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

2020 ◽  
pp. bmjmilitary-2020-001508 ◽  
Author(s):  
Amila S Ratnayake ◽  
M Bala ◽  
C J Fox ◽  
A U Jayatilleke ◽  
S P B Thalgaspitiya ◽  
...  
Keyword(s):  
Limb Salvage ◽  
Vascular Reconstruction ◽  
Arterial Injury ◽  
Vascular Trauma ◽  
Large Animal ◽  
Vascular Injuries ◽  
Skeletal Trauma ◽  
Anatomy And Physiology ◽  
Arterial Injuries ◽  
The Impact

ObjectiveFor 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.MethodsDuring 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.ResultsIn 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.ConclusionsMultiple 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.

scholarly journals Penetrating Proximity Wounds and Minimal Arterial Injuries may not be so Benign

2019 ◽  
pp. 1-4
Author(s):  
Jonathan Gates ◽  
Dina Tabello ◽  
Alfred Croteau ◽  
Adam Shen ◽  
Nishant Merchant
Keyword(s):  
Natural History ◽  
Watchful Waiting ◽  
Arterial Injury ◽  
Standard Approach ◽  
Vascular Injuries ◽  
Arterial Injuries ◽  
History Of

There is a well-established body of literature in the management of vascular injuries that underscores the benign natural history of minor so-called occult arterial injuries. The standard approach for the management of the proximity extremity wound has evolved into one of watchful waiting. We present a case of an occult arterial injury that declared itself with an acute arterial bleed after about 30 hours of observation indicating that caution and preparation remain critical in the management of these patients.

Outcomes of Soft Tissue Reconstruction for Traumatic Lower Extremity Fractures with Compromised Vascularity

2017 ◽  
Vol 83 (10) ◽  
pp. 1161-1165 ◽  
Author(s):  
Ido Badash ◽  
Karen E. Burtt ◽  
Hyuma A. Leland ◽  
Daniel J. Gould ◽  
Alexis D. Rounds ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Lower Extremity ◽  
Limb Salvage ◽  
Arterial Injury ◽  
Soft Tissue Reconstruction ◽  
Complication Rates ◽  
Arterial Injuries ◽  
Flap Failure ◽  
Vascular Compromise ◽  
Tissue Reconstruction

Traumatic lower extremity fractures with compromised arterial flow are limb-threatening injuries. A retrospective review of 158 lower extremities with traumatic fractures, including 26 extremities with arterial injuries, was performed to determine the effects of vascular compromise on flap survival, successful limb salvage and complication rates. Patients with arterial injuries had a larger average flap surface area (255.1 vs 144.6 cm2, P = 0.02) and a greater number of operations (4.7 vs 3.8, P = 0.01) than patients without vascular compromise. Patients presenting with vascular injury were also more likely to require fasciotomy [odds ratio (OR): 6.5, confidence interval (CI): 2.3–18.2] and to have a nerve deficit (OR: 16.6, CI: 3.9–70.0), fracture of the distal third of the leg (OR: 2.9, CI: 1.15–7.1) and intracranial hemorrhage (OR: 3.84, CI: 1.1–12.9). After soft tissue reconstruction, patients with arterial injuries had a higher rate of amputation (OR: 8.5, CI: 1.3–53.6) and flap failure requiring a return to the operating room (OR: 4.5, CI: 1.5–13.2). Arterial injury did not correlate with infection or overall complication rate. In conclusion, arterial injuries resulted in significant complications for patients with lower extremity fractures requiring flap coverage, although limb salvage was still effective in most cases.

scholarly journals Vascular Injury and Its Management: Experience at Universal College of Medical Sciences, Bhairahawa, Nepal

2018 ◽  
Vol 5 (1) ◽  
pp. 8-11
Author(s):  
Santosh Shah ◽  
Rajesh Poudel ◽  
Tika Ram Bhandari ◽  
Damber Bikram Shah ◽  
Ghanshyam Sigdel ◽  
...  
Keyword(s):  
Patient Survival ◽  
Vascular Reconstruction ◽  
Vascular Trauma ◽  
Vascular Injuries ◽  
Peripheral Vascular ◽  
Medical Sciences ◽  
Common Life ◽  
Life Threatening ◽  
Male Patients ◽  
Management Experience

INTRODUCTION: Vascular trauma is a common life-threatening injury leading to serious consequences if not timely and efficiently managed. Although they represent less than 3% of all injuries, they deserve special attention because of their severe complications. The aim of this study was to analyze the causes of injury, presentations, surgical (recent) approaches, outcomes, and complications of vascular trauma.  MATERIALS & METHODS: This was a retrospective analysis performed over 6 months. From December 2015 to May 2016, 12 patients were included in the study and were operated upon for peripheral vascular injuries. Diagnosis was made by physical examination as well as with hand Doppler alone or in combination with Doppler scan. Primary vascular repair was carried out whenever possible; however, if it was not possible, an interposition vein graft was placed.  RESULTS:  Of the total 12 patients who sustained major vascular injuries during this period, 9 sustained injuries to the upper limb vessels, 3 had injuries of the lower limb vessels. Trauma with sharp object was the cause in 4 cases, blunt trauma was the cause in 4 cases and rupture pesudoaneurysm was the cause in 2 cases and ruptured aneurysm was the cause in 2 cases. Of the 12 patients, 12 patients were successfully managed by vascular reconstruction without any residual disability. There were 8 male patients (66.67%) and 4 female patients (33.33%), and their ages ranged from 16–60 years (mean 35 years).  CONCLUSION:  Patients who suffer vascular injuries should be transferred to vascular surgery centers as soon as possible. Decisive management of peripheral vascular trauma will maximize patient survival and limb salvage. Priorities must be established in the management of associated injuries, and delay must be avoided when ischemic changes are present.Journal of Universal College of Medical Sciences (2017) Vol.05 No.01 Issue 15, Page: 8-11

scholarly journals Vascular injuries of the upper extremity

2006 ◽  
Vol 5 (4) ◽  
pp. 271-276 ◽  
Author(s):  
Raafat Shalabi ◽  
Yoysifh Al Amri ◽  
Elham khoujah
Keyword(s):  
Limb Salvage ◽  
Traffic Accidents ◽  
Road Traffic ◽  
Vascular Trauma ◽  
Lower Extremity Injury ◽  
Surgical Approaches ◽  
Trauma Patients ◽  
Vascular Injuries ◽  
Peripheral Vascular ◽  
Study Results

OBJECTIVE: This study analyzes the causes of injuries, presentations, surgical approaches, outcome and complications of vascular trauma of the upper limbs, in spite of limited hospital resources. METHODS: A 5-year retrospective analysis. From 01/01/2001 to 31/12/2005, 165 patients were operated for vascular injuries at King Fahd Hospital, Medina, Saudi Arabia. Of all peripheral vascular trauma patients (115), upper limb trauma was present in 58. Diagnosis was made by physical examination and hand-held Doppler alone or in combination with Doppler scan/angiography. Primary vascular repair was performed whenever possible; otherwise, the interposition vein graft was used. Fasciotomy was considered when required. Patients with unsalvageable lower extremity injury requiring primary amputation were excluded from the study. RESULTS: Fifty patients were male (86%) and eight were female (14%), aged between 2.5-55 years (mean 23 years). Mean duration of presentation was 8 h after the injury. The most common etiological factor was road traffic accidents, accounting for 50.5% in the blunt trauma group and 33% among all penetrating and stab wound injuries. Incidence of concomitant orthopedic injuries was very high in our study (51%). The brachial artery was the most affected (51%). Interposition vein grafts were used in 53% of the cases. Limb salvage rate was 100%. CONCLUSION: Patients who suffer vascular injuries of the upper extremities should be transferred to vascular surgery centers as soon as possible. Decisive management of peripheral vascular trauma will maximize patient survival and limb salvage. Priorities must be established in the management of associated injuries, and delay must be avoided when ischemic changes are present.

scholarly journals Life and Limb: Current Concepts in Endovascular Treatment of Extremity Trauma

2021 ◽  
Vol 38 (01) ◽  
pp. 064-074
Author(s):  
John J. Weaver ◽  
Jeffrey F.B. Chick ◽  
Eric J. Monroe ◽  
Guy E. Johnson
Keyword(s):  
Traumatic Injury ◽  
Standard Of Care ◽  
Vascular Trauma ◽  
Iatrogenic Injury ◽  
Vascular Injuries ◽  
Endovascular Management ◽  
Endovascular Techniques ◽  
Arterial Injuries ◽  
Extremity Trauma ◽  
Extremity Injuries

AbstractTraumatic injury is the leading cause of death worldwide in younger patient populations and extremity trauma with associated vascular injury accounts for many trauma-related deaths. Iatrogenic injury is also a common cause of extremity vascular trauma and the incidence of iatrogenic injury will likely increase as endovascular techniques continue to become more ubiquitous. For many vascular injuries involving the extremities, surgical repair is viewed as the standard of care. Historically, endovascular techniques did not play a role in the treatment of these vascular injuries, rather they were utilized only as part of the diagnostic assessment; however, there is an increasing trend toward endovascular management of extremity vascular trauma. No validated, widely implemented algorithm to select patients for endovascular intervention exists. Transcatheter techniques, however, play an important role in the management of these patients. For arterial injuries, embolization can be used to rapidly achieve hemostasis if the vessel can be sacrificed. More advanced endovascular techniques such as stent-graft placement may be best employed in the context of isolated, proximal extremity injuries, although there is increasing literature supporting the use of advanced techniques for more distal arterial injuries. The management of peripheral venous trauma remains controversial; however, there is growing data describing successful endovascular management of some peripheral venous injuries. The purpose of this article is to review extremity vascular trauma, concepts of injury triage, endovascular techniques, and intraprocedural considerations.

scholarly journals Prevalence and outcome of abdominal vascular injury in severe trauma patients based on a TraumaRegister DGU international registry analysis

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Mohammad Esmaeil Barbati ◽  
Frank Hildebrand ◽  
Hagen Andruszkow ◽  
Rolf Lefering ◽  
Michael J. Jacobs ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Vascular Injury ◽  
Arterial Injury ◽  
Severe Trauma ◽  
Trauma Patients ◽  
Vascular Injuries ◽  
Comparable Rate ◽  
Venous Injury ◽  
The Impact ◽  
Abdominal Vascular Injuries

AbstractThis study details the etiology, frequency and effect of abdominal vascular injuries in patients after polytrauma based on a large registry of trauma patients. The impact of arterial, venous and mixed vascular injuries on patients’ outcome was of interest, as in particular the relevance of venous vessel injury may be underestimated and not adequately assessed in literature so far. All patients of TraumaRegister DGU with the following criteria were included: online documentation of european trauma centers, age 16–85 years, presence of abdominal vascular injury and Abbreviated Injury Scale (AIS) ≥ 3. Patients were divided in three groups of: arterial injury only, venous injury only, mixed arterial and venous injuries. Reporting in this study adheres to the STROBE criteria. A total of 2949 patients were included. All types of abdominal vessel injuries were more prevalent in patients with abdominal trauma followed by thoracic trauma. Rate of patients with shock upon admission were the same in patients with arterial injury alone (n = 606, 33%) and venous injury alone (n = 95, 32%). Venous trauma showed higher odds ratio for in-hospital mortality (OR: 1.48; 95% CI 1.10–1.98, p = 0.010). Abdominal arterial and venous injury in patients suffering from severe trauma were associated with a comparable rate of hemodynamic instability at the time of admission. 24 h as well as in-hospital mortality rate were similar in in patients with venous injury and arterial injury. Stable patients suspected of abdominal vascular injuries should be further investigated to exclude or localize the possible subtle venous injury.

CT Angiography Effectively Evaluates Extremity Vascular Trauma

2008 ◽  
Vol 74 (2) ◽  
pp. 103-107 ◽  
Author(s):  
Peter D. Peng ◽  
David A. Spain ◽  
Monika Tataria ◽  
Jeffrey C. Hellinger ◽  
Geoffrey D. Rubin ◽  
...  
Keyword(s):  
Trauma Center ◽  
Imaging Modality ◽  
Arterial Injury ◽  
Computed Tomographic Angiography ◽  
Vascular Trauma ◽  
Vascular Imaging ◽  
Vascular Injuries ◽  
Peripheral Vascular ◽  
Diagnostic Modality ◽  
Level I

Traditionally, conventional arteriography is the diagnostic modality of choice to evaluate for arterial injury. Recent technological advances have resulted in multidetector, fine resolution computed tomographic angiography (CTA). This study examines CTA for evaluation of extremity vascular trauma compared with conventional arteriography. Our hypothesis is that CTA provides accurate and timely diagnosis of peripheral vascular injuries and challenges the gold standard of arteriogram. Traumatic extremity injuries over a 5-year period were identified using a Level I trauma center registry and radiology database. Information collected included patient demographics, mechanism, imaging modality, vascular injuries, management, and follow-up. Two thousand two hundred and fifty-one patients were identified with extremity trauma. Twenty-four patients were taken directly to the operating room for evaluation and management of vascular injuries. Fifty-two underwent vascular imaging. Fourteen patients had conventional arteriograms with 13 abnormal studies: 7 were managed operatively, 2 embolized, and 4 observed. Thirty-eight patients underwent CTA with 17 abnormal scans: 9 were managed operatively, 3 embolized, and 5 observed. There were no false negatives or missed injuries. CTA provides accurate peripheral vascular imaging while additionally offering advantages of noninvasiveness and immediate availability. Secondary to these advantages, CTA has supplanted arteriography for initial radio-graphic evaluation of peripheral vascular injuries at our Level I trauma center. This study supports CTA as an effective alternative to conventional arteriography in assessing extremity vascular trauma.

Factors Contributing to Morbidity after Combined Arterial and Venous Lower Extremity Trauma

2018 ◽  
Vol 84 (7) ◽  
pp. 1217-1222 ◽  
Author(s):  
Nathan R. Manley ◽  
Louis J. Magnotti ◽  
Timothy C. Fabian ◽  
Michael B. Cutshall ◽  
Martin A. Croce ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Arterial Injury ◽  
Vascular Trauma ◽  
Trauma Patients ◽  
Secondary Intervention ◽  
Ischemic Time ◽  
Packed Red Blood Cells ◽  
Venous Injury ◽  
Arterial And Venous Injuries ◽  
The Impact

The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.

Diagnostic workup and endovascular treatment of popliteal artery trauma

VASA ◽  
2019 ◽  
Vol 48 (1) ◽  
pp. 65-71 ◽  
Author(s):  
Cheong J. Lee ◽  
Rory Loo ◽  
Max V. Wohlauer ◽  
Parag J. Patel
Keyword(s):  
Vascular Injury ◽  
Gold Standard ◽  
Imaging Techniques ◽  
Computed Tomographic Angiography ◽  
Vascular Trauma ◽  
Endovascular Techniques ◽  
Computed Tomographic ◽  
Arterial Injuries ◽  
Arterial Trauma ◽  
Peripheral Arterial

Abstract. Although management paradigms for certain arterial trauma, such as aortic injuries, have moved towards an endovascular approach, the application of endovascular techniques for the treatment of peripheral arterial injuries continues to be debated. In the realm of peripheral vascular trauma, popliteal arterial injuries remain a devastating condition with significant rates of limb loss. Expedient management is essential and surgical revascularization has been the gold standard. Initial clinical assessment of vascular injury is aided by readily available imaging techniques such as duplex ultrasonography and high resolution computed tomographic angiography. Conventional catheter based angiography, however, remain the gold standard in the determination of vascular injury. There are limited data examining the outcomes of endovascular techniques to address popliteal arterial injuries. In this review, we examine the imaging modalities and current approaches and data regarding endovascular techniques for the management popliteal arterial trauma.

scholarly journals The impact of an angiosome-targeted revascularization on healing rate, limb salvage and survival in critical limb threatening ischemia

2021 ◽  
pp. 1-9
Author(s):  
Alexander Croo ◽  
Timothy Versyck ◽  
Alec Duinslaeger ◽  
Charlotte Harth ◽  
Frank Vermassen ◽  
...  
Keyword(s):  
Limb Salvage ◽  
Healing Rate ◽  
The Impact
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