|Year : 2015 | Volume
| Issue : 3 | Page : 88-95
Good Vascular and Neuromuscular Outcome Even in Delayed Repaired Extremities Vascular Trauma-100 Cases Experience
Anil Sharma, Sunil Dixit, Ram Chandra Sherawat, Mohit Sharma, Sunil Sample, Amit Sharan
Department of CTVS, SMS Medical College, Jaipur, Rajasthan, India
|Date of Web Publication||8-Oct-2015|
Ram Chandra Sherawat
Department of CTVS, SMS Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Objectives: To determine whether delayed vascular repair is feasible or has good results in delayed presented cases of vascular trauma, even after >48 h with ischemic changes in some cases. General literature said that <6 h is appropriate for limbs salvage but our study said that this time limitation can be extended to a greater extent. We have chosen this study because our adverse geographical conditions-desert, hilly and tribal, and roads conditions are not so apt that patients get accessible to surgical intervention in the time limit as stated in the literature. Hence, we consider these patients for surgery even after delayed presentation as limb loss is emotionally/psychological deterrent as well as economic hardship to the patient. To the best of our knowledge, this is the first report on delayed vascular trauma repair from our region of India.
Materials and Methods: Prospective analyses of 100 patients operated for peripheral vascular injuries between August 2011 and April 2014 were done. Diagnosis tools included physical examination, pulse oximeter and handheld Doppler alone or in combination with computed tomography angiography. Primary end-to-end vascular repairs or embolectomies were carried out where possible; if not possible, interposition vein graft was placed. Patients with injury > 48 h, with obviously unsalvageable lower extremity injury requiring primary amputation, severe other body organ injury, on ventilator support, vascular injury below trifurcation of popliteal artery, and having ischemic line of demarcation were excluded from the study.
Results: Of the 100 patients, 86 were males (86%) and 14 (14%) were females (14%), and their age ranging from 5 to 80 years. Mean duration of the presentation of our study cases was 56 hours after the injury. The most common etiological reason was road traffic accidents; nearly 67% of the patients in penetrating trauma group and 58% among blunt traumas. The incidence of concomitant orthopedic injuries was 74%. The most common injured artery was brachial artery 36%, followed by popliteal artery 30% and femoral artery 22%. Surgical intervention included primary repair with end-to-end anastomosis in 45%, and embolectomy in 15%, whereas interposition of vein graft were placed in 40% cases. Final outcome was – 77% had viable and functional limbs and 15% had viable, but nonfunctional limbs and amputation after repair was 8%.
Conclusions: Delayed surgery in vascular injuries has a prognostic value for salvaging the extremity/limb and life of the patient as well as vascular injuries require immediate surgical intervention, regardless of localization but the extent of time limitation for vascular intervention can be widened. Patients suffering from vascular injuries to the extremities should be transferred to vascular surgery centers as soon as possible and consider the patient for surgery even after the delayed presentation.
Keywords: Amputation, delayed vascular repair, popliteal artery, road traffic accident
|How to cite this article:|
Sharma A, Dixit S, Sherawat RC, Sharma M, Sample S, Sharan A. Good Vascular and Neuromuscular Outcome Even in Delayed Repaired Extremities Vascular Trauma-100 Cases Experience. Indian J Vasc Endovasc Surg 2015;2:88-95
|How to cite this URL:|
Sharma A, Dixit S, Sherawat RC, Sharma M, Sample S, Sharan A. Good Vascular and Neuromuscular Outcome Even in Delayed Repaired Extremities Vascular Trauma-100 Cases Experience. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2020 Jan 24];2:88-95. Available from: http://www.indjvascsurg.org/text.asp?2015/2/3/88/166939
| Introduction|| |
This is a prospective study of 100 patients, who underwent delayed operative intervention for vascular trauma under vascular unit II at a tertiary care center over a period of 4 years. In this article, we present the outcomes of delayed vascular repair, the different mechanisms of trauma, arteries involved, associated orthopedic or nerve injuries, types of vascular repair employed, and complications associated with the management and Mangled Extremity Severity Score (MESS).
| Materials and Methods|| |
Between August 2010 and April 2014, 100 patients presented to the casualty with extremity vascular injuries. All patients underwent full physical examination and resuscitation according to the principal of the advanced trauma and life support guidelines of trauma management.
This is a prospective study for a period of 4 years from August 2011 to April 2014 of 100 patients, operated in the Vascular Surgery Department of S. M. S Medical College, Jaipur, Rajasthan, India. This study is purely based on clinical examination and patient desire and satisfaction response.
One hundred patients with delayed presentation of peripheral vascular trauma admitted in the Department of Cardiothoracic and Vascular Surgery, S. M. S. Medical College, Jaipur, Rajasthan, India, whose condition had so far been resistant to treatment, were included in the study.
- Patients with injury <48 h<
- With obviously unsalvageable lower extremity injury requiring primary amputation
- With having other severe body organ injuries
- On ventilator support
- Vascular injury below trifurcation of popliteal artery and
- Having presence of ischemic line of demarcation.
Relevant data from a well-defined Performa were evaluated and analyzed to obtain the results of this study. 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. 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 betadine (povidone iodine) solution. Suitable covers for the defect were given by plastic surgeons with split skin grafting or with the application of flap techniques. Repaired vessels, especially at the anastomotic suture lines and at graft localization, were compulsory covered with muscles and soft tissue to prevent desiccation and disruption. In all patients, management of vascular injuries was done in the operating room under general anesthesia, spinal anesthesia or local nerve blocks using standard sterile/vascular techniques, routine use of intravenous (IV) unfractionated heparin in dose of 100 U/kg just before starting the anastomosis was done, followed by IV sodium bicarbonate 1 mg/kg just before releasing the clamps after anastomoses.
The successful repair was assessed by the return of distal pulses at the end of the operation and was confirmed by pulse oximeter and/or Doppler examination of the affected limb. Although associated nerve injuries were not usually repaired at the time of vascular repair, associated major venous injuries were repaired whenever possible, in an attempt to minimize the development of compartment syndrome. Patients with suspected nerve injuries were assessed late postoperatively by electric stimulation studies. One month after discharge from the hospital, patients were routinely examined in the outpatient department where segmental pressures were measured, and functional status of the limb assessed. All patients received IV, preoperative, prophylactic antibiotics, which were continued postoperatively for 5–7 days unless prolonged use was dictated by the presence of contamination or infection, or else advised by the attending orthopedic/plastic surgeons. All patients also received IV heparin for a period of 3 days postoperatively and were discharged home on oral aspirin 75 mg tablet/day and oral acenocoumarol in a maintenance dose for a period of 6 months.
Diagnosis of arterial injury starts with a suspicion based on the recognized anatomy and mechanism of injury. The six “p"s are the classic clinical signs of ischemia: Pain, pallor (in white skinned individuals), poikilothermia, paresthesia, paralysis, and pulselessness. Initial assessment and care of the patient with peripheral vascular trauma focus on control of external hemorrhage and diagnosis of limb ischemia. In an ischemic extremity, assessing the severity of ischemia and identifying the arterial segment involved are the key considerations. It is extremely important to document the neurologic status of the injured extremity and to assess it for compartment syndrome. In hemodynamically unstable trauma patient, a diminished arterial pulse or a cold and pale extremity is difficult to assess, so the diagnosis of ischemia often depends on comparison to the contralateral extremity. Anyone having these signs has limb threatening ischemia which mandates re-establishment of blood supply to prevent irreversible tissue death. Trauma surgeons have divided the clinical presentation of vascular trauma into hard and soft signs. Hard signs include arterial bleeding, expanding or pulsatile hematoma, bruit, pulse deficit or distal ischemia. Any one of these is a fairly reliable sign of vascular trauma. Soft signs include unexplained shock, history of significant bleeding, small hematoma, adjacent nerve injury, and proximity to major vessel and are less indicative of vascular injury.
Diagnosis of the vascular injury was done mostly by assessing the peripheral circulation with the assistance of hand Doppler and physical examination. The time from injury to presentation in hospital was noted [Table 1]. The numbers of patients diagnosed with only hand Doppler, and clinical examinations were (67%) and peripheral computed tomography arteriography had been done in 33%. The patients consisted of 86 males (86%) and 14 females (14%) with age ranging from 5 to 80 years [Table 2]. According to our study, maximum vascular injuries were seen in third and fourth decades. The lower limb vascular extremity trauma (57%) outnumbered the upper-extremity trauma (43%). The left side was more frequently affected as it was involved in 55 patients (55%), the right side in 40 patients (40%) and bilateral in 5 patients (5%). The mechanism of trauma was penetrating in 54 patients (54%), blunt trauma in 46 patients (46%) [Table 3].
However, road traffic accident (RTA) was the single most common cause of extremity vascular injury in both the penetrating and blunt traumas. Other forms of trauma in a descending order of frequency were fall from height, gunshot and stab injuries. Ninety-eight patients (98%) presented with ischemia, 2 patients with bleeding (2%). The brachial artery was the most frequently affected artery as it was injured in 36 patients (36%), followed by the popliteal artery in 30 patients (30%), and femoral artery in 22 (22%) [Table 4]. Other (12%) involved arteries were posterior and anterior tibialis, radial and ulnar, axillary, and subclavian. The vascular injury was more often associated with orthopedic injuries as both occurred in 74 patients (74%) mostly in the form of fracture. Concomitant vein or nerve injury also occurred in 9 patients (9%). Associated nerve injury occurred in 5 patients (5%), and vein injury in 4 patients (4%). The most common venous injuries were popliteal vein in 3 patients and femoral vein in 1 patient. Nerve injuries were seen commonly with brachial and axillary vessels injuries. Brachial plexus injuries were seen with subclavian and axillary artery injuries. The pathophysiology and pattern of arterial injuries were attributed to complete arterial cut in 60 (60%), partial cut in 9 (9%), and blunt arterial injury without cut in 31 (31%) patients. Interposition vein graft was used in 40 patients (40%). End-to-end anastomosis after the resection of contused segment (<2 cm) was the most frequently used single technique of arterial repair in 45 patients (45%) [Figure 1] and give up to 30° flexion to limb as when required.
Before beginning the repair, a Fogarty thrombectomy was performed on both ends of the injured vessel to remove the intraluminal clot and ascertain the presence of good inflow and backflow. The vessel ends were then irrigated with heparinized saline. Full systemic anticoagulation is often contraindicated in the patient with multiple injuries. Repair of major venous injuries was performed in 4 patients (4%) by lateral venorrhaphy, and end-to-end repair was done. Therapeutic or prophylactic fasciotomy was performed in 11 patients (11%) with lower limb trauma and in 3 patients (3%) with upper-limb trauma. Three patients (3%) required revision procedures such as embolectomies, revision of the anastomosis, and revision of the graft. Of these 3 patients who required revision, 2 were in whom primary end-to-end anastomoses were done as primary procedure and 1 was those in whom interposition vein graft was done. Ten patients (10%) developed wound infections mostly in 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 2 patients (2%). Eight patients (8%) underwent delayed/secondary amputation, 2 underwent below knee, 1 above knee, 2 above ankle, 1 Syme's, 1 below elbow, and 1 above elbow. Three patients had acute renal failure. Two of 3 patients recovered, and 1 patient succumb to death, and this complication was seen in patient with age above 70 years. A limb salvage rate was 92%. Endovascular approach to these patients was not done in any of cases due to unavailability of the facility in our institute.
Consequently, a dramatic increase in amputation rate was not present even in delayed repair., While successful treatment of major arterial injuries may be life-saving as well as allowing limbs salvage and restoration of function, return of function is often related to the presence of concomitant injury to peripheral nerves.
The incidence was maximum in 41–50 years of age, followed by 31–40 year age group.
Maximum incidence is RTA comprising 67% in penetrating group and 58% among blunt trauma.
Lower limb injury is maximum with popliteal artery comprising 30% while femoral artery injury comprises 22%. Incidences of injury to the major vessels are less with subclavian artery (1%) and axillary artery (1%).
Although the time of presentation is more than 56 h postinjury, most of them presented with warm limbs with intact motor sensory power (36%). Cold limb with motor sensory power comprises 24%. But cold limbs without motor sensory power (22%) and pregangrenous changes (18%) were relatively common in presentation.
Of the 100 patients, 86 patients have reappearance of distal pulsation. Skin temperature improvement occurs in 96 patients of 100. Pregangrenous changes were reverted in 10 patients of 18. There is motor sensory improvement in 22 patients of 30 patients.
In 77 patients (77%), the postoperated limbs survived and can be used in normal day-to-day activities. Few of them complained of pain which cannot be explained medically. In 15 cases (15%), the limbs survived with well-perfused distal parts but the motor sensory cannot be maintained properly. So they cannot be used for day-to-day function. Eight cases (8%) ultimately went to amputation on follow-up due to gangrenous changes/infection or due to excessive pain with nonhealing ulcer.
We have good follow-up of these patients through mailing address, E-mail, and cell numbers.
| Discussion|| |
Trauma, both blunt and penetrating, is extremely common in India. As a result, trauma to major vessels, in particular arteries, is a not uncommon clinical occurrence. Some of the pathologic consequences of arterial injury, including bleeding and occlusion with tissue ischemia, are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. Whether delayed repair is good, is the purpose of this review. While it will focus on the treatment of injured arteries, attention will be given to those cases who presented late and who require surgical repair rather than simple amputation. Finally, photographs from the author's personal experience are presented in [Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7], [Table 5], [Table 6], [Table 7].
|Figure 6: Preoperative computed tomography angiogram shows popliteal artery block|
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|Figure 7: Postoperative computed tomography shows normal popliteal artery|
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In the Indian scenario, losing a limb is still a taboo, people want to save their limbs whether it is usable or not and everyone wants to give a chance to surgery before amputation especially the younger victims. The main task of a vascular surgeon is not the surgery alone but the pre- and post-operative care that occupy a major portion of the management regime.
As most of the trauma centers are not properly equipped with vascular surgeons and the public are not aware of the seriousness of vascular injury, precious time is lost in the transit and referral of the patient. Many cases come with neurosensory loss and pregangrenous changes. The likely complications of vascular surgery of the patient going into acute renal failure and multiorgan dysfunction after revascularization were explained. Most of the patients still do not give consent to an amputation and insist on giving a trial of surgery.
Causes of vascular trauma: (a) Penetrating injury (gunshot, stab or shotgun, and IV drug abuse), (b) Blunt injury (joint displacement, bone fracture, and contusion), and (c) Invasive procedure (arteriography, cardiac catheterization, and balloon angioplasty).
Vascular trauma occurs in a limited number of patterns, which are determined primarily by the mechanism of injury. Penetrating trauma typically results in varying degrees of laceration or transection of the vessel. The severed ends of a completely transected artery often retract and undergo spasm with subsequent thrombosis. Therefore, a lacerated or incompletely transected vessel typically bleeds more profusely than a completely transected one.
Blunt trauma results in disruption of the arterial wall, ranging in severity from small intimal flaps to extensive transmural damage with either extravasation or thrombosis. Deceleration injury causes deformation of the arterial wall. Bleeding from a lacerated vessel can be free or contained, the latter leading to pseudoaneurysm formation. An arteriovenous fistula is the result of a traumatic communication between an injured artery and vein.
Limb loss is more likely to result from blunt trauma and high-velocity gunshot injuries, mainly because of the greater damage to bone and soft tissue of the injured extremity. Low-velocity gunshot injuries and stab wounds rarely lead to limb loss.
Despite modern surgical interventions, vascular injuries can still cause extremity loss and even death. According to some authors, amputation rates can even reach 78%. The extremity salvage rate in our study was 92% despite delayed presented cases. According to some authors, approximately 90% of the arterial injuries exist due to penetrating traumas. Blunt traumas compose the remaining 10% ratio  while others reported even over 50%. In our study, blunt traumas are reported as 46%. Road traffic injuries among penetrating traumas were very common in our analysis (67%), exclusively in male patients. This is similar to what was reported from Sweden and to some extent from Thailand, but totally different from that from the USA, where gunshot injury was the primary cause. This may be because existing roads seem to be much narrowed for the amount of people traveling on all sorts of vehicles. Furthermore, women usually do not prefer driving in our region which is reflected in less incidence of vascular trauma in females. Also from our study, it is clear that the incidence of vascular trauma was most common in third and fourth decade as this age group is most commonly involved in outdoor activities in our society. In reports, which were issued from war districts , and in some civil settlement regions, firearm injuries are commonly reported.
Fortunately, the frequency of firearm injury and drug abuse in our region are low. Two factors seem to play a key role in such low firearm injuries in our region. In many events such as weddings, national victories, the use of firearms is a very common issue that causes many accidental events. Secondary cause is a conflict, which occurs between families. Vascular injuries are frequent among young male population,, and male patients compose 86% of the cases. Vessels, nerves, and bones may be injured together due to their close relation anatomically., Bone fractures were also accompanying 74% in our study. The patients with bone fracture, nerve injury, and severe soft tissue injuries are assessed by related disciplines and appropriate interventions were maintained. In our patients with fractures, external fixation is more preferred because of easier application and low-infection risk. Peripheral angiography in vascular injuries is controversial. Some authors are suggesting angiography to every preoperative patient ,,, while others do not. In our institution, we performed angiography in about 33% cases particularly when exact site of injury was not clearly demarcated. Many clinicians report their successful vascular injury results without angiography.,, Since the Doppler ultrasound is 95% sensitive and 97% specific in experienced hands, its use reduces the spent time with respect to angiography.,, Under this circumstance, careful clinical examination can give a reliable diagnosis with the combination of Doppler ultrasound, and measurement of peripheral circulation pressure differences with hand Doppler, if applicable. Our opinion is that peripheral angiography should be applied in cases with multi-level vascular and orthopedic injuries. This method is also a gold standard for the patients who cannot be diagnosed by basic diagnostic tools. Both time and expenses will decline with such basic tools. We follow the diagnostic step-by-step method, and our results were found to be similar to those presented by many authors. It is essential to control the bleeding in vascular injuries, particularly, in the vessels, which have a greater diameter, hence the greater risk of hypovolemic shock. Under these circumstances, severely injured patient should be taken to theater as soon as possible with volume expanding solutions particularly blood. In all the patients with associated orthopedic injuries, the orthopedic surgeon performed reduction and fixation of fracture and/or dislocation prior to the vascular repair.
We believe, as previously suggested by other authors that a well-stabilized skeleton is essential before definitive arterial, and soft tissue repair can be performed, unless the limb is immediately threatened requiring urgent arterial repair. However, this is contrary to the view of Hunt and Kingsley, who suggested that arterial revascularization should be followed by skeleton stabilization and nerve and tendon repair. In arterial injuries, successful results were obtained in arterial reconstruction procedures, which were held <72 h after the event., Almost all of the amputations performed in our patients were late cases that were revascularized after 72 h following the injury. 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 our prospective study, 10 patients developed infection. Amputation was required for the failed procedure in spite of repeated revisions. Early fasciotomy should be considered in most cases of combined extremity trauma. The devastating nature of these injuries, largely due to violent forces, the associated muscle and integument trauma, and the often considerable preoperative and operative warm ischemia time, all favors the development of tissue edema that may progress to cause compartment syndrome that may seriously jeopardize a successful arterial reconstruction. Under these conditions, immediately decompressing fasciotomies should be applied.,,,,,, Although our reported fasciotomy rate of 11% in lower extremities and 3% in upper extremities is in accordance with that reported by most authors at 7–10%,, there was no significant morbidity observed due to this procedure. Therefore, we recommend its liberal use especially in cases of established ischemia, as previously pointed out by Fletcher and Little. Fewer thrombotic events occurred with respect to some publications. We encountered few thrombotic events after arterial reconstructions in 2 patients. Systemic anticoagulation with heparin and infusion of complamina (xanthinol nicotinate) can prevent the propagation of distal small vessel thrombosis. 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. Return of good volume distal pulses indicates successful arterial repair, whereas its absence necessitates immediate corrections. Although etiological factors of vascular injuries differ between publications, penetrating injuries are the most commonly encountered reasons., When cases within our series are inspected, one can see that the first rank of the etiological factors belongs to high-velocity trauma in RTAs, and this effects the treatment method applied, and thus saphenous vein graft interposition is used more frequently during both artery or vein injuries encountered. We usually do not prefer synthetic grafts for arterial reconstructions in trauma patients; however, we recommend its use when the size of venous graft does not match to the injured vessel.
In our study, we found 3 mortalities after surgical repair, and they were seen mostly in elderly age group (70–80 years) and in patients who had limbs discoloration due to ischemia preoperatively. Of these 3 patients, 1 succumbs due to acute renal failure and 2 due to septicemia due to infections.
Surgical techniques – Specific surgical techniques must be mastered if successful vascular repair is to be achieved. These include: Proximal and distal exposure for control with vascular clamps and loops; dissection and isolation of injured vessels including veins; heparinization - Local and/or systemic; use of vascular sutures; magnification loops; assessment of injury - Debridement, contusion, intimal flap, and distal dissection and thrombosis; selective use of shunting; anatomic repairs - With vein patch, end/end anastomosis without tension and reversed autologous vein graft for larger defects; technical details of spatulated ends, running versus interrupted sutures; distal thrombectomy; completion arteriography; fasciotomy and soft tissue coverage. Proper handling of the autogenous vein graft is important. A higher level of technical skill is required in dealing with smaller vessels, and use of magnification loops has much to recommend it. Spasm of the vessels is more frequent and may require topical lidocaine or intra-arterial papaverine.
MESS could predict amputation of severely injured lower limbs, having score of equal or more than 7 with 91% sensitivity and 98% specificity and had a 100% predictable value for amputation. This relatively simple, readily available scoring system of objective criteria was highly accurate in acutely discriminating between limbs that were salvageable and those that were unsalvageable and better managed by primary amputation but our study disprove/invalid it even score >14 we could go for surgery and has good results.
Complications of delayed vascular repair are considerable and occur in up to 30% of cases. The major acute complications are thrombosis, infection, stenosis, and renal failure. Completion angiography, the use of only autologous material for repair and adequate soft tissue coverage are the means to decrease these risks. Delayed complications are discussed as well.
| Conclusions|| |
Delayed surgery in vascular injuries has a prognostic value for saving the extremity and life of the patient. Vascular injuries require immediate surgical intervention, regardless of localization but can extent this up to a large period. Patients who suffer vascular injuries to the extremities should be transferred to vascular surgery centers as soon as possible and consider the patient for surgery even after delayed presentation. Despite the specialized skills required, we believe delayed repair of vascular injuries primarily extremity injuries is feasible and has good vascular and neuromuscular results. Surgeons' skill and experience also have utmost priority to save extremities.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]