Improved results in the treatment of civilian vascular injuries associated with fractures and dislocations

Patients with vascular injuries associated with fractures or dislocations of the extremities were managed according to a standard protocol, which included the liberal use of preoperative arteriography, early fasciotomy when indicated, individualization of timing and type of orthopedic procedures, arterial reconstruction primarily with interposition reversed saphenous vein grafts, repair of major venous injuries, routine completion arteriography, and regular postoperative monitoring of Doppler-derived ankle/brachial indices. Adherence to these principles led to a limb salvage rate of 97% in 38 patients with such injuries.     

The continuing challenge of popliteal vascular injuries

During a 6 year period, 35 patients with 56 popliteal vascular injuries were treated. Thirty-three arteries and 23 popliteal veins were affected. Fifty-four percent of the patients had both an arterial and a venous injury. Twenty injuries were due to penetrating trauma and 15 injuries to blunt force. An overall amputation rate of 16 percent followed attempts at vascular repair. Blunt injuries were associated with a 30 percent amputation rate, whereas penetrating injuries were associated with only a 5 percent amputation rate. When our results were reviewed and compared with those of others, several factors important for determining the rate of limb salvage in popliteal vascular injuries were noted: (1) early recognition and prompt treatment, (2) absence of blunt injury with attendant soft tissue damage; (3) resection of damaged arterial tissue with end-to-end anastomosis or saphenous vein grafting in conjunction with the liberal employment of local heparin and a Fogarty catheter thrombectomy, (4) repair of concomitant popliteal venous injuries; (5) use of completion arteriography to reveal technical errors amenable to correction at time of operation; and (6) fasciotomy, used liberally but selectively.     

Revascularization of the limbs using vein grafts after vascular injuries

We report on 32 patients with vascular injury of a limb undergoing a total of 41 revascularization procedures with interposition vein grafts. A combined arterial and venous injury was present in nine cases, an isolated venous injury in four, and an isolated arterial injury in 19 cases. Eighteen per cent of patients with arterial injuries had normal distal pulses on initial examination. Preoperative arteriography was performed in 12 cases, and intraoperative arteriography in four. All venous injuries were diagnosed at operation. In most cases, the contralateral greater saphenous vein was used for grafting. Four patients had postoperative thrombosis after arterial reconstruction resulting in below knee amputation in two cases. Two patients suffered from postoperative swelling caused by venous insufficiency, one after ligation of an injured axillary vein, and the other one following venous thrombosis of a superficial femoral vein repair. It is concluded that revascularization of arterial and venous injuries of the extremities with interposition vein grafts is successful in most cases resulting in low amputation rates, and should be attempted in all major vascular injuries in viable limbs.     

Vascular injuries in everyday practice

BACKGROUND: It was the objective of this retrospective study to analyse the causes of injury, surgical approaches, outcome, and complications in patients with vascular trauma and to report our experience with vein homografts for arterial reconstruction in the upper and lower limbs and cervicothoracic region in patients operated on over a period between 1981-2001. PATIENTS: In 128 patients with peripheral arterial injuries the mechanism was direct penetration in 90 cases and blunt injury in 20 cases. In 4 cases a chronic damage (false aneurysm, AV fistula) was observed. Isolated vascular trauma was present in 97 patients (75.8%), 31 cases (24.2%) were aggravated by concomitant bone fractures, and nerve or soft tissue damage. Most frequently injured vessels were the superficial femoral (22.6%), crural (22.6%), and ulnar and radial (13.2%) arteries. 16 patients with penetrating cervicothoracic arterial injuries were registered during this period. 8 patients underwent emergency exploration and 8 patients angiography prior urgent exploration. RESULTS: Saphenous vein interposition grafting was applied with good results in 34 patients, polytetrafluoroethylene and Dacron grafts were used in eight cases, end to end anastomosis in 12 cases, venous bypasses in 5 cases, venous patches in 7 cases. 17 patients underwent arterial repair and 9 venous repair. Vein homografts as an arterial substitute were implanted in 8 patients. Five secondary amputations were performed and five patients died. The limb salvage rate was 95% and the primary patency rate of vein homografts was 75% (excluded primary amputations). The penetrating cervicothoracic injuries were all repaired with improvement in level of consciousness and neurological deficit when present. CONCLUSIONS: Most vascular injuries of the extremities can be managed successfully unless associated with severe concomitant damage of the bones, nerves and soft tissues. In the absence of suitable autologous vein grafts, homografts appear to be an interesting alternative for arterial repair. In penetrating cervicothoracic vascular injuries immediate operative repair offers the best chance of recovery.     

Complex upper extremity vascular trauma in an urban population

Eighty patients with upper extremity vascular trauma were treated during a 4-year period. Of 123 vascular injuries, 95 were arterial, 1 was primary venous, and 27 were associated venous injuries. Causes included penetrating (64%), blunt (27%), and iatrogenic injuries (9%). Arteries injured were ulnar (34), radial (28), brachial (22), subclavian (6), and axillary (5). Numbers of patients with associated injuries were nerve (53), vein (27), bone (23), and soft tissue injuries (60). The most common techniques of arterial repair were end-to-end anastomosis (50), followed by interposition saphenous vein grafting (40). Fasciotomy was used in 36 patients. Two arterial repairs failed during surgery and required revision (1) or thrombectomy (1). One radial artery repair thrombosed during late follow-up, with maintenance of normal extremity perfusion via the ulnar artery. No amputations were required, and 83% of all patients treated for nerve injuries resolved or improved their neurologic deficits. Two or more operations for surgical debridement and subsequent wound closure were required in 35 patients. This study supports an aggressive approach to diagnosis and treatment of complex upper extremity vascular trauma emphasizing meticulous surgical technique, liberal use of fasciotomy, and aggressive intraoperative debridement and repair of associated injuries.     

Vascular trauma of the lower limbs

BACKGROUND: This study was conducted to evaluate the results of treatment of vascular trauma of the lower extremities and those factors associated with limb loss. Design: a retrospective evaluation of a series with lower extremities vascular trauma. Setting: University Hospital. METHODS: Thirty-one patients accounting for 45 vascular lesions of the lower extremities (27 arterial and 18 venous injuries), over a 15 years period ending December 1998. Age, sex, modality of the trauma, site of the lesion and associated skeletal injuries, diagnostic procedures, ischemic time, arterial and venous repair performed were analyzed. RESULTS: Perioperative mortality was 7.4%. For arterial injuries, limb salvage was obtained in 22 patients (81.5%). Five amputations (18.5%), 1 primary and 4 secondary have been performed. Amputation rate was 26.7% for popliteal lesions versus 8.3% for other locations, 40% when a skeletal lesion was associated versus 5.9% for those without such injuries, 37.5% for reverse saphenous vein interpositions versus 5.6% for arterial repair without interposition. CONCLUSIONS: In this study, the factors influencing limb loss in vascular trauma of the lower extremities are popliteal location, the association with skeletal injuries, the need of saphenous vein interposition for arterial repair.     

Noniatrogenic pediatric vascular trauma

Twenty-four noniatrogenic pediatric vascular injuries in 20 patients (75% male; mean age, 14 years) were treated during a 3-year period. Of 18 arterial and six venous injuries, 65% were penetrating and 35% were blunt injuries. Eighty percent of all patients had significant associated injuries that required repair. Angiography was performed in 13 of 20 patients, with four performed during surgery. Repair methods were ligation in two of six venous injuries and three of 18 arterial injuries, primary repair in three of six venous injuries and six of 18 arterial injuries, and autogenous saphenous vein graft in seven of 18 arterial injuries. Exploration and debridement, thrombectomy, and nonoperative management were used in one arterial injury each. Fasciotomy was employed in six of 13 arterial injuries in the extremities. There was one operative death, no reoperations, and no early or late amputations. Mean follow-up of 27 months demonstrated normal palpable and Doppler pulses (by noninvasive testing) distal to all arterial repairs. This study supports an aggressive approach to the diagnosis and treatment of noniatrogenic pediatric vascular trauma, emphasizing the liberal use of fasciotomy and meticulous vascular repair for the successful management of these challenging injuries.     

Popliteal vascular trauma. A community experience

Preventing amputation continues to be a significant challenge when popliteal vascular injuries occur. A retrospective review of cases from the San Diego County (California) Trauma System identified 108 patients with 76 blunt and 32 penetrating arterial injuries. The limb preservation rate was 88%; there were 13 amputations. The fracture-dislocated knee injury and close-range shotgun blasts were particularly limb threatening. In general, the trauma system achieved rapid evaluation of injuries and early operative intervention. All 13 patients who underwent amputations presented with signs of severe ischemia. Concomitant injuries to the popliteal vein, tibial nerves, and soft tissue were significantly more frequent in patients who underwent amputations. The importance of complete fasciotomy for compartment hypertension, early reconstructive management of soft-tissue injuries, and expeditious arterial repair, frequently without preoperative roentgenographic suite arteriography, is emphasized. An aggressive, multidisciplinary approach is required to achieve a functional extremity when popliteal vascular trauma occurs.     

Lower extremity vascular trauma: a comprehensive, aggressive approach

During this study, 25 patients (26 limbs) incurred 37 vascular injuries to the lower extremity. The majority were young males injured by penetrating trauma (84%). There were 25 arterial and 12 venous injuries (two isolated). Sixteen patients had soft-tissue injuries, 12 had fractures, and six had peroneal nerve damage. Twenty-two arterial injuries were repaired, the majority (17) by saphenous vein bypass. Three tibial vessels were ligated. All major venous injuries were repaired. No synthetic material was used. Vascular repair took precedence in all but two cases. After repair, the vascular surgeon assisted with stabilization. Thirteen limbs required fasciotomy; nine required subsequent debridements and later plastic reconstruction. Limb salvage was 96%. More important, 21 patients can ambulate independently on the injured extremity (84%). These results support an aggressive approach to lower extremity vascular trauma with repair of all major arterial and venous injuries in conjunction with aggressive debridement and soft-tissue repair.     

Penetrating femoropopliteal injury during modern warfare: experience of the Balad Vascular Registry

OBJECTIVE: Wounding patterns, methods of repair, and outcomes from femoropopliteal injury have been documented in recent civilian literature. In Operation Iraqi Freedom, as in past conflicts, these injuries continue to be a therapeutic challenge. Therefore, the objective of the current study is to document the pattern of femoropopliteal injuries, methods of repair, and early outcomes during the current military campaign in Iraq. METHODS: From September 1, 2004, to April 30, 2007, all vascular injuries arriving at the Air Force Theater Hospital (the central echelon III medical facility in Iraq; equivalent to a civilian level I trauma center), Balad Air Base, Iraq were prospectively entered into a registry. From this, injuries involving the lower extremities were reviewed. RESULTS: During the 32-month study period, 9289 battle-related casualties were assessed. Of these, 488 (5.3%) were diagnosed with 513 vascular injuries, and 142 casualties sustained 145 injuries in the femoropopliteal domain. Femoral level injury was present in 100, and popliteal level injury occurred in 45. Injuries consisted of 59 isolated arterial, 11 isolated venous, and 75 combined. Fifty-eight casualties were evacuated from forward locations. Temporary arterial shunts were placed in 43, of which 40 (93%) were patent on arrival at our facility. Our group used shunts for early reperfusion before orthopedic fixation, during mass casualty care, or autogenous vein harvest in 11 cases. Arterial repair was accomplished with autogenous vein in 118 (88%), primary means in nine (7%), or ligation in seven (5%). Venous injury was repaired in 62 (72%). Associated fracture was present in 55 (38%), and nerve injury was noted in 19 (13%). Early limb loss due to femoropopliteal penetrating injury occurred in 10 (6.9%). Early mortality was 3.5% (n = 5). CONCLUSIONS: Femoropopliteal vascular injury remains a significant reality in modern warfare. Femoral injuries appear more prevalent than those in the popliteal region. Early results of in-theater repair are comparable with contemporary civilian reports and are improved from the Vietnam era. Rapid evacuation and damage control maneuvers such as temporary shunting and early fasciotomy assist timely definitive repair and appear effective.     

Vascular injury about the knee. Improved outcome

The records of 41 patients with 43 vascular injuries about the knee (34 popliteal artery, five tibial-peroneal trunk, one proximal anterior tibial artery, and three isolated popliteal veins) were analyzed. The etiology of the injuries were gunshot wounds (22), blunt trauma (11), shotgun wounds (4), and stab wounds (4). Associated injuries included fractures (67%), popliteal vein (54%), and nerves (32%). Arterial repairs consisted of primary repair (19), lateral repair (1), saphenous vein grafts (13), and saphenous vein patching (1). Five patients received polytetrafluoroethylene (PTFE) grafts. Fasciotomy was performed in 27 limbs. The associated venous injuries (21) and isolated venous injuries (3) were managed with ligation (14), primary repair (9), and vein patch (1). The amputation rate was 11 per cent for popliteal artery injuries (4/34). No other amputations were required. All four amputations were associated with massive limb injury (3) or diagnostic delay (1). One patient died during hemodialysis for renal failure resulting from prolonged shock and myoglobinuria. Successful management correlates best with prompt repair of both popliteal arterial and venous injuries and early fasciotomy. Vein repair (vs ligation) is associated with better long-term results.     

Management of extremity with combined neurovascular and musculoskeletal trauma

Twenty-five civilians with combined neurovascular and musculo-skeletal trauma to 27 extremities were studied retrospectively. The mechanism of injury was crushing in 16, avulstion in six, and penetrating in three. Autogenous saphenous vein was used to restore arterial circulation in the majority. Nine patients had concurrent repair of venous injuries. Fractures were immobilized by a variety of techniques, the Hoffman external skeletal fixation being preferred. Immediate fasciotomy was performed in five patients and delayed fasciotomy in four. All patients had soft-tissue debridement and initial wound closure with split-skin grafts as biologic dressings. Three immediate amputations were the result of irreversible neurovascular and soft-tissue trauma. Sepsis played a role in three late amputations; delayed primary treatment,, irreversible neurologic injuries and extensive soft-tissue damage contributed. A carefully individualized multidisciplinary approach resulted in salvage of 20 of 27 severely injured extremities.     

Venous injuries of the lower extremities and pelvis: repair versus ligation.

Many surgeons advocate repair of venous injuries to prevent the sequelae of venous ligation. Since 1986, we have treated 74 patients with 79 venous injuries of the lower extremity or pelvis. There were 68 men and six women with a mean age of 29.2 years (range, 16-62 years). The mechanisms of injury were gunshot wounds in 61 patients, stab wounds in 11 patients, and shotgun wounds and blunt trauma in one patient each. Forty-eight injuries were treated by ligation; 31 injuries were treated by repair. Repairs included two interposition grafts, eight end-to-end repairs, 16 venorrhaphies, and five vein patches. In addition, we developed a venous injury staging system (VIS), which ranged from grade I (less than 50% laceration) to grade IV (complete interruption with soft-tissue injury). Patient age, mechanism, location of injury, associated injuries, and incidence of arterial injury were not different between the patients treated by ligation and those treated by repair. Patients treated with venous ligation had a greater VIS (mean, 3.45 vs. 2.0), a greater incidence of shock (71% vs. 39%), and higher transfusion requirements (9.23 vs. 4.82 units). Postoperative morbidity rates were identical, however. There was no increase in the need for fasciotomy in patients treated with venous ligation. Eighty-six percent of the patients treated by ligation were totally free of edema at discharge. The others had only mild edema that did not interfere with daily activities at discharge and follow-up. Ligation is a safe alternative to repair in patients with injuries to the lower extremities or pelvis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Peripheral vascular injuries associated with falls from heights

Peripheral vascular injuries associated with falls from heights are uncommon. We report our 15-year experience with ten such injuries in 230 patients who jumped or fell from heights of at least 3 stories. These injuries occurred in seven patients and included four popliteal artery thromboses or disruptions, two popliteal vein disruptions, one traumatic tibial arteriovenous fistula, one subclavian artery pseudoaneurysm, one radial artery transection, and one lacerated medial circumflex artery. Although the mechanism of injury is multifactorial, all were associated with significant orthopedic trauma. Early recognition of vascular injuries, minimization of ischemic time, completion arteriography, venous repair, and liberal use of fasciotomy are emphasized to maximize limb salvage.     

Management of traumatic popliteal vein injuries

PurposeThe aim of this study was to evaluate different repair methods of popliteal vein injuries, and to assess the relationship between early patency and surgical outcome.MethodsThirty patients with popliteal vein injuries underwent surgical repair procedure at our hospital from March 2000 to April 2010. Patients who were haemodynamically unstable and those with massive bleeding from limb wounds were taken directly to the operating room. Stable patients underwent preoperative colour-flow duplex ultrasonography (CFDU).ResultsOur study group consisted of 26 males and 4 females, ranging in age from 17 to 60 years with a mean age of 25.3 ± 5.9 years. The mechanism of trauma was penetrating in 27 patients and blunt in the remaining 3 patients. Treatment included primary venous repair in 11 cases, end-to-end anastomosis in 8, interposition vein graft in 10, and interposition polytetrafluoroethylene (PTFE) graft in 1. There were 26 patients with associated arterial injury, of which 4 cases had primary repair, 9 had end-to-end anastomosis, 11 had saphenous vein graft interposition, and 2 had PTFE graft interposition. Associated bone fracture was seen in 6 patients. There were no deaths. One patient required a below-knee amputation. Postoperative CFDU revealed thrombosed venous repair in 7 cases without any sequelae.ConclusionPopliteal venous injuries can be repaired with minimal downside and a good early patency rate. Additionally, transient venous patency allows for establishment of venous and lymphatic collateralisation. Alternatively, venous ligation should be considered only in unstable patients who refuse blood transfusion (Jehovah's witnesses). In these victims, adjuvant management may be required such as the use of fasciotomy and anticoagulation treatment.     

Vascular trauma in infants and children.

A 20-year retrospective evaluation of vascular trauma in infants and children was undertaken. The study included 53 cases of blunt and penetrating vascular injuries in pediatric patients. There were 36 males and 17 females ranging in age from 24 days to 14 years (average, 10 years). The most frequently encountered sites of arterial trauma were the brachial or superficial femoral artery, and of venous trauma the inferior vena cava. Any patient presenting to the Emergency Center with an injury in proximity to a major vessel, hematoma formation, audible bruit, or palpable thrill underwent prompt arteriography or immediate operative exploration of the injury sit. All patients in the series were managed operatively. There were 41 major arterial and 32 major venous injuries. No patient required a major amputation. Most injuries were repaired by primary closure or segmental resection and end-to-end anastomosis; interposition vein grafts and substitute conduits were used in four patients with more extensive injuries. A 13% operative mortality was encountered: the most frequent cause of death was intraoperative exsanguinating hemorrhage. The triad for successful management of vascular trauma in pediatric patients is: 1) a high index of suspicion, 2) performance of aggressive diagnostic studies when indicated, and 3) prompt surgical intervention.     

Popliteal artery trauma: a high risk injury

The clinical presentation and management of 28 popliteal artery injuries following penetrating and blunt trauma during a 6 year period is reviewed. Clinical and Doppler evaluation identified an arterial injury in 24 (85 per cent) patients. In eight (29 per cent) patients with arteriovenous fistulae or false aneurysms, pedal pulses were palpable during initial assessment. Three (10.7 per cent) patients had limb amputation attributable to delayed vascular repair, crush injury and sepsis. End-to-end arterial repair following blunt trauma resulted in early failure with thrombosis in two patients. Autogenous vein grafting was used in 12 patients and is advocated in all blunt popliteal arterial injuries. Routine repair of associated venous injuries and liberal criteria for early fasciotomy were used. Exoskeletal fixation or skeletal traction for compound and comminuted fractures is recommended for simplicity of application and wound management. The significant functional orthopaedic disability following blunt arterial trauma at the knee is emphasized.     

Isolated iliac vascular injuries and outcome of repair versus ligation of isolated iliac vein injury

Objective

The incidence of morbidity and mortality for iliac vascular injuries in the literature are likely overestimated owing to associated injuries. Data for isolated iliac vascular injuries are very limited. No large studies have reported the incidence of morbidity for repair versus ligation of isolated iliac vein injuries.

Noninvasive diagnosis of vascular trauma by duplex ultrasonography

Duplex ultrasonography was used prospectively in the initial evaluation of 198 patients with 319 potential vascular injuries of the neck and extremities. Patients who were unstable or who had obvious arterial trauma were excluded. Injury was caused by gunshot in 104 (53%), blunt trauma in 42 (21%), stab wound in 34 (17%), and shotgun in 18 (9%). Duplex ultrasonography correctly characterized and localized vascular injuries in 23 patients: arterial disruptions (13), intimal flaps (4), acute pseudoaneurysms (3), arteriovenous fistulas (2), and shotgun pellet arteriopuncture (1). Nineteen other patients had vasospasm (13) or external compression (6) without evidence of intrinsic vessel injury, these 42 studies had true-positive results. Twenty patients underwent arterial repair (13 on the basis of duplex ultrasonography alone), one had primary amputation, three required fasciotomy, and 18 were observed. Two patients with false-negative results had minor shotgun pellet arteriopunctures that were missed by duplex ultrasonography, but neither needed repair. One hundred fifty-three patients had true-negative results on duplex ultrasonography: all clinically had only proximity injuries and easily palpable distal pulses. The result of one duplex ultrasonography study was found to be false-positive on arteriography. The sensitivity of duplex ultrasonography was 95%, the specificity was 99%, and the overall accuracy was 98%. These results closely approximate those reported with the use of exclusion arteriography in the evaluation of similar vascular trauma patients. Furthermore, duplex ultrasonography has no interventional risks and is more cost-effective for screening such injuries than arteriography or exploration. Duplex ultrasonography is a reliable method of diagnosis in patients with potential peripheral vascular injuries.     

Popliteal artery injury in Kuwait

While there is an abundant literature on popliteal artery injury secondary to penetrating trauma, few reports deal with popliteal artery injury caused by severe blunt trauma with or without fracture. Eight cases of popliteal artery injury are described. Seven of the patients had sustained blunt trauma, usually resulting also in damage to bone and soft tissues. The popliteal vein was involved in five of the injuries. The time lag between causal trauma and vascular repair averaged 25 hours. Delay was due mainly to failure to consult the vascular surgeon at an early stage. Leg amputation was necessary in two cases. Two patients died. The importance of early recognition of the vascular injury and appropriate surgical measures was illustrated in this small series of patients from a developing Middle Eastern country. Adequate fasciotomy, venous repair, use of intraoperative Doppler and repeated postoperative débridement are discussed in connection with management.