|Year : 2014 | Volume
| Issue : 1 | Page : 3-7
Management of Vascular Trauma: A Single Center Experience
Dheeraj Sharma, Gaurav Goyal, Abhinav Singh, Anula Sisodia, Sanjeev Devgarha, Rajendra Mohan Mathur
Department of Cardiothoracic and Vascular Surgery, S.M.S. Medical College, Jaipur, Rajasthan, India
|Date of Web Publication||9-Oct-2014|
Department of Cardiothoracic and Vascular Surgery, S.M.S. Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Introduction: This was a retrospective study of the experience with extremity vascular trauma at a tertiary level referral center in North India. The objective of this study was to analyze the cause of injury, surgical approach, outcome, and complications in patients with vascular trauma operated from 2003 to 2013.
Materials and Methods: A retrospective analysis of records of patients who were operated for peripheral vascular injuries in the last 10 years (November 2003 to November 2013) was done. Diagnosis was made by physical examination and hand Doppler alone or in combination with computed tomography angiography. There were 3948 patients; primary vascular repair was carried out where possible; if not possible an interposition vein graft was placed. Patients with isolated venous trauma or unsalvageable lower extremity injury requiring primary amputation were excluded from the study.
Results: Of 3948 patients, 3347 were male (84.78%), and 601 were females (15.22%); their ages range was 5-80 years. Mean duration of the presentation was 11 h after the injury. Road traffic accidents were the most common cause of injury: 67% in those with penetrating trauma and 58% in those with blunt trauma. The incidence of concomitant orthopedic injuries was very high in our patients (73.6%). The most common injured artery was the brachial artery (36.4%), followed by the popliteal (30.4%) and femoral artery (21.7%). Primary repair was performed in 58.3%, interposition vein grafts in 41.4%. Majority of patients had a good outcome-78% had functional, viable limbs. About 13% had a nonfunctional, but viable limb; the secondary amputation rate was 9%.
Conclusion: Early diagnosis and treatment of vascular injuries is crucial for saving the patient's limb and life. Our study is the largest study from a single center in India/South West Asia: Increased awareness is required to ensure that patients identified to have a vascular injury are transferred to a specialist vascular surgery center at the earliest. Vascular injuries require immediate localization and surgical intervention. Prompt and decisive management maximizes patient survival and limb salvage- and as we demonstrate, this is possible even in patients with delayed presentation or when early ischemic changes are present. Protocols must be established in the management of associated injuries to avoid delay.
Keywords: Amputation, repair, trauma, treatment, vascular
|How to cite this article:|
Sharma D, Goyal G, Singh A, Sisodia A, Devgarha S, Mathur RM. Management of Vascular Trauma: A Single Center Experience. Indian J Vasc Endovasc Surg 2014;1:3-7
|How to cite this URL:|
Sharma D, Goyal G, Singh A, Sisodia A, Devgarha S, Mathur RM. Management of Vascular Trauma: A Single Center Experience. Indian J Vasc Endovasc Surg [serial online] 2014 [cited 2019 Jan 20];1:3-7. Available from: http://www.indjvascsurg.org/text.asp?2014/1/1/3/142354
| Introduction|| |
Trauma has emerged as a major public health problem in developing as well as developed countries, and vascular trauma is an important component of this problem. The great majority of these injuries are due to penetrating trauma, with stab, gunshot wounds and road traffic accidents (RTAs) being the most common cause.  However, the mechanism of injury seems to differ between different parts of the world. ,
During the first and second world wars, important knowledge had been gained both in diagnosis and treatment of vascular injuries, but vascular reconstructive methods were mainly introduced during the Korean and Vietnamese wars with the tremendous progress. , Consequently, a dramatic decrease in amputation rate was achieved. ,,, While successful treatment of major arterial injuries may be life-saving as well as allowing limb salvage and restoration of function,  return of function are often related to the presence of concomitant injury to peripheral nerves. 
This was a retrospective study of patients who underwent operative intervention for vascular trauma under one vascular unit in a tertiary care center over a period of 10 years. In this report we present the different mechanisms of trauma, arteries involved, associated orthopedic or nerve injuries and types of vascular repairs performed and complications associated with the management.
| Materials and Methods|| |
During the 10-year period between November 2003 and November 2013, 3948 patients presented with extremity vascular injuries. Patients with isolated venous trauma and patients with obviously unsalvageable lower extremity injury requiring primary amputation were excluded from the study. All patients underwent full physical examination and resuscitation according to the principles of the advanced trauma and life support guidelines of trauma management.
Depending on the mode of presentation, patients were either taken immediately to the operating room for vascular or orthopedic/vascular management or were assessed by preoperative computed tomography (CT) angiography. In all patients with associated orthopedic injury, reduction of joint dislocation or bone fracture and immobilization by internal or external fixation was done before vascular repair unless the extremity was threatened and required immediate revascularization. Patients with more severe soft tissue and muscle injuries were treated with thorough debridement of all grossly nonviable tissue, removal of foreign bodies and copious irrigation with isotonic saline and povidone-iodine solution. Repaired vessels especially at the anastomotic suture lines and at graft localization were compulsorily covered with muscles and soft tissue to prevent desiccation and disruption. Coverage of the repair was performed by Plastic Surgeons with split skin grafting or flaps. In all patients, management of vascular injuries was done only in the operating room under general anesthesia or local nerve blocks. Repairs were performed using standard vascular techniques. We routinely use 5000 U intravenous unfractionated heparin at the start of the anastomosis. Intravenous sodium bicarbonate is administered immediately before restoring the flow after anastomosis (preclamp release).
Successful repair was assessed by the return of distal pulses at the end of the operation and was confirmed by Doppler examination of the affected limb. Although associated nerve injuries were not usually repaired at the time of vascular repair, major associated venous injuries were repaired whenever possible, in an attempt to minimize development of compartment syndrome. After discharge from the hospital, patients were examined in the outpatient department after a month when segmental pressures were measured, and functional status of the limb assessed. All patients received intravenous preoperative prophylactic antibiotics continued postoperatively for 5-7 days. Prolonged antibiotic use was dictated by the presence of contamination or infection, or if advised by the attending orthopedic/plastic surgeons. All patients also received intravenous heparin for 3 days postoperatively and were discharged home on oral aspirin 150 mg and oral acenocumarol 1 mg once daily for 1-month.
| Results|| |
The diagnosis of the vascular injury was established as soon as the patient reached our center by physical examination and assessment of the peripheral circulation with a hand-held Doppler. Clinical history of the six P's: Pulselessness, poikilothermia, pallor, pain, paresthesia or paralysis along with the classical hard and soft signs of vascular injury (arterial bleeding, expanding pulsatile hematoma etc.) were used in the diagnosis. The time interval between beginning of the trauma and arrival to our center was a mean of 11 h. 67% were diagnosed to have vascular compromise based only on clinical/Doppler examination; CT arteriography was required in 33%.
There were 3347 males (84.78%); 601 females (15.22%). The age range was 5-80 years [Table 1]. The maximum numbers of injuries were seen in the third and fourth decades. Trauma to the lower limb (63%) was more common than upper extremity trauma (37%). Involvement of the left side was more frequent-2254 patients (57.1%); injury to the right side was seen in 1410 patients (35.7%). Bilateral trauma occurred in 284 patients (7.2%).
Penetrating trauma was present in 2104 patients (53.3%), blunt trauma in 1844 patients (46.7%) [Table 2].
Overall, RTA was the single most common cause of extremity vascular injury in both the penetrating and blunt trauma. Other forms of trauma in a descending order of frequency were fallen from height, gunshot and stab injuries.
3474 patients (88%) presented with ischemia, 474 patients with bleeding (12%). The brachial artery was the most frequently affected artery as it was injured in 1437 patients (36.4%), followed by the popliteal artery in 1200 patients (30.4%), and femoral artery in 857 (21.7%) [Table 3]. Other involved arteries were posterior and anterior tibials (181), radial and ulnar (211), axillary (43) and subclavian (19). The vascular injury was more often associated with orthopedic injuries as both occurred in 2906 patients (73.6%) mostly in the form of fracture. Fractures were present in 73.6%; concomitant vein or nerve injury occurred in 355 patients (9%). Associated vein injury occurred in 158 patients (4%) - popliteal vein in 109, femoral vein in 49 patients. Nerve injuries were present in 197 patients (5%); commonly with brachial and axillary vessels injuries. The pattern of arterial injury was attributed to complete arterial transection in 2357 (59.7%), partial in 359 (9.1%) and blunt arterial injury/contusion without transection in 1232 (31.2%) patients.
Completion of the arterial repair was preferred over orthopedic fixation when there was advanced ischemia with a threatened limb. End-to-end anastomosis after the resection of contused segment was the most frequently used single technique of arterial repair in 2302 patients (58.3%). Interposition vein graft was the favored conduit for reconstruction: This was used in 1634 patients (41.1%). Prosthetic grafts were used for subclavian artery repair where there was no open wound (12 cases, 0.3%) [Table 4]. A balloon embolectomy catheter was used in all cases to remove thrombus and to relieve arterial spasm.
Repair of major venous injuries was performed in 158 patients (4%) by lateral venorraphy or end to end repair. Therapeutic or prophylactic fasciotomy was performed in 291 patients (11%) with lower limb trauma and in 44 patients (3%) with upper limb trauma. 122 patients (3.1%) required reintervention: Embolectomy/revision of the anastomosis/graft revision (primary operations were the primary end to end repairs in 92, 28 interposition vein grafts, 2 prosthetic grafts).
383 patients (9.7%) developed wound infection-mostly when trauma was in the lower limb. Infected wounds were treated with the appropriate antibiotics according to the cultural sensitivity along with frequent wound dressings. However in spite of this secondary hemorrhage resulted in 83 patients (2.1%). A majority of these blowouts (56 patients) occurred in repair with prosthetic grafts. 343 patients (8.7%) underwent delayed amputation: 163 needed below knee, 41 above knee, 118 below the elbow and 21 above elbow amputation [Table 5].
A limb salvage rate of 91.3% was, therefore, achieved in 3605 out of 3948 patients. Postoperatively, there were 11 deaths; a mortality rate of 0.27%. These were in patients above 70 years presenting with advanced ischemia who underwent revascularization: 8 patients succumbed to acute renal failure and 3 to septicaemia following wound infection.
| Discussion|| |
Successful outcome in vascular trauma depends on early diagnosis and early referral to the specialists with in "Golden Period" of 6 h failing which extremity loss and death can be as high as 78% even when specialist intervention is available.  Approximately 90% of the arterial injuries occur secondarily to penetrating trauma  with blunt injury in 10-50%. , Vascular injury occurring following RTAs is reported from some countries like Sweden and Thailand. This differs totally from that from the USA, war zones , and in some areas of civil unrest,  where gunshot/firearm injury is the primary cause. 
In our study, the extremity salvage rate of 91.3% was acceptable keeping in mind that most patients presented late. Vascular injury is secondary to blunt trauma in male patients secondary to RTAs was the most common presentation. This may be attributed to the poor state of transport infrastructure, poor adherence to traffic rules and a vehicular density, which overloads the traffic control system. The male predominance reflects the socioeconomic and cultural patterns seen in India where fewer women own or drive a vehicle. The frequency of firearm injury at our center is low. Vascular trauma was most common in third and fourth decade: This is the age group is most commonly involved in outdoor economically productive activity.
Most patients present with multiple injuries and in these patients, a protocol based multidisciplinary team approach is essential. Orthopedic fixation should be expedient to prevent undue prolongation of the ischemic time: External fixation is preferred because of easier application and lower infection risk. Some authors recommend peripheral angiography in all preoperative patients; ,,, however, we find that a case based approach is better. A Doppler ultrasound combined with a sound clinical evaluation reduces the time to diagnosis and cost involved in routine angiography. ,, We restricted use of angiography to cases where there were no hard signs, multilevel vascular/orthopedic injuries or then exact site of injury was not clearly demarcated. We follow a diagnostic/management protocol and our results match what is reported from other centers worldwide. ,,,,,,,,
Though it is essential to control the bleeding in vascular injuries, blind application of clamps should never be allowed-compression, and urgent mobilization to the operating room can save lives that would otherwise be at risk from trying to control major vascular bleeding without appropriate anesthesia backup or instrumentation. This also minimizes the risk of occurrence of a superadded infection and subsequent graft blowout. Preprocedure resuscitation with blood and other oxygen is also critical in ensuring that the patient does not go into hypovolemic shock.
Skeletal stabilization is considered essential before definitive arterial, and soft tissue repair can be performed,  unless the limb is immediately threatened requiring urgent arterial repair. Infection is also a major factor, increasing amputation rate after a successful vascular surgery intervention. For this reason, vigorous and appropriate tissue debridement is a very important intervention before and after the revascularization procedure.  In all the patients with associated orthopedic injuries, we follow a policy of the orthopedic surgeon performing reduction and fixation of fracture and/or dislocation prior to the vascular repair. Almost all the amputations in our study were needed in patients who were revascularized after 8 h following the injury. In our study, risk factors for mortality after surgical repair are older age, advanced ischemia, acute renal failure and septicemia.
There were fewer thrombotic events as compared to some publications,  however due to the study being retrospective we cannot comment definitively on this aspect. Wagner et al.  showed a significant impact on limb salvage with systemic heparin when compared to patients without heparin. Some have chosen to use local heparin instillation instead of systemic administration. We use both depending upon the nature of the injury. We encountered few thrombotic events after arterial reconstructions in 122 patients. Systemic anticoagulation with heparin can prevent propagation of distal small vessel thrombosis.
Repair using a vein graft has the best results; we do not prefer synthetic grafts for arterial reconstructions in trauma patients; however, we recommend its use only in certain scenarios (e.g. subclavian injury, gross size mismatch in vein grafts). Return of a good distal pulse indicates a successful repair, whereas its absence necessitates immediate remedial measures.
High-velocity trauma with major soft tissue injury and increased pre/intra-operative warm ischemia time and cause tissue edema with progression to compartment syndrome. This may jeopardize a successful arterial reconstruction. The threshold for performing decompressing fasciotomy should be low as pointed out by Fletcher and Little: ,,,,, Most authors report a fasciotomy rate of 7-10%. , Our fasciotomy rate of 11% in lower extremities and 3% in upper extremities, is similar, addition of a fasciotomy causes no significant morbidity. We recommend liberal use of early fasciotomy, especially in cases of established ischemia.
| Conclusion|| |
Early diagnosis and treatment of vascular injuries is crucial for saving the patient's limb and life. A high index of suspicion is critical for detection and appropriate referral. Our study is largest study from a single center in India/south west Asia: Increased awareness is required to ensure that patients identified to have a vascular injury are transferred to a specialist vascular surgery center at the earliest. Vascular injuries require immediate localization and surgical intervention. Protocols must be established in the management of associated injuries to avoid delay. Meticulous surgical technique, early fasciotomy, aggressive debridement of necrotic tissues with a multidisciplinary team approach is essential. Prompt and decisive management maximizes patient survival and limb salvage- and as we demonstrate, this is possible even in patients with delayed presentation or when early ischemic changes are present.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]