Popliteal artery and trifurcation injuries: Is it possible to predict the outcome?

Eur J VascSurg 8, 226-230 (1994)

Popliteal Artery and Trifurcation Injuries" Is it Possible to Predict the Outcome? Miltos K. Lazarides, Dimitrios P. Arvanitis, George C. Kopadis, Spyros S. Tsoupanos and John N. Dayantas Department of Vascular Surgery, Athens General Hospital, Athens 11527, Greece The records of 18 consecutive patients with popliteal and/or trifurcation civilian arterial injuries, who underwent revascularisation procedures during a 5-year period, were retrospectively assessed. All patients were classified using four, previously described, severity scoring systems in an effort to investigate the accuracy of predicting the outcome of this type of injury. Classification of the severity of popliteal artery trauma would be useful (a) for setting objective criteria (if any)for primary amputation and (b) for retrospective assessment of the results in vascular audit. The amputation rate in this group was 28%. Limbs which could not be salvaged were all in the "trifurcation" group and in this subset of patients the amputation rate was 71% (5/7). The scoring index having the higher overall accuracy (94%) was the mangled extremity syndrome index (MESI) with a predictive value for amputation of 83%. The use of these indices as criteria for primary amputation needs further evaluation as no scoring system was specific enough to permit primary amputation on that basis alone. The predictive value for limb salvage was 100%,for all four scoring systems enabling their use in vascular trauma audit. Key Words: Popliteal artery; Arterial injury; Severity scoring indices; Isolated-limb thrombolysis.

Introduction

Patients and Methods

Despite progress in surgical technique popliteal and/ or trifurcation arterial trauma leads to amputation in a significant number of patients, ranging from 0 to 60%. 1'2 This variation is probably the result of differences in the severity of injuries among the various series than due to variation in surgical skill. 3 If amputation rates are compared without estimating the severity of the injuries, some surgeons may appear to perform worse than they actually are and vice versa. The purpose of this study was to investigate the applicability of four, previously designed scoring systems4-7 in an effort to assess the severity of any popliteal and/or trifurcation injury. Prediction of outcome in popliteal artery trauma would be useful for setting objective criteria (if any) for primary amputation in irretrievable extremities, where limb-saving procedures might be dangerous or even lifethreatening.

During a 5-year period (1988-April 1993), 18 consecutive patients with popliteal and/or trifurcation arterial injuries were treated. Our policy was to operate on all patients in w h o m an arterial injury was detected even in cases where limb salvage was initially believed to be unlikely. Therefore no primary amputations were performed. There were 17 men and one woman ranging in age from 13 to 70 years (mean = 30.1, SD = 12.8). The cause of injury was vehicular (car/ motorcycle/pedestrian) accident in 12 cases, shotgun injury in two, stab wounds in three cases and one shrapnel injury due to an explosion. The time between injury and restoration of flow was <6 h in nine patients, 6-12h in eight patients and > 1 2 h in one. Injuries to adjacent structures were common including bone, nerve, vein and soft tissue. Fractures were present in 12 (67%) patients, nerve injuries in nine (50%) and vein injuries in 13 (72%) patients. Severe soft tissue trauma with extensive skin loss was present in nine (50%) patients, blunt trauma in six (33%) and penetrating trauma of moderate severity in three (17%) patients. Remote concomitant injuries

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Popliteal Artery Injury Outcome

occurred in three patients (two craniofacial, one thoracic) a n d one additional patient p r e s e n t e d with myocardial infarction due to preexisting ischaemic heart disease c o m p o u n d e d by h y p o t e n s i o n . The level of the arterial injury was the popliteal artery in 11 patients, the popliteal artery and one distal artery in one patient, the popliteal and two distal arteries in three patients, two distal arteries in one patient and all three distal arteries in two patients. Seven patients had preoperative arteriography. Injuries involving distal arteries (tibioperoneal trunk was considered as "distal") were characterised as trifurcation injuries. The medical records of all the patients were r e v i e w e d and injuries were retrospectively classified using four severity scoring systems, the m a n g l e d extremity s y n d r o m e index (MESI), 4 the limb salvage index (LSI), 5 the predictive salvage index (PSI) 6 a n d the m a n g l e d extremity severity score (MESS). 7

227

cal evidence of increased intracompartmental pressure. An intraluminal (Javid) s h u n t was used in five patients w h o required fracture stabilisation before arterial (and venous) repair. In one patient with poor outflow d u e to small vessel thrombosis distal to an avulsed trifurcation, previous intraoperative thrombolysis using recombinant tissue plasminogen activator (rtPA) was a t t e m p t e d to i m p r o v e the patency of a popliteal-tibial graft w i t h o u t success, s In six cases skin grafts were used for coverage and in two patients associated severe soft tissue injury required cross-leg flap reconstruction. There were no deaths in the peroperative or postoperative period; h o w e v e r five patients required a m p u t a t i o n giving an overall a m p u t a t i o n rate of 28%. All limbs which could not be salvaged were in the "trifurcation" injury group; in the latter subset of patients the a m p u t a t i o n rate was 71% (5/7). Perman e n t m o d e r a t e or major disability in four nona m p u t e e s was also observed as a result of nerve and/ or e x t e n d e d muscle injury. The patients w h o s e legs w e r e a m p u t a t e d were all in the s u b g r o u p with a delay in restoration of flow > 6 h . Four additional limbs in the same s u b g r o u p were salvaged with a delay in restoration of flow 7, 8 a n d 12 h (two cases) respectively. Five out of six patients w h o scored more than 20 in MESI lost their limbs, but no patient w h o scored less than 20 in MESI was a m p u t a t e d (Table 1). Positive predictive value for a MESI score >20 was estim a t e d at 83%. Positive predictive values for an a m p u tation using LSI, PSI a n d MESS w e r e 71%, 63% and 45% respectively (Table 1). Negative predictive value for all indices was 100%, as n o patient was a m p u t a t e d having less than the "critical" score in any system, Cutoff points for all scoring systems were the ones suggested by the original authors 4-7 (Table 1). There

Results Vascular repair was p e r f o r m e d in all 18 patients and the type of arterial repair was autologous vein interposition bypass in 12 patients, e n d - t o - e n d anastomosis in two, lateral arteriorraphy in five and vein patch arterioplasty in one patient (in two patients, two arteries were repaired). The popliteal vein was repaired using s a p h e n o u s vein interposition graft in three patients and PTFE graft in one, in three other patients lateral v e n o r r a p h y was p e r f o r m e d and in six patients ligation of a major distal vein was required. External fixation for skeletal immobilisation was u s e d in 10 patients a n d in two, a combination of internal a n d external fixation was e m p l o y e d . C o m p a r t m e n t fasciotomies w e r e p e r f o r m e d in 13 patients with clini-

Table 1. Application of four different severity scoring indices in 18 consecutive patients with popliteal and/or trifurcation artery trauma

Index

1

MESI Gregory et LSI Russell et PSI Howe et

al. 4

al. 5

al. 6

MESS Johansen et

al. 7

2

3

4

Patients (n = 18) 9 10 11

6

7

8

6 7 22 23 12 (criticalscore 20 or greater)

28

10

42

8

12

1 1 7 6 3 (critical score 6 or greater)

7

2

7

2

4 3 10 10 4 (critical score 8 or greater)

10

4

9

3 5 9 11 5 (criticalscore 7 or greater)

9

5

8

a

5

a

a

12

13

14

15

16

17

18

8

25

16

18

11

21

13

19

3

2

7

3

5

4

6

4

6

4

5

3

10

5

8

5

10

5

8

4

4

2

10

7

7

7

8

7

10

a

a

a: amputation. Eur J Vasc Surg Vol 8, March 1994

228

M.K. Lazarides et al.

was a strong correlation b e t w e e n MESI and LSI scores (correlation coefficient r = 0.873) which were f o u n d to have the higher overall accuracy (94 a n d 89% respectively) in our series. Overall accuracy for PSI and MESS were 83 and 67% respectively.

Discussion

The popliteal artery is the third most c o m m o n location for civilian peripheral artery trauma, and results in a m p u t a t i o n more often than any other arterial injury. 9"1° A m p u t a t i o n rates in various recent reports range from 0 to 60% (Table 2) and possible explanations of this wide variation include: (a) varying severity of the injuries; (b) differences in reporting routines b e t w e e n various reports; (c) the small n u m b e r of patients in most of the series; and (d) different surgical standards. Predicting the o u t c o m e in popliteal artery injuries w o u l d be beneficial in two ways: (a) in setting objective criteria for primary amputation; and (b) c o m p a r i n g the expected and the observed o u t c o m e

w o u l d be helpful in identifying potentially suboptimal results and thus suggest changes in the m e t h o d of treatment. The indications for primary a m p u t a t i o n in popliteal artery trauma continues to be debated and a n u m b e r of criteria have b e e n p r o p o s e d such as: (a) complete disruption of the posterior tibial n e r v e in adults; (b) severe crush injuries with w a r m ischaemia time of more than 12 hours; (c) multi-level o p e n fractures with vascular compromise; and (d) coexistence of other life-threatening injuries precluding prol o n g e d limb-saving procedures. 1, 3, 21,22 Recently several reports have a t t e m p t e d to predict extremity injuries resulting in a m p u t a t i o n with a high degree of sensitivity and specificity. 4-7 This s t u d y applied previously described scores specifically to popliteal arterial injuries, resulting in a positive predictive value (of an amputation) of 83% using MESI, 71% using LSI and 63 or 45% using PSI or MESS respectively. The application of these indices as an indication for primary a m p u t a t i o n using the p r o p o s e d cut-off points, needs further evaluation, as one patient in our series using MESI, two

Table 2. Amputation rates in recent (1982-1992) popliteal artery trauma reports

Number of patients

Amputation rate

Location

Primary amputation

107

13%

P

excluded

Keeley et al. 198311

51

16%

T

excluded

Shah et al. 198512

30

0%

P+T

Lange et al. 19851

23

61%*

P+T

included

Swetnam et al. 198613

36

44%

T

included

Downs et al. 198614

63

29%

P

included

Krige et al. 198715

28

11%

P

included

Whitman et al. 198716

47

19%

P+T

excluded

Wagner et al. 198817

99

15%**

P+T

included

Gnanadev et al. 1988TM

19

0%

P

McNutt et al. 19892o

17

35%**

T

included

Snyder 1982l°

Peck et al. 199021

108

12%

P+T

included

Russel et al. 19915

17

35%

P

included

Russel et al. 19915

29

24%

T

included

Padberg et al. 199219

68

30%

T

included

P: popliteal artery injuries. T: trifurcation injuries. * open trauma only. ** blunt trauma only. Eur J Vasc Surg Vol 8, March 1994

Popliteal Artery Injury Outcome

using LSI, three using PSI and six patients using MESS would have been wrongly amputated (Table 1). The inadequacy of these indices has been stressed in other s e r i e s . 20'21'23'24 We conclude that with the possible exception of the disruption of the posterior tibial nerve in adults, no objective criteria based on any predictive index can be used for primary amputation in popliteal arterial injuries. The accurate prediction of salvage in all limbs using any of these indices (100% negative predictive value for all severity indices) permits the use of these scoring systems in vascular trauma audit. Comparison of expected and observed salvaged limbs in a series, according to one of these scores, permits the assessment of the results of the surgical team. There is considerable controversy rega~rding the benefit of routine angiography in evaluating patients with leg injuries. In our practice patients having any "hard" sign of arterial trauma (i.e. active haemorrhage or unequivocal distal ischaemia) require immediate surgical exploration without previous arteriography. There is evidence that physical examination alone has a positive predictive value of an arterial injury approaching 100%. 25 However preoperative arteriography is indicated for equivocal cases or to localise the extent of clinically apparent arterial trauma. Controversy concerning the sequence of arterial and bone repair has become less important with the introduction of intraluminal shunts in severe arterial trauma. In cases where fracture stabilisation is urgently demanded, the use of shunt has been advocated to reestablish flow, followed by bone stabilisation and then definitive arterial repair. Temporary arterial shunting is also advocated while harvesting the saphenous vein in cases where a > 6 h delay (including transportation) before limb reperfusion is anticipated. If venous trauma is also present, venous shunting will prevent any rise in compartmental pressure following arterial revascularisation. 26 The application of thrombolysis in the presence of arterial trauma has not been fully evaluated. Isolated-limb thrombolysis using clot specific lytic agents (i.e. rtPA! might be of some value in extremity trauma complicated by distal small vessel thrombosis. In summary, recommendations reflecting our experience as well as the current literature in the management of popliteal artery injuries include: (a) arterial repair as a priority and if not feasible, use of intraluminal shunting combined with venous shunting if needed; (b) external rather than internal fracture fixation; (c) aggressive debridement of all devitalised tissue; (d) liberal use of four-compartment

229

fasciotomies, especially if revascularisation is delayed by >6 h; (e) tissue coverage of the vascular repair but avoiding primary skin closure in contaminated wounds; (f) close postoperative observation. The decision to perform a primary amputation should be based on thorough clinical multidisciplinary consideration and no limb should be classified as unsalvageable at first sight.

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24 SCHWABCW. Discussion in JOHANSENK, DAINESM, HOWEYT, HELFET D, HANSEN ST. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990; 30: 572. 25 FRYKBERGER, DENNISJW, BISHOPK, LANEVEL, ALEXANDERRH. The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: results at one year. J Trauma 1991; 31: 502-511. 26 BARROS D'SA AA, MOOREHEAD RJ. Combined arterial and venous intraluminal shunting in major trauma of the lower limb. Eur J Vasc Surg 1989; 3: 577-581.

Accepted 8 October 1993