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Upper extremity arterial injuries: Factors influencing treatment outcome
Injury, Int. J. Care Injured 40 (2009) 815–819
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Upper extremity arterial injuries: Factors influencing treatment outcome M. Dragas a,*, L. Davidovic a, D. Kostic a, M. Markovic a, S. Pejkic a, T. Ille b, N. Ilic a, I. Koncar a a b
Clinic for Vascular Surgery, Clinical Centre of Serbia, 8 Koste Todorovica St, Belgrade 11000, Serbia Institute for Medical Statistics, Belgrade Medical School, Belgrade, Serbia
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 20 August 2008
Objective: The aim of the study was to identify factors influencing surgical treatment outcome following upper extremity arterial injuries. Methods: This 15-year study (January 1992 to December 2006) included 167 patients with 189 civilian, iatrogenic or military upper extremity arterial injuries requiring surgical intervention. Patient data were prospectively entered into a vascular trauma database and retrospectively analysed. Results: The most frequently damaged vessel was the brachial artery (55% of injuries), followed by the axillary (21.7%), antebrachial (21.2%) and subclavian (2.1%) arteries. Three primary amputations (1.8%) were performed because of extensive soft-tissue destruction and signs of irreversible ischaemia on admission. Seven secondary amputations (4.2%) were due to graft failure, infection, anastomotic disruption or the extent of soft-tissue and nerve damage. Fasciotomy was required in 9.6% of cases. Operative mortality was 2.4% (four deaths). Early graft failure, compartment syndrome, associated skeletal and brachial plexus damage and a military mechanism of injury were found to be significant risk factors for limb loss (p < 0.01). Conclusion: Although careful physical examination should diagnose the majority of upper extremity arterial injuries, angiography is helpful in detailing their site and extent. Prompt reconstruction is essential for optimal results. Nerve trauma is the primary cause of long-term functional disability. ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Arterial injury Upper extremity Limb loss
Introduction
Methods
According to reports from large urban trauma centres, extremity vascular trauma is a problem that has grown over the past few decades.21,12 The reasons for this can be found in the increasing numbers of road traffic accidents, firearm-related urban violence and expansion of interventional cardiovascular diagnostic and therapeutic procedures that use vascular access. In some regions of the world, such as the Balkans, local military conflicts at the end of the 20th century caused epidemics of vascular injuries.8,20 Upper extremity vascular trauma constitutes approximately 40% of all limb vascular injuries, with significant long-term morbidity and invalidity. Considering that most of these trauma victims are young, active men, it is understandable their condition and long-term sequelae present important medical and socio-economic problems.8 The objective of this retrospective 15-year single-centre analysis of upper extremity arterial trauma management was to determine the current patterns of these injuries in our population and to identify factors influencing surgical treatment outcome.
From January 1992 to December 2006, 167 people were treated for upper extremity arterial trauma in the Clinic for Vascular Surgery of the Serbian Clinical Centre. Data were entered into a vascular trauma database and retrospectively analysed. Initial resuscitation and evaluation were performed according to Advanced Trauma Life Support guidelines.1 The diagnosis of upper extremity arterial injury and indications for surgery were based on the findings of clinical examination, Doppler and duplex ultrasonography, angiography and computerised tomography (CT). Casualties with evidence of pulsatile arterial bleeding, persistent haemodynamic instability or severe ischaemia were taken immediately to the operating theatre. The remainder underwent additional imaging procedures (duplex sonography, angiography or CT) to identify the exact location and extent of arterial damage. All confirmed arterial injuries were surgically treated as soon as possible, using standard arterial exposure and repair procedures. Associated skeletal injuries were diagnosed preoperatively. After proximal and distal bleeding control (if required), the limb was stabilised with reduction and internal or external bone fixation, as necessary, before arterial repair. The ischaemia time was shortened by the selective use of arterial shunts.
* Corresponding author. Tel.: +381 64 1110807; fax: +381 11 3065177. E-mail address: [email protected] (M. Dragas). 0020–1383/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2008.08.012
816
M. Dragas et al. / Injury, Int. J. Care Injured 40 (2009) 815–819
Associated venous injuries were repaired if feasible, with simple lateral suture or end-to-end anastomosis, or they were ligated. Primary epineurial suture was performed in cases of associated clean nerve transection. In grossly contaminated wounds with extensive tissue destruction, nerve endings were identified and marked with non-resorbable sutures for delayed repair. Postoperatively the trauma victims were closely monitored by the attending surgeon in the intensive care unit for signs of compartment syndrome or graft failure. Clinical signs of compartment syndrome and elevated tissue pressures (>30 mmHg) were considered indications for open fasciotomy; no prophylactic fasciotomies were carried out. If indicated, occluded grafts were immediately revisited for thrombectomy and repair. Broad-spectrum prophylactic antibiotics (second generation cephalosporins) were discontinued in the absence of signs of infection after 48 h. Statistical analysis was performed with SPSS version 10.0. Chisquared testing, one-way analysis of variance for proportions and Spearman rank correlation were used for univariate risk factor analysis of variables related to limb loss. Stepwise logistic regression analysis identified independent risk factors for limb loss. A p-value <0.05 was considered statistically significant.
Fig. 2. Effects on outcome of delay to operation.
The study population comprised 167 consecutive cases and a total of 189 upper extremity arterial injuries, with an overall mortality of 2.4% (4 deaths). The group included 149 males (89.2%) and 18 females (10.8%), with a mean age of 38.7 (9–77 years), representing 120 (71.8%) civilian, 31 (18.6%) military and 16 (9.6%) iatrogenic injuries. A military mechanism of trauma significantly correlated with increased risk of limb loss after arterial damage (r = 0.201, p < 0.01), as shown in Fig. 1. Overall limb salvage rate was 94% (primary amputations included). Mechanisms of injury included gunshot (18%), explosion (11.4%), stab wounds (22.8%), cut wounds (25.1%) and blunt trauma (22.7%). Most amputations occurred among blunt trauma victims (13.2%), which was not statistically significant (r = 0.027, p > 0.05). The most frequently damaged vessel was the brachial (55%), followed by axillary (21.7%), antebrachial (21.2%) and subclavian arteries (2.1%); 16 people had multiple arterial trauma of the injured limb. Only 25% of our casualties presented in the ‘golden interval’ (within 6 h of trauma); 66% were admitted >12 h from injury and underwent 90% of the amputations (9), as shown in Fig. 2 (r = 0.156, p < 0.05).
In the majority of cases, the correct diagnosis was based on the initial physical examination (combined with arterial pressure index measurement), since more than 80% of the casualties had ‘hard signs’ of arterial injury on admission. The leading symptoms were ischaemia in 57% and arterial haemorrhage in 28% of cases. Angiography was performed in 37% of the study population. Associated injuries of the limb were found in 108 (65%) cases (Fig. 3). Six individuals (3.6%) had polytrauma and required resuscitative thoracic and abdominal surgery before arterial repair. There were 2 (33%) amputations in this group, which was statistically significant (x = 8.267, p < 0.05). Bone fractures and dislocations were present in 45 (27%) cases. The 9 (20%) amputations in this group identified skeletal trauma as an important risk factor for limb loss in our series (r = 0.359, p < 0.01). The distribution of the 91 (55%) neural injuries is presented in Fig. 4; 8 amputations were noted in 32 people with brachial plexus damage (25%), which was found to be a significant risk factor for limb loss (r = 0.390, p < 0.01). Injuries to the other nerves were not found to increase the risk of limb loss (p > 0.05). A total of 29 associated venous injuries were reconstructed with lateral sutures or end-to-end anastomosis, whereas 33 (53%) were ligated, which did not adversely effect the outcome of surgical treatment (r = 0.067, p > 0.05). Three individuals (1.8%) had signs of irreversible limb ischaemia on admission and underwent primary amputation. All three were casualties of military explosion, with massive softtissue destruction and a treatment delay of >12 h. Six people (3.6%)
Fig. 1. Types of arterial injury.
Fig. 3. Types and percentages of associated injuries.
Results
M. Dragas et al. / Injury, Int. J. Care Injured 40 (2009) 815–819
817
Table 1 Risk factors associated with limb loss. Variable
Univariate analysis (p)
Multivariate analysis (p)
War injury Brachial plexus injury Skeletal injury Compartment syndrome Graft failure
<0.01 <0.01 <0.01 <0.01 <0.01
0.011 0.008 0.007 0.004 0.000
Discussion Fig. 4. Associated injuries to peripheral nerves.
had isolated antebrachial artery damage which was ligated without consequences. Reconstructive procedures were performed in 158 (94.6%) cases, accounting for 7 (4.2%) secondary amputations and a limb salvage rate of 95.8% (Fig. 5). Direct reconstruction was possible in 57 (36%) cases, whereas 101 (64%) required grafting. Saphenous vein graft was used in all but 2 cases of subclavian artery trauma, where polytetrafluoroethylene interposition grafting was carried out instead. Injuries which required anatomical or extra-anatomical bypass were associated with increased risk of limb loss (F = 6.568, p < 0.05). Therapeutic upper extremity fasciotomy was performed in 16 (9.6%) cases with impending or established compartment syndrome. There were 4 (25%) amputations in this group (r = 0.261, p < 0.01). Of 13 (8.2%) early graft thromboses, 4 underwent successful repair and had good outcome; 3 grafts remained occluded after several thrombectomy attempts, which resulted in 2 amputations. For six individuals, reoperation was contraindicated because of poor general condition and associated trauma; three had signs of massive infection and soft-tissue necrosis and eventually underwent above-elbow amputation. The remaining three people developed good collateral circulation and were discharged with viable limbs. Early graft occlusion was identified as a significant risk factor for limb loss in our series (r = 9.864, p < 0.01). In all, 158 (94.6%) reconstructions were performed with a patency rate (primary and secondary) of 94.3% and a limb salvage rate of 95.6%. Independent risk factors (p < 0.01) associated with limb loss after upper extremity arterial injury identified by methods of univariate and multivariate statistical analysis are listed in Table 1.
Despite significant advances in surgical technique, evacuation and treatment strategies, the amputation rate for upper extremity war wounds (in our series 16.1%) remains relatively unchanged since the Korean conflict (Table 2).7–9,14,17,26 This is probably the result of several contributing factors. The majority of war injuries are caused by fragmenting explosive devices and high-velocity missiles. Besides the extensive tissue destruction through direct impact, shock waves and cavitary effects, these high-energy projectiles cause a large amount of associated trauma. Additionally, expeditious evacuation, modern body armouring and aggressive resuscitative techniques performed on the battlefield now increase the numbers requiring repair of severe vascular injuries, whereas previously such casualties did not survive to operation.7 Most authors agree that penetrating upper extremity vascular trauma in the civilian setting carries a minimal risk of limb loss (1.8% in our series), as shown in Table 3a.2,4,6,10,35 Blunt trauma in an urban environment is mainly caused by motor vehicle accidents and, in contrast to penetrating injuries, presents a complex problem. Because of the significant masses and high velocities involved, the transfer of energy is great, associated injuries are common and amputation rates approach those of war wounds (in our series 13.2%)3,24,28,31,32 as displayed in Table 3b. Significantly higher amputation rates in cases of combined arterial and skeletal trauma of the upper extremity compared with those of isolated arterial injury are well documented (Table 4).9,20,23,27,30 The reasons for this can be found in delayed diagnosis of vascular damage, higher incidence of graft failure due to the disruption of collaterals, more extensive soft-tissue destruction and possible delay in diagnosis and treatment of compartment syndrome. The order in which these injuries are to be treated remains debatable. Although several authors have demonstrated the safety of arterial repair before orthopaedic procedures,27 we agree with others who think that stability of the damaged extremity is important for successful vascular reconstruction.22 The ischaemia time during the orthopaedic procedure can be effectively shortened by the selective application of arterial shunts.25 Associated nerve injuries have been repeatedly identified as the primary cause of long-term morbidity and functional disability following upper extremity arterial trauma.19 Early surgical repair of these injuries has proved superior to delayed reconstruction. The management of casualties with proximal avulsion brachial Table 2 Outcome of arterial upper extremity war injuries.
Fig. 5. Procedures performed and outcome; pl, plexus; b/p, bypass; amp, amputation.
Series
Author, year
Amputation %
WWII Korea Vietnam Yugoslavia Afghanistan Iraq
DeBakey,9 1946 Hughes,17 1958 Rich,26 1970 Davidovic,8 1997 Fox,14 2005 Clouse,7 2006
37% 13% 13% 14% 18% 9.3%
M. Dragas et al. / Injury, Int. J. Care Injured 40 (2009) 815–819
818
Table 3a Outcome of arterial upper extremity civilian penetrating injuries. Series 4
Borman, 1984 Cikrit,6 1990 Andreev,2 1992 Degiannis,10 1995 Zellweger,35 2004
No of patients
Amputation %
267 101 50 72 124
1.5% 1% 2% 1.4% 0.8%
Table 3b Outcome of arterial upper extremity civilian blunt injuries. Series 31
Sturm, 1980 Thompson,32 1993 Bhargava,3 1996 Rozycki,28 2003 Menakuru,24 2004
No of patients
Amputation %
29 17 54 62 148
17.2% 24% 24% 18% 6%
plexus damage, however, still remains controversial. Poor functional outcome and high incidence of persistent causalgia has led to recommendations for primary amputation of these severely wounded limbs.29 However, in the past decade with the introduction of spinal root reimplantation techniques,5 this has been contradicted by the excellent results of early and aggressive surgical reconstructive treatment published by some authors.5,16 In this series, if repair of associated venous lesions required anything more than lateral suture or end-to-end anastomosis, ligation was our practice so long as compartment syndrome and obvious signs of venous hypertension were absent. We found no additional morbidity among 33 people undergoing venous ligation, which is consistent with other reports.33 Unfortunately, because of inadequate transportation only 25% of our patients were treated within 6 h from injury and 66% presented after >12 h, which adversely affected the results of surgical treatment (p < 0.05). The importance of reducing delay to treatment by means of aero-medical evacuation and temporary arterial shunting has been well documented in many military and civilian publications.7,10,14,17,18,26,35 The preferred method of arterial reconstruction in our series was reversed saphenous vein interposition grafting, performed in 62 (39%) cases. Harvesting an adequate length of the greater saphenous vein is not time consuming and allows adequate debridement of the injured artery and the creation of secure, tension-free anastomosis with the preservation of all collaterals. In our study, trauma requiring complex vascular reconstructions (anatomical or extra-anatomical bypass) was associated with increased risk for limb loss (p < 0.05), which was due to the severity of injuries (83% caused by high energy transfer, with associated injuries in 90% of cases) rather than to the procedure itself. Therapeutic fasciotomies were performed in 16 (9.6%) cases in which clinical signs of compartment syndrome developed. Table 4 Outcome of combined skeletal/vascular upper extremity trauma. Series
Amputation % Isolated arterial injury
Combined injury (artery + bone)
DeBakey9 Spencer30 McNamara23 Romanoff27 Lovric20
42% 15% 2.5% 11% 0%
60% 55% 23% 36% 10%
Although four (25%) amputations were noted in this group (p < 0.01), none was the result of delayed fasciotomy. These findings are similar to those of Dente et al.,11 who reported that 18.5% of amputations were carried out in cases which had required upper extremity fasciotomy in a level I trauma centre. Some authors recommend liberal use of prophylactic fasciotomies, in view of the devastating consequences of developed compartment syndrome.15 Nevertheless, we note that prophylactic fasciotomies can have potentially serious complications,34 although therapeutic fasciotomies can be relatively safe in the presence of clinical signs of impending compartment syndrome and elevated tissue pressures.34,13 Conclusion Injury patterns that involve high energy transfer are associated with increased risk of limb loss. Although careful physical examination is diagnostic for the majority of upper extremity arterial injuries, angiography is helpful in detailing their site and extent. Time-saving by prompt transportation and temporary arterial shunting is essential. Swift and adequate reconstruction of arterial injuries is crucial for optimal results. Efforts should be concentrated on early diagnosis and treatment of complications such as graft failure, development of compartment syndrome and infection. Associated nerve injuries remain the primary cause of long-term functional disability. Conflict of interest This original manuscript we are submitting, including related data, figures and tables, has not been previously published or submitted for publication elsewhere. All authors: Marko Dragas, Lazar Davidovic, Dusan Kostic, Miroslav Markovic, Sinisa Pejkic, Tatjana Ille, Nikola Ilic and Igor Koncar state that no funding, sponsorship or conflict of interest was involved regarding this manuscript. References 1. American College of Surgeons. Advanced trauma life support, 5th ed., Chicago, IL: American College of Surgeons; 1992. 2. Andreev A, Kavrakov J, Penkov P. Management of acute arterial trauma of the upper extremity. Eur J Vasc Surg 1992;6:593–8. 3. Bhargava JS, Kumar R, Singh RB, Makkar A. Civilian vascular trauma: an experience of 54 cases. J Indian Med Assoc 1996;94:47–9. 4. Borman KR, Snyder WH, Weigelt JA. Civilian arterial trauma of the upper extremity: an 11-year experience in 267 patients. Am J Surg 1984;148:796–9. 5. Carlstedt T, Anand P, Hallin R, et al. Spinal nerve root repair and reimplantation of avulsed ventral roots into the spinal cord after brachial plexus injury. J Neurosurg 2000;93:237–47. 6. Cikrit DF, Dalsing MC, Bryant BJ, et al. An experience with upper-extremity vascular trauma. Am J Surg 1990;160:229–33. 7. Clouse WD, Rasmussen TE, Perlstein J, et al. Upper extremity vascular injury: a current in-theater wartime report from operation Iraqi freedom. Ann Vasc Surg 2006;20:429–34. 8. Davidovic L, Lotina S, Kostic D, et al. Vascular trauma in the Yugoslav civil conflict. Eur J Em Surg 1997;20:67–72. 9. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War II: an analysis of 2,471 cases. Ann Surg 1946;123:534–79. 10. Degiannis E, Levy RD, Sliwa K, et al. Penetrating injuries of the brachial artery. Injury 1995;26:249–52. 11. Dente CJ, Feliciano DV, Rozycki GS, et al. A review of upper extremity fasciotomies in a level I trauma center. Am Surg 2004;70:1088–93. 12. Fingehut A, Leppaniemi AK, Androulakis GA, et al. The European experience with vascular injuries. Surg Clin North Am 2002;82:175–88. 13. Fitzgerald AM, Gaston P, Quaba A, McQueen MM. Long term sequelae of fasciotomy wounds. Br J Plast Surg 2000;53:690–3. 14. Fox CJ, Gillespie DL, O’Donnell SD, et al. Contemporary management of wartime vascular trauma. J Vasc Surg 2005;41:638–44. 15. Hofmeister EP, Shin AY. The role of prophylactic fasciotomy and medical treatment in limb ischemia and revascularization, in compartment syndrome and Volkmann’s ischemic contracture. Hand Clin 1998;14:457–65.
M. Dragas et al. / Injury, Int. J. Care Injured 40 (2009) 815–819 16. Hsu SPC, Shih YH, Huang MC, et al. Repair of multiple cervical root avulsion with sural nerve graft. Injury 2004;35:896–907. 17. Hughes CW. Arterial repair during the Korean War. Ann Surg 1958;147:555–61. 18. Humphrey PW, Nichols WK, Silver D. Rural vascular trauma: a twenty-year review. Ann Vasc Surg 1994;8:179–85. 19. Joshi V, Harding GE, Bottoni DA, et al. Determination of functional outcome following upper extremity arterial trauma. Vasc Endovascular Surg 2007;41: 111–4. 20. Lovric Z, Wertheimer B, Candric K, et al. War injuries of major extremity vessels. J Trauma 1994;36:248–51. 21. Mattox KL, Feliciano DV, Burch J, et al. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Ann Surg 1989;209:698–705. 22. McHenry TP, Holcomb JB, Aoki N, et al. Fractures with major vascular injuries from gunshot wounds: implications of surgical sequence. J Trauma 2002;53:717. 23. McNamara JJ, Brief DK, Stremple JF, et al. Management of fractures with associated arterial injury in combat casualties. J Trauma 1973;13:17. 24. Menakuru SR, Behera A, Jindal R, et al. Extremity vascular trauma in civilian population: a seven-year review from North India. Injury 2005;36:400–6. 25. Reber PU, Patel AG, Sapio NL, et al. Selective use of temporary intravascular shunts in coincident vascular and orthopedic upper and lower limb trauma. J Trauma 1999;47:72.
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26. Rich NM, Baugh JH, Hughes CW. Acute arterial injuries in Vietnam: 1,000 cases. J Trauma 1970;10:359–69. 27. Romanoff H, Goldberger S. Combined severe vascular and skeletal trauma: management and results. J Cardiovasc Surg 1979;20:493. 28. Rozycki GS, Tremblay LN, Feliciano DV, McClelland WB. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma 2003;55: 814–24. 29. Shaw AD, Milne AA, Christie J, et al. Vascular trauma of the upper extremity and associated nerve injuries. Injury 1995;26:515–8. 30. Spencer FC, Grewe RF. The management of arterial injuries in battle casualties. Ann Surg 1955;141:304. 31. Sturm JT, Bodily KC, Rothenberger DA, Perry Jr JF. Arterial injuries of the extremities following blunt trauma. J Trauma 1980;20:933–6. 32. Thompson PN, Chang BB, Shah DM, et al. Outcome following blunt vascular trauma of the upper extremity. Cardiovasc Surg 1993;1:248–50. 33. Timberlake G, Kerstein MD. Venous injury: to repair or ligate, the dilemma revisited. Am Surg 1995;61:139–45. 34. Velmahos GC, Theodorou D, Demetriades D, et al. Complications and nonclosure rates of fasciotomy for trauma and related risk factors. World J Surg 1997;21:247–53. 35. Zellweger R, Hess F, Nicol A, et al. An analysis of 124 surgically managed brachial artery injuries. Am J Surg 2004;188:240–5.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Upper extremity arterial injuries: Factors influencing treatment outcome M. Dragas a,*, L. Davidovic a, D. Kostic a, M. Markovic a, S. Pejkic a, T. Ille b, N. Ilic a, I. Koncar a a b
Clinic for Vascular Surgery, Clinical Centre of Serbia, 8 Koste Todorovica St, Belgrade 11000, Serbia Institute for Medical Statistics, Belgrade Medical School, Belgrade, Serbia
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 20 August 2008
Objective: The aim of the study was to identify factors influencing surgical treatment outcome following upper extremity arterial injuries. Methods: This 15-year study (January 1992 to December 2006) included 167 patients with 189 civilian, iatrogenic or military upper extremity arterial injuries requiring surgical intervention. Patient data were prospectively entered into a vascular trauma database and retrospectively analysed. Results: The most frequently damaged vessel was the brachial artery (55% of injuries), followed by the axillary (21.7%), antebrachial (21.2%) and subclavian (2.1%) arteries. Three primary amputations (1.8%) were performed because of extensive soft-tissue destruction and signs of irreversible ischaemia on admission. Seven secondary amputations (4.2%) were due to graft failure, infection, anastomotic disruption or the extent of soft-tissue and nerve damage. Fasciotomy was required in 9.6% of cases. Operative mortality was 2.4% (four deaths). Early graft failure, compartment syndrome, associated skeletal and brachial plexus damage and a military mechanism of injury were found to be significant risk factors for limb loss (p < 0.01). Conclusion: Although careful physical examination should diagnose the majority of upper extremity arterial injuries, angiography is helpful in detailing their site and extent. Prompt reconstruction is essential for optimal results. Nerve trauma is the primary cause of long-term functional disability. ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Arterial injury Upper extremity Limb loss
Introduction
Methods
According to reports from large urban trauma centres, extremity vascular trauma is a problem that has grown over the past few decades.21,12 The reasons for this can be found in the increasing numbers of road traffic accidents, firearm-related urban violence and expansion of interventional cardiovascular diagnostic and therapeutic procedures that use vascular access. In some regions of the world, such as the Balkans, local military conflicts at the end of the 20th century caused epidemics of vascular injuries.8,20 Upper extremity vascular trauma constitutes approximately 40% of all limb vascular injuries, with significant long-term morbidity and invalidity. Considering that most of these trauma victims are young, active men, it is understandable their condition and long-term sequelae present important medical and socio-economic problems.8 The objective of this retrospective 15-year single-centre analysis of upper extremity arterial trauma management was to determine the current patterns of these injuries in our population and to identify factors influencing surgical treatment outcome.
From January 1992 to December 2006, 167 people were treated for upper extremity arterial trauma in the Clinic for Vascular Surgery of the Serbian Clinical Centre. Data were entered into a vascular trauma database and retrospectively analysed. Initial resuscitation and evaluation were performed according to Advanced Trauma Life Support guidelines.1 The diagnosis of upper extremity arterial injury and indications for surgery were based on the findings of clinical examination, Doppler and duplex ultrasonography, angiography and computerised tomography (CT). Casualties with evidence of pulsatile arterial bleeding, persistent haemodynamic instability or severe ischaemia were taken immediately to the operating theatre. The remainder underwent additional imaging procedures (duplex sonography, angiography or CT) to identify the exact location and extent of arterial damage. All confirmed arterial injuries were surgically treated as soon as possible, using standard arterial exposure and repair procedures. Associated skeletal injuries were diagnosed preoperatively. After proximal and distal bleeding control (if required), the limb was stabilised with reduction and internal or external bone fixation, as necessary, before arterial repair. The ischaemia time was shortened by the selective use of arterial shunts.
* Corresponding author. Tel.: +381 64 1110807; fax: +381 11 3065177. E-mail address: [email protected] (M. Dragas). 0020–1383/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2008.08.012
816
M. Dragas et al. / Injury, Int. J. Care Injured 40 (2009) 815–819
Associated venous injuries were repaired if feasible, with simple lateral suture or end-to-end anastomosis, or they were ligated. Primary epineurial suture was performed in cases of associated clean nerve transection. In grossly contaminated wounds with extensive tissue destruction, nerve endings were identified and marked with non-resorbable sutures for delayed repair. Postoperatively the trauma victims were closely monitored by the attending surgeon in the intensive care unit for signs of compartment syndrome or graft failure. Clinical signs of compartment syndrome and elevated tissue pressures (>30 mmHg) were considered indications for open fasciotomy; no prophylactic fasciotomies were carried out. If indicated, occluded grafts were immediately revisited for thrombectomy and repair. Broad-spectrum prophylactic antibiotics (second generation cephalosporins) were discontinued in the absence of signs of infection after 48 h. Statistical analysis was performed with SPSS version 10.0. Chisquared testing, one-way analysis of variance for proportions and Spearman rank correlation were used for univariate risk factor analysis of variables related to limb loss. Stepwise logistic regression analysis identified independent risk factors for limb loss. A p-value <0.05 was considered statistically significant.
Fig. 2. Effects on outcome of delay to operation.
The study population comprised 167 consecutive cases and a total of 189 upper extremity arterial injuries, with an overall mortality of 2.4% (4 deaths). The group included 149 males (89.2%) and 18 females (10.8%), with a mean age of 38.7 (9–77 years), representing 120 (71.8%) civilian, 31 (18.6%) military and 16 (9.6%) iatrogenic injuries. A military mechanism of trauma significantly correlated with increased risk of limb loss after arterial damage (r = 0.201, p < 0.01), as shown in Fig. 1. Overall limb salvage rate was 94% (primary amputations included). Mechanisms of injury included gunshot (18%), explosion (11.4%), stab wounds (22.8%), cut wounds (25.1%) and blunt trauma (22.7%). Most amputations occurred among blunt trauma victims (13.2%), which was not statistically significant (r = 0.027, p > 0.05). The most frequently damaged vessel was the brachial (55%), followed by axillary (21.7%), antebrachial (21.2%) and subclavian arteries (2.1%); 16 people had multiple arterial trauma of the injured limb. Only 25% of our casualties presented in the ‘golden interval’ (within 6 h of trauma); 66% were admitted >12 h from injury and underwent 90% of the amputations (9), as shown in Fig. 2 (r = 0.156, p < 0.05).
In the majority of cases, the correct diagnosis was based on the initial physical examination (combined with arterial pressure index measurement), since more than 80% of the casualties had ‘hard signs’ of arterial injury on admission. The leading symptoms were ischaemia in 57% and arterial haemorrhage in 28% of cases. Angiography was performed in 37% of the study population. Associated injuries of the limb were found in 108 (65%) cases (Fig. 3). Six individuals (3.6%) had polytrauma and required resuscitative thoracic and abdominal surgery before arterial repair. There were 2 (33%) amputations in this group, which was statistically significant (x = 8.267, p < 0.05). Bone fractures and dislocations were present in 45 (27%) cases. The 9 (20%) amputations in this group identified skeletal trauma as an important risk factor for limb loss in our series (r = 0.359, p < 0.01). The distribution of the 91 (55%) neural injuries is presented in Fig. 4; 8 amputations were noted in 32 people with brachial plexus damage (25%), which was found to be a significant risk factor for limb loss (r = 0.390, p < 0.01). Injuries to the other nerves were not found to increase the risk of limb loss (p > 0.05). A total of 29 associated venous injuries were reconstructed with lateral sutures or end-to-end anastomosis, whereas 33 (53%) were ligated, which did not adversely effect the outcome of surgical treatment (r = 0.067, p > 0.05). Three individuals (1.8%) had signs of irreversible limb ischaemia on admission and underwent primary amputation. All three were casualties of military explosion, with massive softtissue destruction and a treatment delay of >12 h. Six people (3.6%)
Fig. 1. Types of arterial injury.
Fig. 3. Types and percentages of associated injuries.
Results
M. Dragas et al. / Injury, Int. J. Care Injured 40 (2009) 815–819
817
Table 1 Risk factors associated with limb loss. Variable
Univariate analysis (p)
Multivariate analysis (p)
War injury Brachial plexus injury Skeletal injury Compartment syndrome Graft failure
<0.01 <0.01 <0.01 <0.01 <0.01
0.011 0.008 0.007 0.004 0.000
Discussion Fig. 4. Associated injuries to peripheral nerves.
had isolated antebrachial artery damage which was ligated without consequences. Reconstructive procedures were performed in 158 (94.6%) cases, accounting for 7 (4.2%) secondary amputations and a limb salvage rate of 95.8% (Fig. 5). Direct reconstruction was possible in 57 (36%) cases, whereas 101 (64%) required grafting. Saphenous vein graft was used in all but 2 cases of subclavian artery trauma, where polytetrafluoroethylene interposition grafting was carried out instead. Injuries which required anatomical or extra-anatomical bypass were associated with increased risk of limb loss (F = 6.568, p < 0.05). Therapeutic upper extremity fasciotomy was performed in 16 (9.6%) cases with impending or established compartment syndrome. There were 4 (25%) amputations in this group (r = 0.261, p < 0.01). Of 13 (8.2%) early graft thromboses, 4 underwent successful repair and had good outcome; 3 grafts remained occluded after several thrombectomy attempts, which resulted in 2 amputations. For six individuals, reoperation was contraindicated because of poor general condition and associated trauma; three had signs of massive infection and soft-tissue necrosis and eventually underwent above-elbow amputation. The remaining three people developed good collateral circulation and were discharged with viable limbs. Early graft occlusion was identified as a significant risk factor for limb loss in our series (r = 9.864, p < 0.01). In all, 158 (94.6%) reconstructions were performed with a patency rate (primary and secondary) of 94.3% and a limb salvage rate of 95.6%. Independent risk factors (p < 0.01) associated with limb loss after upper extremity arterial injury identified by methods of univariate and multivariate statistical analysis are listed in Table 1.
Despite significant advances in surgical technique, evacuation and treatment strategies, the amputation rate for upper extremity war wounds (in our series 16.1%) remains relatively unchanged since the Korean conflict (Table 2).7–9,14,17,26 This is probably the result of several contributing factors. The majority of war injuries are caused by fragmenting explosive devices and high-velocity missiles. Besides the extensive tissue destruction through direct impact, shock waves and cavitary effects, these high-energy projectiles cause a large amount of associated trauma. Additionally, expeditious evacuation, modern body armouring and aggressive resuscitative techniques performed on the battlefield now increase the numbers requiring repair of severe vascular injuries, whereas previously such casualties did not survive to operation.7 Most authors agree that penetrating upper extremity vascular trauma in the civilian setting carries a minimal risk of limb loss (1.8% in our series), as shown in Table 3a.2,4,6,10,35 Blunt trauma in an urban environment is mainly caused by motor vehicle accidents and, in contrast to penetrating injuries, presents a complex problem. Because of the significant masses and high velocities involved, the transfer of energy is great, associated injuries are common and amputation rates approach those of war wounds (in our series 13.2%)3,24,28,31,32 as displayed in Table 3b. Significantly higher amputation rates in cases of combined arterial and skeletal trauma of the upper extremity compared with those of isolated arterial injury are well documented (Table 4).9,20,23,27,30 The reasons for this can be found in delayed diagnosis of vascular damage, higher incidence of graft failure due to the disruption of collaterals, more extensive soft-tissue destruction and possible delay in diagnosis and treatment of compartment syndrome. The order in which these injuries are to be treated remains debatable. Although several authors have demonstrated the safety of arterial repair before orthopaedic procedures,27 we agree with others who think that stability of the damaged extremity is important for successful vascular reconstruction.22 The ischaemia time during the orthopaedic procedure can be effectively shortened by the selective application of arterial shunts.25 Associated nerve injuries have been repeatedly identified as the primary cause of long-term morbidity and functional disability following upper extremity arterial trauma.19 Early surgical repair of these injuries has proved superior to delayed reconstruction. The management of casualties with proximal avulsion brachial Table 2 Outcome of arterial upper extremity war injuries.
Fig. 5. Procedures performed and outcome; pl, plexus; b/p, bypass; amp, amputation.
Series
Author, year
Amputation %
WWII Korea Vietnam Yugoslavia Afghanistan Iraq
DeBakey,9 1946 Hughes,17 1958 Rich,26 1970 Davidovic,8 1997 Fox,14 2005 Clouse,7 2006
37% 13% 13% 14% 18% 9.3%
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818
Table 3a Outcome of arterial upper extremity civilian penetrating injuries. Series 4
Borman, 1984 Cikrit,6 1990 Andreev,2 1992 Degiannis,10 1995 Zellweger,35 2004
No of patients
Amputation %
267 101 50 72 124
1.5% 1% 2% 1.4% 0.8%
Table 3b Outcome of arterial upper extremity civilian blunt injuries. Series 31
Sturm, 1980 Thompson,32 1993 Bhargava,3 1996 Rozycki,28 2003 Menakuru,24 2004
No of patients
Amputation %
29 17 54 62 148
17.2% 24% 24% 18% 6%
plexus damage, however, still remains controversial. Poor functional outcome and high incidence of persistent causalgia has led to recommendations for primary amputation of these severely wounded limbs.29 However, in the past decade with the introduction of spinal root reimplantation techniques,5 this has been contradicted by the excellent results of early and aggressive surgical reconstructive treatment published by some authors.5,16 In this series, if repair of associated venous lesions required anything more than lateral suture or end-to-end anastomosis, ligation was our practice so long as compartment syndrome and obvious signs of venous hypertension were absent. We found no additional morbidity among 33 people undergoing venous ligation, which is consistent with other reports.33 Unfortunately, because of inadequate transportation only 25% of our patients were treated within 6 h from injury and 66% presented after >12 h, which adversely affected the results of surgical treatment (p < 0.05). The importance of reducing delay to treatment by means of aero-medical evacuation and temporary arterial shunting has been well documented in many military and civilian publications.7,10,14,17,18,26,35 The preferred method of arterial reconstruction in our series was reversed saphenous vein interposition grafting, performed in 62 (39%) cases. Harvesting an adequate length of the greater saphenous vein is not time consuming and allows adequate debridement of the injured artery and the creation of secure, tension-free anastomosis with the preservation of all collaterals. In our study, trauma requiring complex vascular reconstructions (anatomical or extra-anatomical bypass) was associated with increased risk for limb loss (p < 0.05), which was due to the severity of injuries (83% caused by high energy transfer, with associated injuries in 90% of cases) rather than to the procedure itself. Therapeutic fasciotomies were performed in 16 (9.6%) cases in which clinical signs of compartment syndrome developed. Table 4 Outcome of combined skeletal/vascular upper extremity trauma. Series
Amputation % Isolated arterial injury
Combined injury (artery + bone)
DeBakey9 Spencer30 McNamara23 Romanoff27 Lovric20
42% 15% 2.5% 11% 0%
60% 55% 23% 36% 10%
Although four (25%) amputations were noted in this group (p < 0.01), none was the result of delayed fasciotomy. These findings are similar to those of Dente et al.,11 who reported that 18.5% of amputations were carried out in cases which had required upper extremity fasciotomy in a level I trauma centre. Some authors recommend liberal use of prophylactic fasciotomies, in view of the devastating consequences of developed compartment syndrome.15 Nevertheless, we note that prophylactic fasciotomies can have potentially serious complications,34 although therapeutic fasciotomies can be relatively safe in the presence of clinical signs of impending compartment syndrome and elevated tissue pressures.34,13 Conclusion Injury patterns that involve high energy transfer are associated with increased risk of limb loss. Although careful physical examination is diagnostic for the majority of upper extremity arterial injuries, angiography is helpful in detailing their site and extent. Time-saving by prompt transportation and temporary arterial shunting is essential. Swift and adequate reconstruction of arterial injuries is crucial for optimal results. Efforts should be concentrated on early diagnosis and treatment of complications such as graft failure, development of compartment syndrome and infection. Associated nerve injuries remain the primary cause of long-term functional disability. Conflict of interest This original manuscript we are submitting, including related data, figures and tables, has not been previously published or submitted for publication elsewhere. All authors: Marko Dragas, Lazar Davidovic, Dusan Kostic, Miroslav Markovic, Sinisa Pejkic, Tatjana Ille, Nikola Ilic and Igor Koncar state that no funding, sponsorship or conflict of interest was involved regarding this manuscript. References 1. American College of Surgeons. Advanced trauma life support, 5th ed., Chicago, IL: American College of Surgeons; 1992. 2. Andreev A, Kavrakov J, Penkov P. Management of acute arterial trauma of the upper extremity. Eur J Vasc Surg 1992;6:593–8. 3. Bhargava JS, Kumar R, Singh RB, Makkar A. Civilian vascular trauma: an experience of 54 cases. J Indian Med Assoc 1996;94:47–9. 4. Borman KR, Snyder WH, Weigelt JA. Civilian arterial trauma of the upper extremity: an 11-year experience in 267 patients. Am J Surg 1984;148:796–9. 5. Carlstedt T, Anand P, Hallin R, et al. Spinal nerve root repair and reimplantation of avulsed ventral roots into the spinal cord after brachial plexus injury. J Neurosurg 2000;93:237–47. 6. Cikrit DF, Dalsing MC, Bryant BJ, et al. An experience with upper-extremity vascular trauma. Am J Surg 1990;160:229–33. 7. Clouse WD, Rasmussen TE, Perlstein J, et al. Upper extremity vascular injury: a current in-theater wartime report from operation Iraqi freedom. Ann Vasc Surg 2006;20:429–34. 8. Davidovic L, Lotina S, Kostic D, et al. Vascular trauma in the Yugoslav civil conflict. Eur J Em Surg 1997;20:67–72. 9. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War II: an analysis of 2,471 cases. Ann Surg 1946;123:534–79. 10. Degiannis E, Levy RD, Sliwa K, et al. Penetrating injuries of the brachial artery. Injury 1995;26:249–52. 11. Dente CJ, Feliciano DV, Rozycki GS, et al. A review of upper extremity fasciotomies in a level I trauma center. Am Surg 2004;70:1088–93. 12. Fingehut A, Leppaniemi AK, Androulakis GA, et al. The European experience with vascular injuries. Surg Clin North Am 2002;82:175–88. 13. Fitzgerald AM, Gaston P, Quaba A, McQueen MM. Long term sequelae of fasciotomy wounds. Br J Plast Surg 2000;53:690–3. 14. Fox CJ, Gillespie DL, O’Donnell SD, et al. Contemporary management of wartime vascular trauma. J Vasc Surg 2005;41:638–44. 15. Hofmeister EP, Shin AY. The role of prophylactic fasciotomy and medical treatment in limb ischemia and revascularization, in compartment syndrome and Volkmann’s ischemic contracture. Hand Clin 1998;14:457–65.
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