Asian Cardiovasc Thorac Ann 2008;16:212-214
© 2008 Asia Publishing EXchange Ltd
Management of Extremity Vascular Trauma: Jammu Experience
Arvind Kohli, MCh,
Gurjit Singh, MCh
Department of Cardiovascular and Thoracic Surgery, Government Medical College, Jammu, India
For reprint information contact: Arvind Kohli, MCh, Tel: 91 94191 83529, Fax: 91 191 258 4247, Email: drarvind7{at}sancharnet.in, 39 B/D Gandhi Nagar, Jammu (J&K), PIN 180004, India.
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ABSTRACT
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Experience in 111 patients treated for extremity vascular trauma between 1995 and 2004 is described. Only 40 (36%) patients presented within 6 hours of sustaining the injury. Penetrating injuries due to stabbing and gunshots were the causes in 65 patients, and blunt trauma in 46. There were associated bone fractures in 73 patients. The brachial artery was the most commonly injured upper limb vessel, whereas the femoral vessels were most often damaged in the lower limb. Surgical procedures consisted of end-to-end anastomosis in 50 patients, an interposition graft in 32, lateral arteriorrhaphy in 14, ligation in 6 and venous patch plasty in 5. Concomitant artery and vein repair was carried out in 12 patients, 6 underwent embolectomy and fasciotomy was performed in 16. Three (2.7%) patients died postoperatively. Good blood flow was obtained after repair in 69 (62%) patients, 29 (26%) had collateral compensation, 5 underwent primary amputation and 5 required secondary amputation. Most vascular injuries due to limb trauma can be managed successfully unless associated with severe damage to bones, nerves or soft tissues.
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INTRODUCTION
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There has been a steady increase in the incidence of vascular injuries all over the world.1 Complex trauma to the extremities can be fatal unless a prompt diagnosis is made and appropriate surgical management applied.2,3 Vascular injury has 2 main consequences: hemorrhage and ischemia; in the words of an anonymous Czech surgeon, "bloody vascular trauma, either it bleeds too much or does not bleed at all". The incidence of vascular trauma is high in our state of Jammu and Kashmir, owing to militancy-related violence, and being hilly terrain, delayed presentation of vascular injuries is quite common. This retrospective study reviewed 9 years’ experience of the management of vascular injuries at our center.
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PATIENTS AND METHODS
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There were 111 patients treated for arterial injuries at the Government Medical College between 1995 and 2004. Of these, 74 (67%) were male and 37 (33%) were female, with an age range of 5–66 years. The greatest proportion (33; 30%) presented in the 4th decade. Associated venous injuries in 12 (11%) patients and nerve injuries in 6 (5%) were repaired concomitantly. The causes and types of vascular injury are given in Table 1
. The brachial artery was the most commonly injured upper limb vessel, whereas in the lower limb, the femoral vessels were most often damaged (Table 2). The initial management was a critical clinical assessment. Evaluation with a Doppler study and arteriography depended on hard signs of vascular injury (observed pulsatile bleeding, visible expanding hematoma, presence of thrill/bruit over the artery, cool pulseless distal extremity) as well as soft signs (history of hemorrhage, decreased pulse compared to contralateral extremity). The injury was assessed by handheld Doppler flowmetry in 74 (65%) patients, and by preoperative angiography in 22 (20%). After acquiring the Doppler device, it was used in all patients; however, the criteria for an arteriogram were a stable patient and surgical exploration in an unstable or bleeding patient. There were 153 surgical procedures performed, as detailed in Table 3. Postoperatively, the patients were put on a strict protocol of anticoagulation. Dextran therapy was also given.
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RESULTS
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Three (2.7%) patients died: 2 in the immediate postoperative period due to exsanguination or secondary coagulopathy, and the other within 2 days due to pulmonary embolism (Table 4). Primary amputation was carried out in 5 patients (3 below and 1 above the knee, and 1 arm). All patients who underwent amputation and the 3 who died had concomitant arterial, venous and bony injuries signifying severe trauma, and they were evaluated using the MESS scoring system.4 Five patients required a secondary lower limb amputation; fasciotomies had been attempted without success in all of them. There was restoration of blood flow with good distal pulse strength after primary surgery in 65 (59%) patients, and this number increased to 69 (62%) after second-look embolectomy or revision of the anastomosis. The other 29 patients had collateral compensation leading to limb salvage after revascularization. Patients who presented within 6 hours of injury had a higher rate of limb salvage than those who presented later (Table 5). Patients with isolated vascular injuries had a higher rate of limb salvage than those with associated bone fractures (Table 5). Two of the 6 patients who underwent nerve repair suffered a permanent nerve deficit; both had penetrating trauma of the axilla with associated brachial plexus injury. All survivors were followed up at 3 weeks, and limb function was rated as good, satisfactory or poor. All salvaged upper limbs had good function at 3 weeks, however, one of the 5 secondary lower limb amputations was performed on the 25th postoperative day because of poor function at follow-up. There was no opportunity for long-term follow-up in most cases.
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DISCUSSION
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Vascular injuries of the extremities remain the most important cause of limb amputation, if not treated early and competently. According to Andrikopoulos and colleagues,3 the amputation rate can be as high as 78%. On the other hand, Razmadze and colleagues5 reported a limb salvage rate of 77.7%. In our series, a limb salvage rate of 88.5% was achieved. The mainstay of diagnosis in our patients was critical clinical assessment, keeping in mind both the hard and soft signs of vascular trauma and the time elapsed since injury. Objective assessment in the form of a Doppler study was used in most patients. Arteriography was carried out in stable patients with associated soft signs of injury, to make a conclusive decision. Anderson and colleagues6 have documented reduced dependency on arteriography for penetrating vascular extremity trauma.
Our protocol for management of vascular trauma depended on whether the injury was associated with bone fracture. Vascular control was achieved first in all 73 patients with associated fractures, followed by fracture fixation, mostly using an external fixator because of its technical simplicity and low infection rate, and finally vessel repair was performed by either end-to-end anastomosis or use of an interposition graft. Autologous vein was the first choice of graft; a prosthetic graft was used only for repair involving the subclavian or external iliac vessels. The most challenging cases were those with concomitant bony, soft tissue and nerve injuries. The decision on amputation was taken on the basis of the MESS value (Mangled Extremity Severity Score), which included the degree of skeletal and soft tissue injury, limb ischemia, shock, age of the patient and time elapsed since injury.4 Patients who underwent infrapopliteal graft repairs, those with delayed presentation in whom the no-reflow phenomenon hampered revascularization, and cases of fulminant infection because of extensive skeletal trauma were considered to be at high risk of secondary amputation.
Unfractionated heparin was used in the early part of this series for postoperative anticoagulation, and low-molecular-weight heparin was used more recently. Low-molecular-weight dextran was given routinely because it was considered to improve the results, especially in cases of delayed presentation. Salemark and colleagues7 found that dextran significantly prolonged bleeding-times in arteries but also significantly improved early patency in both types of vessel. Fasciotomy was performed in 16 patients in whom limb edema might have impeded the restoration of blood flow; however, it was beneficial in only 10. The other 6 had to undergo amputation because of extensive tissue damage combined with bony and vascular injuries, leading to a high MESS score. Fasciotomy has been recommended in several reports.8,9 However, Magee and colleagues10 argued that if early intervention is possible, fasciotomy is hardly necessary, especially in patients with lower limb vascular trauma.
It was concluded from this experience that management of vascular trauma should be undertaken with an aggressive approach applying early intervention and critical clinical assessment, proper diagnosis with a Doppler study and arteriography in difficult cases, followed by good vessel reconstructive techniques. This gave good results in most cases of vascular injury, with a high percentage of limb salvage.
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REFERENCES
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- Bishara RA, Pasch AR, Lim LT, Meyer JP, Schuler JJ, Hall RF Jr, et al. Improved results in the treatment of civilian vascular injuries associated with fractures and dislocations. J Vasc Surg 1986;3:707–11.[Medline]
- Alexander JJ, Piotrowski JJ, Graham D, Franceschi D, King T. Outcome of complex vascular and orthopedic injuries of the lower extremity. Am J Surg 1991;162:111–6.[Medline]
- Andrikopoulos V, Antoniou I, Panoussis P. Arterial injuries associated with lower-extremity fractures. Cardiovasc Surg 1995;3:15–8.[Medline]
- Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score. Clin Orthop Relat Res 1990;256:80–6.[Medline]
- Razmadze A. Vascular injuries of the limbs: a fifteen-year Georgian experience. Eur J Vasc Endovasc Surg 1999;18:235–9.[Medline]
- Anderson RJ, Hobson RW 2nd, Lee BC, Manno J, Swan KG, Padberg FT Jr, et al. Reduced dependency on arteriography for penetrating extremity trauma: influence of wound location and noninvasive vascular studies. J Trauma 1990;30:1059–63.[Medline]
- Salemark L, Knudsen F, Dougan P. The effect of dextran 40 on patency following severe trauma in small arteries and veins. Br J Plast Surg 1995;48:121–6.[Medline]
- Menzoian JO, Doyle JE, Cantelmo NL, LoGerfo FW, Hirsch E. A comprehensive approach to extremity vascular trauma. Arch Surg 1985;120:801–5.[Abstract/Free Full Text]
- Peck JJ, Eastman AB, Bergan JJ, Sedwitz MM, Hoyt DB, McReynolds DG. Popliteal vascular trauma. A community experience. Arch Surg 1990;125:1339–44.[Abstract/Free Full Text]
- Magee TR, Collin J, Hands LJ, Gray DW, Roake J. A ten year audit of surgery for vascular trauma in a British teaching hospital. Eur J Vasc Endovasc Surg 1996;12:424–7.[Medline]
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ABSTRACT
INTRODUCTION
