The delayed management of main arterial injuries in extremity trauma: Surgical challenges and outcomes

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.

Limb Salvage after Lower-Leg Fracture and Popliteal Artery Transection-The Role of Vessel-First Strategy and Bone Fixation Using the Ilizarov External Fixator Device: A Case Report

Open traumatic lesion of the popliteal artery is relatively rare. Ischemia time longer than 6 h and severity of limb ischemia have been shown to be associated with an increased risk of limb loss. Severe local infection is critical in the presence of major soft tissue trauma or open fractures. We report the case of a young female who suffered a traumatic transection of the popliteal artery associated with an open fracture of the distal tibia and fibula managed by direct vessel reconstruction with an end-to-end repair and skeletal stabilization initially with half-pin external fixation, then replaced by an Ilizarov circular frame. The patient had a very satisfactory outcome, but the fracture healed malunited, later corrected by open reduction and internal fixation with lag-screwing and a neutralization plate.

Triple vessel injury with single penetrating trauma to the lower extremity requiring popliteal to posterior tibial artery bypass

This is a case report describing the delayed presentation of injury to all three lower extremity infrapopliteal arteries after a 34 year old male sustained multiple gunshot wounds, including one to his left lower extremity. As part of his initial assessment, ankle brachial index was performed and was found to be abnormal. Further work up for this was delayed due to need for emergent trauma laparotomy. After this procedure, more detailed evaluation with CT angiography of the extremity injury was performed. Though imaging indicated adequate perfusion of the lower extremity, serial neurovascular examination revealed inadequate perfusion. The patient required arterial reconstruction and fasciotomies. This case demonstrates the need for continued surveillance of extremity perfusion in atypical trauma cases when index of suspicion suggests the degree of injury may be worse than initial work up may indicate.

Nerve injuries of the upper extremity associated with vascular trauma-surgical treatment and outcome

Peripheral nerve injuries are often associated with injuries of adjacent tissue. As a result of anatomic proximity between nerves and vascular structures, there is a high chance of combined injuries of these structures (23 %). The aim of our study is to describe and analyze associated nerve and vascular injuries of the upper extremity in patients treated at the Clinic of Neurosurgery in Belgrade over a 10-year period. This study included 83 patients that received surgical treatment at the Clinic of Neurosurgery in Belgrade after having been diagnosed with upper extremity nerve injury. The study included all patients that satisfied these criteria over a period of 10 years. The patients with associated vascular injuries, 36 of them, were considered our study group, while 47 patients without associated vascular injuries were considered our control group. Finally, we compared treatment outcome between these groups. The final outcome evaluation was performed 2 years after surgical treatment. In our study group, 84.8 % surgical nerve repair was successful (fair, good, and excellent outcome), while in the control group (patients without vascular injury), surgical nerve repair was successful in 87.9 %. The overall satisfactory neurological outcome (M3-M5) was present in 86.6 % of nerve repairs. Our study shows that there is no significant difference between the treatment outcome in patients with associated nerve and vascular injuries and patients with isolated nerve injuries if they are diagnosed in time and treated appropriately. Successful treatment can only be accomplished through a multidisciplinary approach undertaken by a highly qualified medical team.