Revascularization of the limbs using vein grafts after vascular injuries

irip/ Vol. 29, No. 2, pp. 105-108, 1998 8 1998 Else&r Science Ltd. All rights reserved Printed in Great Britain 0020-1383/98 $19.00+0.00 ELSEVIER

PII: SOO20-1383(97)00142-3

Revascularization of the limbs after vascular injuries E. Bastounis’,

E. Pikoulisl,

A. K. LeppSniemi”,

using

P. Michail’

vein grafts

and D. Alexiou’

Yst Department of Surgery, University of Athens Medical School, Athens, Greece and “Department of Surgery, University of Helsinki, Helsinki, Finland

report on 32 pafienfs with z)ascular injury of a Iimb undergoing a total of 41 rez~ascularization procedures with inferposition vein grafts. A combined arterial and venous injury was present in nine cases, an isolated zlenous 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 intraoperatiz)e arteriography in four. AD 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 posfoperative swelling caused by venous insufficiency, one after ligation of an injured axillary uein, and the other one following zlenous thrombosis of a superficial femoral vein repair. It is concluded that reoascularization of arterial and venous injuries of the extremities zoith interposition vein grafts is successful in most cases resulting in low amputation rates, and should be attempted in all major vascular injuries in eliable limbs. 0 1998 Elsezlier Science Ltd. All rights reserved. Wt

Injury,

Vol. 29, No. 2, 105-108,1998

Introduction The current management of vascular injuries of the limbs is based on the experiences gained from treating wounded soldiers with limb threatening blood vessel injuries. Recognizing the risks and and serious consequences of ligation of major arteries of the injured limbs, reperfusion procedures were first attempted during World War II, although the amputation frequency was still about 40 per cent. With increasing use of vascular reconstruction procedures, the amputation frequency fell to 13 per cent in the Korean war, and 12per cent in the Vietnam war’,‘. Autologous vein grafts were used in 31 per cent of the vascular injuries treated by Hughes ef al. in KoreaX.

The purpose of this study was to review our experience in managing civilian vascular injuries of the limbs using autologous vein grafts with special emphasis on the early results and complications associated with the vascular repair.

Material

and methods

During a lkyear period (1980-93), 32 patients were treated with interposition vein grafts for vascular injuries of the limbs. Patients with severe head or chest injuries were excluded. The age of the patients ranged from 16 to 76 years (mean 35); 19 were male. The trauma was blunt in 18 cases (traffic accident in 15, sports injury in three) and penetrating in 14 (stab wound in eight, gunshot wound in six). The patients presented to the emergency department after a delay of 0.5-48 h (mean 5.2) from the injury. The main clinical signs suggesting a vascular injury are listed in Table 1. Specifically, absent or decreased distal pulse was detected in 3/5 patients with arterial injuries of the upper limb, and in 20/23 patients with arterial injuries of the lower limb. All patients underwent a Doppler ultrasound examination with measurements of blood pressure indexes. Preoperative arteriography was performed in 12

Table 1. Presence of clinical signs suggesting vascular injury of a limb. Arterial injuries were present in 5/8 and 23/24 patients with upper and lower limb injuries, respectively Upper limb (n = 8)

Sign Absent or decreased Haemorrhage Pseudoaneurysm Neurological deficit Multiple signs

pulse

3 2 0 3 0

Lower limb (n = 24) 20 12 3 3 16

106

Injury:

Table II. Site of the blood vascular injury of a limb Vessel Axillary Brachial External iliac Common femoral Superficial femoral associated deep femoral Popliteal Anterior tibia1 associated posterior tibia1

vessel injury

in 32 patients

Artery

Vein

1 2

1 2

1

1

Artery

-

with

Associated

injury

Fracture humerus femur tibia and fibula Knee dislocation Nerve injury brachial plexus peroneal nerve

Vol. 29, No. 2,1998

Table IV. Postoperative complications attributed to the vascular injury in 32 patients with vascular injury of a limb

1 1 1 1 5

Arterial thrombosis Venous insufficiency/oedema Soft-tissue infection *Resulted

No. of patients

in amputation

4* 4 in two cases.

-

A

injuries

of the Care of the Injured

Complication

cases, and intraoperative arteriography in four. No venographies were performed pre- or intraoperatively. The locations of the blood vessel injuries are summarized in Table II. A combined arterial and venous injury was present in nine cases, and an isolated venous injury in four. Of the 19 patients with isolated arterial injuries, one patient had a combined anterior and posterior tibia1 artery injury, and another patient a combined superficial and deep femoral artery injury. Among the total of 43 vascular injuries, 24 were partial lacerations, 15 complete transections, and four were intimal lesions. Associated limb injuries are listed in Table III. In patients with a combined arterial and venous injury, both the artery and the vein were repaired with interposition grafts in eight cases. The venous repair was performed first. In one patient with a combined axillary artery and vein injury, the artery was repaired with a vein graft, and the axillary vein was ligated and a fasciotomy was performed. All four isolated venous injuries, And 19 isolated arterial injuries were treated with interposition vein grafts. In one case with a combined deep and superficial femoral artery injury, both arteries were repaired with interposition vein grafts. In one case with a combined anterior and posterior tibia1 artery injury, the former was repaired with a vein graft and the latter one ligated. In most cases, the contralateral greater saphenous vein was used for grafting. In the case with a combined anterior and posterior tibia1 artery injury, a segment of the adjacent greater saphenous vein was used for reconstruction of the the anterior tibia1

Table III. Associated limb vascular injury of a limb

Journal

and vein

-

1;) 6

International

in 32 patients

with

No. of patients 2 5 4 1 3 2

artery. In one case with a combined brachial artery and vein injury, the ipsilateral cephalic vein was used. Fasciotomy was added to the vascular procedure in seven patients. Postoperative anticoagulation was used for 6-12 h in all cases.

Results There were no deaths. Overall, 10 patients (31 per cent) suffered from postoperative complications directly attributed to the vascular repair (Table IV). Four patients had postoperative thrombosis after arterial reconstruction of the lower extremities. Two of them underwent successful early thrombectomies, whereas two cases ended up having below knee amputations 10 and 30 days postoperatively-one with a popliteal artery injury associated with severe soft-tissue and bone injury leading to septic complications, and the other one after an unsuccessful attempt to re-revascularize the limb 5 days after the Two patients suffered from initial operation. postoperative swelling caused by venous insufficiency, one after ligation of an injured axillary vein, and the other one following venous thrombosis of superficial femoral vein repair. All four incidents of postoperative soft-tissue infections in the injured limbs were associated with inadequate debridement of necrotic tissue.

Discussion Vascular trauma occurs in approximately 3 per cent of all civilian and military injuries’, but the incidence of penetrating vascular injuries, especially, seems to be increasine. In this series, 56 per cent of the injuries were caused by blunt trauma, which may reflect the relatively low incidence of gunshot and high incidence of motor vehicle injuries, accidents in Greece. The cornerstone of successful management of vascular injuries is early diagnosis. Clinical evaluation of a patient with vascular injury of a limb includes assessment of colour and temperature of the extremity, and palpation of bruits and distal pulses’. The presence of palpable pulses does not exclude a proximal arterial injury; Drapanas et al. reported that 33 of 128 patients (27.3 per cent) had pulses detected distal to the injury”. In this series, 5/28 patients (18 per cent) with arterial injuries had normal distal pulses.

Bastounis

et al.: Revascularization

Table V. ‘Hard’ injury Hard

and

‘soft’

signs

Active haemorrhage Absent pulse Large expanding haematoma Distal ischemia Bruit or thrill

signs

107

of the limbs suggesting

a VaSCUlar

Soft signs Small haematoma Nerve deficit Decreased distal History of arteral

pulse bleeding

The importance of early diagnosis and revascularization of vascular injury was clearly demonstrated in the Vietnam war’. If the diagnosis of a vascular injury of the lower limb below the adductor foramen was delayed for more than 8 h, the amputation frequency was 86 per cent, but only 13 per cent, if the delay was less than 8 h”‘. In some cases, however, revascularization is worthwhile even after longer delays, as demonstrated by one of our patients who underwent a successful repair of the superficial femoral artery (and fasciotomy) 48 h after the injury. Clinical signs of a vascular injury can be divided into hard and soft signs (Table V). If hard criteria are present, physical examination is the most expeditious and accurate way of determing the presence of an arterial injury, with accuracy exceeding 95 per cent”. In a prospective study of 366 penetrating extremity wounds, 100 per cent of patients with the presence of hard signs had vascular trauma”. Physical examination, however, is inaccurate in excluding a vascular injury”. In one study including 61 patients with normal physical examination, an occult vascular injury was found on subsequent arteriography in 17 cases (28 per cent)“‘. By itself, the clinical diagnosis results in false positive results in 42 per cent and false negative in 20 per cent patients’“. Therefore, angiography is indicated in patients with suspected vascular injuries and no other indications for surgical exploration to exclude occult injuries. In an already diagnosed vascular injury, an angiogram is helpful in locating the site of the injury, and identifying multiple injuries to the same vessel provided that it does not cause long delays. Although in our series all patients underwent a Doppler ultrasound examination with measurements of blood pressure indexes, preoperative arteriography was required in 12 cases, and intraoperative arteriography in four. Major venous injuries are more difficult to diagnose. Haemorrhage, haematoma, or extensive oedema may suggest a venous injury, especially when the presence of arterial trauma, fracture, or extensive soft tissue injury is ruled out. All venous injuries in this series were diagnosed intraoperatively confirming the occult nature, and need for a high index of suspicion in this type of injury. Even if 40-60 per cent of venous bypasses thrombose within 7 days, their repair is useful, because even a short period of patent grafts helps in the development of venous collaterals. In addition, the possibility ’ of recanalization may be important in salvaging a useful, functioning limb’“.

Vascular grafts are used in 20-50 per cent of patients with limb vessel injuries’,‘“,“. The greater saphenous vein is the most widely used graft, although controlled studies comparing other graft sites or materials are rare. The preference of more durable synthetic grafts could be justified in limbs with extensive tissue loss or infection. The incidence of a concomitant nerve injury is about 71 per cent in the upper and 32 per cent in the lower limb’,‘“. In all three of our patients with brachial plexus injury, there was a gradual restoration of movement. In contrast, neither patient with showed any significant peroneal nerve injury improvement in the nerve function.

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15 Meyer J., Walsh J., Schriler J. et al. The early fate of venous

repair

after civilian

vascular

trauma:

a clinical

108

Injury:

International

hemodynamic and venographic assessment. Ann. Surg. 1987; 206: 458-464. 16 Vaughn G. D., Mattox K. L., Feliciano D. V. et al. Surgical experience with expanded polytetrafluoroethylene (PTFE) as a replacement graft for traumatized vessels. J. Trauma 1979; 19: 403-408. 17 Lau J. M., Mattox K. L., Beall A. C. Jr. et al. Autogenous venous interposition grafts in repair of major venous injuries. I. Trauma 1977; 17: 541-546.

Journal

of the Care of the Injured

Vol. 29, No. 2,1998

18 Visser P. A., Hermeck A. S., Pierce G. E. et al. Prognosis of nerve injuries incurred during acute trauma to peripheral arteries. Am. 1. Surg. 1980; 140: 596-599. Paper

accepted

18 August

1997.

Requests for reprints should be addressed to: Elias Bastounis, Antinoros 4 Str., 11634 Athens, Greece.