirements accordingly. This paper attempts to assess the surgical specialties and skills of particular importance in the management of casualties in crisis areas.

METHODS

MEDLINE (1949-2007) and Google search were used. Causes of death among casualties in Afghanistan and the Iraq war were analyzed.

RESULTS

The leading causes of injury were explosive devices, gunshot wounds, aircraft crashes, and terrorist attacks. Of the casualties, 55% died in hostile action and 45% in nonhostile incidents. Chest or abdominal injuries (40%) and brain injuries (35%) were the main causes of death for soldiers killed in action. The case fatality rate in Iraq was approximately half as high as in the Vietnam War. In contrast, the amputation rate was twice as high. Approximately 8-15% of the deaths appeared to be preventable.

CONCLUSIONS

Military surgeons must have excellent skills in the fields of thoracic, visceral, and vascular surgery as well as practical skills in neurosurgery and oral and maxillofacial surgery. It also is of vital importance to ensure the availability of sufficient medical evacuation capabilities. Furthermore, there is a need for a standardized registration system for all injuries similar to the German Trauma Registry.

Management of Vascular Injuries in a Forward Hospital

BACKGROUND

Management of vascular injuries poses a challenging problem under warlike conditions. Several authorities recommend limb revascularisation only within first 6-8 hours, as the outcome after delayed revascularisation is poor.

METHODS

A retrospective analysis of 61 consecutive patients with vascular injury in a forward hospital over a 25- month period was carried out.

RESULTS

Vascular injuries constituted 3.1% of all injuries. The mean injury to treatment delay (lag time) was 11 hours, and 10 patients received treatment after 12 hours. The overall amputation rate was 15%, but only 6.5% for those revascularised within 12 hours and 44% for those undergoing surgery after 12 hours (Chi-square 4.59, p < 0.05). Presence of associated fractures was associated with an adverse outcome (Chi-square 4.24, p < 0.05), as was ligation in comparison to revascularisation (Chi-square 7.86, p < 0.005). Popliteal injuries were associated with a high amputation rate.

CONCLUSIONS

Failure to revascularise (ligation of artery), presence of associated fracture, and restoration of circulation beyond 12 hours are associated with a high amputation rate.