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ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 115-120

Study of risk factors affecting the limb salvage in patients with lower extremity arterial trauma


Department of Vascular and Endovascular Surgery, Ganga Ram Institute of Postgraduate Medical Education and Research, New Delhi, India

Date of Web Publication6-Jun-2019

Correspondence Address:
Dr. Mukesh Kumar Garg
Department of Vascular and Endovascular Surgery, Ganga Ram Institute of Postgraduate Medical Education and Research, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_80_18

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  Abstract 


Background: Vascular injury in extremity is a complication of both blunt and penetrating trauma. In Indian scenario, patients generally present late to the tertiary care center with mangled extremity for treatment. The aim of the study is to assess the risk factors affecting the outcome in the management of patients with lower extremity arterial trauma. Materials and Methods: A single-center, observational study was conducted at Sir Ganga Ram Hospital, New Delhi, from January 2013 to June 2017. Sixty patients of lower extremity arterial trauma who underwent revascularization were included and followed up for 6 months. All the risk factors (mode/mechanism of injury, time since injury, compartment syndrome, mangled extremity severity score [MESS], etc.,) and limb salvage were assessed at 6 months. Statistical analysis was performed using Chi-square test and Fisher's exact test. Results: Majority of the patients presented late (6–24 h) of injury and had high mean MESS (7.85). The most common mechanism of injury was blunt trauma (83.3%), and popliteal artery (72%) was the most commonly injured artery. Limb salvage was achieved in 75% of the patients. Time since injury and MESS score affected the limb salvage significantly. On multivariate analysis, MESS score was the single independent factor which affected the limb salvage (95% confidence interval, 0.231–0.769, P = 0.005). Conclusions: MESS is the most important predictors for limb salvage. Multidisciplinary team approach with timely diagnosis and immediate repair is the key to the ultimate goal of functional limb salvage.

Keywords: Limb salvage, mangled extremity severity score, vascular trauma


How to cite this article:
Garg MK, Bedi VS, Yadav A, Agarwal S, Satwik A, Srivastava A. Study of risk factors affecting the limb salvage in patients with lower extremity arterial trauma. Indian J Vasc Endovasc Surg 2019;6:115-20

How to cite this URL:
Garg MK, Bedi VS, Yadav A, Agarwal S, Satwik A, Srivastava A. Study of risk factors affecting the limb salvage in patients with lower extremity arterial trauma. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Nov 22];6:115-20. Available from: http://www.indjvascsurg.org/text.asp?2019/6/2/115/259661




  Introduction Top


There are more road traffic injuries (RTIs) and more RTI-related deaths in India than any other country in the world.[1] Vascular injury of the extremities is a complication following both penetrating and blunt trauma. Limb salvage rate is around 95% after vascular repair in timely performed, uncomplicated penetrating arterial injury.[2],[3] Limb salvage is critically dependent on ischemic time.[4] The amputation rate was significantly reduced when ischemic time was <6 h.

In Indian scenario, patients generally present late to the tertiary care center with mangled extremity for treatment. The effect of risk factors gets compounded because of delayed presentation. On top of that, most of the patients presenting to urban centers have blunt mechanism of injury in contrast to penetrating in developed countries which further differentiate the outcome. In the light of this background having different set of risk factors, this study was contemplated to assess the effect of the risk factors on the limb salvage in the management of patients with lower extremity arterial trauma.


  Materials and Methods Top


A single-center, observational study was conducted at Sir Ganga Ram Hospital, New Delhi, from January 2015 to June 2017. Sixty patients of lower extremity arterial trauma who underwent revascularization were included and followed up for 6 months. In our institution, isolated distal tibial vessels are repaired by plastic surgeons and injuries involving proximal tibial vessels and tibioperoneal (TP) trunk with popliteal artery were repaired by vascular team. Isolated distal tibial vessels were excluded from the study.

All consecutive patients having lower extremity arterial trauma undergoing vascular repair during the study period were enrolled. In addition, data of the past 2 years of patients with lower extremity arterial trauma were extracted from hospital information system, and telephonic follow-up was performed to know the limb salvage. All the patients who had concomitant life-threatening chest/abdominal/head trauma were excluded.

The patients [Figure 1] presenting to emergency were initially assessed and managed as per advanced trauma life support guidelines. Life-threatening injuries were prioritized, and patients undergoing primary treatment for concomitant life-threatening injuries were excluded from the study. Simultaneous assessment and resuscitation were performed. History regarding the mode of injury, time since injury, and associated trauma was recorded. Full clinical vascular examination and clinical assessment for compartment syndrome were performed. Mangled extremity severity score (MESS) was calculated and documented. Duplex evaluation was performed by the on-call vascular team in the emergency to confirm the diagnosis of the vascular injury, level of injury, and extent of injury. Other than direct visualization of the injury site, few indirect findings in the form of no flow, reduced flow, or dampened monophasic flows in distal crural vessels in the presence of normal triphasic flows proximal to injury and obvious thrombosis in the artery near to the injury were considered for immediate exploration without any diagnostic computed tomography (CT) angiogram. However, if the patient has suspected multilevel vascular injury or indeterminate findings and large open wounds prohibiting the vascular ultrasound, CT angiogram [Figure 2] was performed. In the presence of spectral waveform analysis on duplex scan, continuous wave Doppler was not performed and ankle brachial indices were not recorded.
Figure 1: Clinical photograph of the patient with lower extremity arterial trauma

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Figure 2: Computed tomography angiogram. (a) Popliteal artery injury. (b) Pseudoaneurysm arising from profunda femoris

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In patients having open wound and comminuted fractures, multidisciplinary approach was followed. Decision for revascularization was taken in collaboration with plastic surgeon and orthopedic surgeons. The patients who had viable limb and confirmed the diagnosis of vascular injury on clinical examination and imaging were shifted to operating room for revascularization.

When the patients were being transferred to the operating room, meanwhile, patients received intravenous fluids (crystalloids and colloids), sodium bicarbonate infusion and had preoperative preparation with urinary catheterization, blood group cross matching etc. Majority of the patients were operated under general anesthesia. Viability of the limb was reassessed. Patients having compartment syndrome with severe calf tenderness at presentation underwent fasciotomy before revascularization attempt. This was done for couple of reasons. First, as the time since injury was more and patients have questionable viability, to assess the viability of the leg and reconsideration of decision for revascularization, fasciotomy was attempted. Second, fasciotomy released the tension on the muscles in the compartment and bought some time for revascularization. The patients who had tense compartment in the legs underwent fasciotomy. Viability of the muscles was assessed using electrocautery stimulation. The patients who had nonviable muscles in more than two compartments underwent primary amputation and were excluded from the study. The patients who had viable muscles underwent revascularization. Vascular repair was performed before the bone fixation and nerve repair. In patients having arterial transection/laceration/intimal injury, on table assessment of the extent of injury was performed and plan for end to end anastomosis or interposition graft was made [Figure 3] and [Figure 4].
Figure 3: (a) Common femoral artery injury with complete transection (b) Complete transection repaired with vein interposition graft

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Figure 4: (a) Intimal injury of the short segment popliteal artery. (b) Repair of the popliteal artery with interposition graft

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After the vessel repair, hemodynamic success was confirmed by duplex evidence of flow in the vessels distal to injury following which the patient was handed over to plastic surgeon and orthopedic surgeons for fixation of bone, nerve repair, and local or regional flap cover. After the bony fixation, integrity of vascular repair was reconfirmed; any laxity in the vein graft was corrected by gently tucking the bypass graft in the nearby muscle, and the wound was closed.

All the patients received antiplatelets (aspirin or clopidogrel), Dextran (Microspan), broad-spectrum IV antibiotics, and blood transfusion (if needed). Patients were kept in intensive monitoring and monitored for reperfusion injury. Reperfusion injury was monitored in the form of local and systemic signs. Local features included compartment syndrome. Systemic features included myoglobinuria and acute kidney injury. The outcome was assessed in terms of mortality and limb salvage. Limb salvage rate was defined as the patients having viable limb after vascular intervention without any delayed/secondary major amputation at 6 months.

Statistical testing was conducted with the Statistical Package for the Social Science system version SPSS 17.0 (IBM Corporation, New York, USA). Data have been presented as mean ± standard deviation, frequencies, and percentages. Nominal categorical data were assessed to find the association between the variables using Chi-squared test or Fisher's exact test as appropriate.


  Results Top


A total of 60 lower extremity arterial trauma patients who underwent vascular intervention were included in the study. Age distribution has been shown in [Table 1]. Age of patients ranged from 11 to 56 years with a mean age of 32.25 years and a standard deviation of 11.51 years. Fifty-seven patients (95%) were males and 3 patients (5%) were females.
Table 1: Age distribution

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Majority (83.33%) of the patients presenting to our institution had blunt trauma in the form of road traffic accident as the mode of injury. Rest of the patients had penetrating trauma as a mode of injury. Only 26.7% of the patients presented in golden hours of trauma (<6 h). About 43.3% of the patients presented in 6–24 h and rest 30% presented even later than 24 h.

In the present study, it was found that popliteal artery (73.3%) was the most commonly injured vessel as a single vessel injury as well as combined with superficial femoral artery (SFA) or crural arteries. The frequency distribution is shown in [Table 2].
Table 2: Frequency distribution of lower limb vessel injuries

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Compartment syndrome was present in 60% of the patients at the time of presentation. Six patients (10%) developed compartment syndrome in the postoperative phase which was diagnosed clinically (distended calf muscles with severe tenderness) and underwent fasciotomy. Patients with delayed compartment syndrome did not need any major amputation. Patients were classified on the basis of MESS (<7 and >7). Mean MESS score was 7.85. Nearly, 78.33% of the patients had MESS score more than 7, and limb salvage rate in this subgroup was 68% while limb salvage rate was 100% in the subgroup with MESS <7. Only 5% of the patients included in the study had shock at the time of presentation.

Limb salvage rate was defined as the patients having viable limb after vascular intervention without any delayed/secondary major amputation. Patients having minor amputation, i.e., distal to ankle joint were also considered to be under salvaged group. Limb salvage rate was 75%. Fifteen patients (25%) of the patient who had amputation, five patients had in 1st week of operation and the rest had amputation at a variable interval with in 6 months of operation. No patient died during the postoperative period and during the 6 months of follow-up.

On univariate analysis, 16 variables were studied for the limb salvage. Time since injury and MESS score >7 were significantly associated with limb salvage [Table 3]. Time since injury (<6 h) predicted the better outcome in the form of limb salvage. Higher MESS score was associated with poor primary outcome in the form of limb salvage.
Table 3: Univariate analysis of the risk factors affecting the limb salvage

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On multivariate analysis, MESS score >7 was independently associated with poor rate of limb salvage (95% confidence interval [CI], 0.231–0.769, P = 0.005).


  Discussion Top


Lower extremity arterial trauma is both life-threatening and limb-threatening surgical emergency. Urgent vascular intervention (primary repair/end-to-end anastomosis/interposition graft/arterial ligation) is warranted for the limb salvage. There are various risk factors which affect the outcome.

Mechanism of injury varies in civilian and military trauma and varies widely in different regions according to the rate of trauma. Pezeshki Rad et al. concluded in their study that the most common cause of injury was blunt trauma due to motor vehicle accident. In Turkey, Britain, Georgia, and United States, penetrating trauma due to gunshot and stab was reported to be the most common cause of peripheral vascular injury.[5] In the present study, majority (83.33%) of the patients included in the study had blunt trauma in the form of road traffic accident as the mode of injury. Rest of the patients had penetrating trauma.

Kauvar et al. reported that amputation rate following blunt trauma was 9.1% and penetrating trauma was 5.1%.[6] Hafez et al. reported in their single-center study on 550 lower extremity arterial injuries that the amputation rate following blunt injury was 24%, compared with 15% from penetrating trauma.[7] Mullenix et al. reported on popliteal artery trauma that the amputation rate from blunt injury was 18% and that from penetrating injury was 9%.[8]

In the present study, limb salvage rate following blunt trauma was 76% and penetrating trauma was 70%. The possible explanation for this aberration in the limb salvage rate is that most of the patients present late and have higher MESS score which independently affect the outcome.

Limb salvage is critically dependent on ischemic time.[4] In 1947, Miller and Welch reported that warm ischemic time for skeletal muscle was between 4 and 8 h.[9] Most authors used 6 h as the definition of early intervention. However, studies have suggested that skeletal muscle is, in fact, even more sensitive to ischemia. Following reestablishment of the circulation, Hammersen et al. demonstrated microcirculatory changes in human skeletal muscle consistent with reperfusion injury at 3–4 h.[10]

Patients who underwent revascularization within 6 h had 100% limb salvage rate. Patients who presented after 6 h and underwent revascularization had performed badly with limb salvage rate of 65.3% with 33.3% of secondary amputation. Patients who presented even later, i.e., after 24 h performed worst and had limb salvage rate of 61.22%. On univariate analysis, it was found that there was significant correlation between the limb salvage rates. In India, due to lack of awareness, poor transport services, and dedicated vascular center, patients generally present late and have poor limb salvage rates.

Hafez et al. concluded that the amputation rate from common femoral artery (CFA) and SFA injuries was 12% while that in popliteal and tibial arterial injuries was 21%. Combined arterial injuries (both above knee and below knee) are associated with higher secondary amputation rates on multivariate analysis.[7] Moniz et al. also concluded that rate of amputation from femoral arterial injuries was 26%, that from popliteal injuries was 54%, and that from tibial injuries was 36%. Injury to the popliteal artery has long been recognized as frequently resulting in limb loss.[11]

In the lower extremity, however, mechanism influences the arterial injury pattern, with the popliteal artery most frequently injured in blunt trauma and SFA, the most frequently injured in penetrating trauma.

In the present study, 73.3% of patients who underwent revascularization had injury involving popliteal artery [Table 2]. Blunt trauma commonly affects the popliteal artery and penetrating trauma affects the CFA. The most common mechanism of injury in the present study is the blunt trauma, and popliteal artery is the most common site of injury. Three patients had CFA injury, and out of this, one patient underwent secondary amputation. Patients who had injury to profunda femoris did not undergo amputation. Limb salvage rate in the patients having popliteal artery injury was 77.27%, but limb could not be salvaged in the patient who had combined popliteal and SFA injury. The possible explanation for more patients to be having popliteal artery injury in this study is that population included is the subset of civilian patients. Civilian patients present more with road traffic accidents (blunt trauma) than any other mechanism of injury. On univariate analysis, the arterial injury pattern did not correlate with limb salvage [Table 3].

Compartment syndrome is one of the poor prognostic indicators for limb salvage. Hafez et al. considered fasciotomy as a crucial therapeutic adjunct to lower limb arterial injury. Fasciotomy is absolutely indicated in patients with tense compartment on presentation.[7] The judicious use of prophylactic fasciotomy was recommended by Howard and Makin.[12] Seligson et al. recommended fasciotomy in all cases.[13] Limbs with noncontractile muscle in up to two compartments are generally considered for revascularization while those with more noncontractile muscle are recommended primary amputation in view of the high risk for reperfusion injury and poor functional outcome thereafter. Farber et al. concluded that patients presenting late had higher rates of amputation (24.3% vs. 8.4%, P < 0.001) and compartment syndrome (28.4% vs. 11.4%, P = 0.001). Multivariate analysis identified late fasciotomy was predictor of limb amputation (odds ratio, 3.8; 95% CI, 2.02–7.15, P < 0.0001).[14]

In the present study, 70% of the patients had compartment syndrome that underwent fasciotomy. It is believed that compartment syndrome is associated with poor limb salvage rate. However, in the present study, on statistical analysis, the correlation between the limb salvage and compartment syndrome was not statistically significant (P = 0.192) [Table 3]. The possible explanation for this kind of aberration may be the small sample size with limited follow-up. Yet, the presence of compartment syndrome should be considered as a poor predictor of limb salvage.

The MESS is probably the most common scoring system used,[15] followed by the Predictive Salvage Index,[16] Limb Salvage Index,[17] Mangled Extremity Syndrome Index, nerve injury, ischemia, soft tissue, skeletal injury, shock, age of patient score, and the Hannover Fracture Scale.[18],[19]

In the present study, decision for primary amputation was not done on the basis of MESS score. The patient was evaluated by a team consisting of vascular surgeon, plastic surgeon, and orthopedic surgeon, and a cumulative disease for revascularization was taken irrespective of MESS score. It was observed that mean MESS score at the time of presentation was 7.85. Hence, as per the study, majority of the patients had MESS score >7 [Table 3]. Increase in MESS score in the present study appears to be attributed to delay in presentation.

On correlation of MESS score with limb salvage rate, it was found that there was a significant inverse correlation with P = 0.001 [Table 3] which signified that higher the MESS score, lower would be the limb salvage rate.

In the multivariate analysis to predict limb salvage using stepwise method, 15 variables were studied for the limb salvage. MESS score was independently associated with poor rates of limb salvage (P = 0.005).

However, there are certain shortcomings of this study which need to be highlighted. Patients having injury to distal tibial vessels were not included. In our institution, although injuries involving proximal tibial vessels and TP trunk with popliteal artery were repaired by vascular team, isolated distal tibial vessels are repaired by plastic surgeons. To avoid the bias of different operating team, patients having distal tibial vessel injuries were not included. Second, the selection criteria of this study were very stringent and this prevented us from taking all the patients having vascular trauma for repair.


  Conclusions Top


Time since injury and MESS are the two most important predictors for limb salvage as well as secondary amputation. Warm ischemia time must be minimized to prevent the amputations. To reduce the ischemia time, hard signs of injury must be identified and the patient must be transferred to dedicated vascular center or to the trauma center having the vascular expertise immediately. In case of delay in transfer, prophylactic fasciotomy can be performed in the patients developing compartment syndrome. Vascular surgeons should be trained in duplex scan so that early decision for exploration and vascular repair can be taken without any angiographic delay. In cases of mangled extremity, multidisciplinary team approach should be utilized. Patients should undergo primary amputation that has high MESS score or has delayed presentation with obvious gangrenous changes and tense compartment syndrome. This may avoid unnecessary revascularization and its morbidity, and a collective decision for primary amputation should be taken. Early revascularization, intensive postoperative care, and team approach help in achieving the goal of functional limb salvage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Global Status Report on Road Safety: Time for Action. Geneva: World Health Organization; 2009.  Back to cited text no. 1
    
2.
Topal AE, Eren MN, Celik Y. Lower extremity arterial injuries over a six-year period: Outcomes, risk factors, and management. Vasc Health Risk Manag 2010;6:1103-10.  Back to cited text no. 2
    
3.
Kohli A, Singh G. Management of extremity vascular trauma: Jammu experience. Asian Cardiovasc Thorac Ann 2008;16:212-4.  Back to cited text no. 3
    
4.
Ashworth EM, Dalsing MC, Glover JL, Reilly MK. Lower extremity vascular trauma: A comprehensive, aggressive approach. J Trauma Acute Care Surg 1988;28:329-36.  Back to cited text no. 4
    
5.
Pezeshki Rad M, Ravari H, Bahadori A, Ajami O. Angiographic findings of patients with blunt or penetrating extremity injuries: Focus on indications and contraindications. Bull Emerg Trauma 2014;2:27-31.  Back to cited text no. 5
    
6.
Kauvar DS, Sarfati MR, Kraiss LW. National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma. J Vasc Surg 2011;53:1598-603.  Back to cited text no. 6
    
7.
Hafez HM, Woolgar J, Robbs JV. Lower extremity arterial injury: Results of 550 cases and review of risk factors associated with limb loss. J Vasc Surg 2001;33:1212-9.  Back to cited text no. 7
    
8.
Mullenix PS, Steele SR, Andersen CA, Starnes BW, Salim A, Martin MJ, et al. Limb salvage and outcomes among patients with traumatic popliteal vascular injury: An analysis of the national trauma data bank. J Vasc Surg 2006;44:94-100.  Back to cited text no. 8
    
9.
Miller HH, Welch CS. Quantitative studies on the time factor in arterial injuries. Ann Surg 1949;130:428-38.  Back to cited text no. 9
    
10.
Hammersen F, Barker JH, Gidlöf A, Menger MD, Hammersen E, Messmer K. The ultrastructure of microvessels and their contents following ischemia and reperfusion. InIschemia and Reperfusion, Karger Publishers: 1989; 13:1-26.  Back to cited text no. 10
    
11.
Moniz MP, Ombrellaro MP, Stevens SL, Freeman MB, Diamond DL, Goldman MH, et al. Concomitant orthopedic and vascular injuries as predictors for limb loss in blunt lower extremity trauma. Am Surg 1997;63:24-8.  Back to cited text no. 11
    
12.
Howard PW, Makin GS. Lower limb fractures with associated vascular injury. J Bone Joint Surg Br 1990;72:116-20.  Back to cited text no. 12
    
13.
Seligson D, Ostermann PA, Henry SL, Wolley T. The management of open fractures associated with arterial injury requiring vascular repair. J Trauma Acute Care Surg 1994;37:938-40.  Back to cited text no. 13
    
14.
Farber A, Hamburg N, Onigman T, Kalish J, Shaw P, Joglar F, et al. Delayed fasciotomy in patients with extremity vascular injury is associated with increased risk of adverse limb outcomes: A review of the national trauma data bank. J Vasc Surg 2010;52:1118.  Back to cited text no. 14
    
15.
Johansen KA, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma Acute Care Surg 1990;30:568-73.  Back to cited text no. 15
    
16.
Howe HR Jr., Poole GV Jr., Hansen KJ, Clark T, Plonk GW, Koman LA, et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg 1987;53:205-8.  Back to cited text no. 16
    
17.
Russell WL, Sailors DM, Whittle TB, Fisher DF Jr., Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg 1991;213:473-80.  Back to cited text no. 17
    
18.
Krettek C, Seekamp A, Köntopp H, Tscherne H. Hannover Fracture Scale'98—re-evaluation and new perspectives of an established extremity salvage score. Injury. 2001; 32: 317-28.  Back to cited text no. 18
    
19.
Seekamp A, Köntopp H, Tscherne H. Hannover fracture scale'98 – Reevaluation and new prospects for an established score system. Unfallchirurg 2001;104:601-10.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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