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ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 129-133

Management of lower limb vascular injuries in a tertiary care centre: An Indian scenario


Department of Plastic and Reconstructive Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission27-May-2020
Date of Decision05-Aug-2020
Date of Acceptance12-Aug-2020
Date of Web Publication13-Apr-2021

Correspondence Address:
Devika Rakesh
Department of Plastic and Reconstructive Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_72_20

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  Abstract 


Context: Lower limb vascular trauma accounts for majority of peripheral vascular injuries. Delay in diagnosis and referral to higher centers in developing countries like India poses a major challenge with regard to optimum management of these vascular injuries. Aims: The aim was to study the time gap between injury and revascularization and the incidence of reperfusion injuries in patients presenting late to the hospital. Materials and Methods: This descriptive prospective study involved 51 patients who presented with clinical signs of vascular injury confirmed by handheld Doppler. In cases presenting late (more than 6 h), decision to proceed with revascularization versus primary amputation was based on distal muscle viability tested intraoperatively. All anastomosis were done under microscopic magnification with the use of venous graft wherever needed. Results: All 51 patients in the study were males with a mean age group of 32.6 years. Six patients underwent primary amputation. Road traffic accidents were the most common cause of injury with popliteal artery involvement in most cases. Of the total 45 patients who underwent revascularization, 25 patients (55.5%) presented within the golden period of 6 h and only five patients (11.1%) underwent revascularization within 6 h of injury despite which we had a limb salvage rate of 88.8%. Reperfusion injury was seen in 14 patients, vascular thrombosis in three patients and two deaths were reported. Conclusions: We thus recommend that decision to reperfuse the involved limb should not be solely based on the time elapsed but also on factors such as muscle viability and neurological status, especially in a country like India.

Keywords: Limb salvage, lower limb vascular trauma, reperfusion


How to cite this article:
Garg R, Mittal RK, Kathpal SS, Rakesh D. Management of lower limb vascular injuries in a tertiary care centre: An Indian scenario. Indian J Vasc Endovasc Surg 2021;8:129-33

How to cite this URL:
Garg R, Mittal RK, Kathpal SS, Rakesh D. Management of lower limb vascular injuries in a tertiary care centre: An Indian scenario. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jun 24];8:129-33. Available from: https://www.indjvascsurg.org/text.asp?2021/8/2/129/313565




  Introduction Top


Peripheral vascular injuries are a challenge to the treating surgeon. They account for approximately 3% of all the injuries.[1] Challenge is to intervene early and to save both life and limb. Peripheral vascular injury of limbs account for 80% of all vascular trauma and lower extremities are involved in 2/3 of patients.[2] They are almost always associated with lower limb fractures. Gustilo, et al.[3] have classified these fractures. According to their classification, in type III fractures both bone and soft tissues are badly injured, and if the major vessels of the leg are involved with inadequate distal circulation, the fracture is classified as Type IIIc. Timely restoration of circulation has to be performed to save the limb. In a developing country like India, there are limited resources available to manage such type of cases. This combined with delays in diagnosis and referral of patients to higher centers, pose a major challenge to limb salvage. More is the ischemia time; more are the chances of reperfusion injury. Reperfusion injury is the tissue damage caused when blood supply returns to the tissue after a period of ischemia or lack of oxygen. Reperfusion of ischemic tissues results in both a local and a systemic inflammatory response that, in turn, may result in widespread microvascular dysfunction and altered tissue barrier function. If severe enough, the inflammatory response after ischemia reperfusion injury may even result in the systemic inflammatory response syndrome or the multiple organ dysfunction syndrome, which accounts for up to 30%–40% of intensive care unit mortality.[4] Very few studies on vascular injury are reported from developing countries like India,[5] and a single-surgeon experience on the outcomes is lacking. There is a need for a study on this condition in order to analyze and find the critical issues in the management of these injuries in the Indian scenario.

This study was aimed at studying the time gap between injury and revascularization and the incidence of reperfusion injuries in patients who presented late to the hospital.


  Materials and Methods Top


This was a descriptive prospective study done over a period of 2½ years from May 2017 to December 2019. These patients presented to the Emergency Department of Dayanand Medical College and Hospital, Ludhiana. All patients were resuscitated as per hospital protocol. Hard signs (pulselessness, pallor, paresthesis, paralysis, and pain) and soft signs (a wound adjacent to a great vessel) of vascular injury were looked for. Use of handheld Doppler was done to aid in diagnosis. Computed tomography (CT) angiography was done in cases where there was suspicion of multiple level vascular injuries or where the diagnosis was in doubt. Once diagnosis of vascular injury was established, patient was enrolled in the study.

In cases of delayed presentation to the Emergency Department (more than 6 h), the decision to proceed with revascularization versus primary amputation was based on distal muscle (gastrocnemius) viability. We did not base our plan of action (salvage or amputation) on any scoring it was based collectively on hard signs of vascular injury on examination guided by handheld Doppler, CT angiography in doubtful cases and distal muscle (gastrocnemius) viability either tested pre operatively (intact toe or ankle movements) or intra operatively by open fasciotomy and observation of the color of the muscle and contractile response of muscle to direct stimulation with electrosurgery. Limbs with isolated noncontractile muscle were revascularised while that with completely non contractile muscle group were amputated primarily. The revascularization was done after taking due consent from the patient's relatives. The neurological status of the limb was also taken into consideration prior to revascularization. The limb was explored as per the standard incisions and the location of the bone, under tourniquet control. Fogarty catheter was passed in every case and anastomosis done after ensuring back flow. Venous graft was used wherever there was tension along the suture suture line or where direct end to end anastomosis was not possible. All anastomosis was done under microscopic magnification using 8-0 ethilon. Venous repair, if needed, was done only in injuries at thigh level.

The sequence of surgery was, orthopedic fixation followed by vascular repair. In cases that presented late (>6 h), orthopedic fixation followed vascular repair. Fifty one patients were enrolled in the study. Of these, six patients underwent primary amputation.

The parameters assessed were demographic profile, mode of injury, time of presentation following injury, the vessel involved, any associated head injury, and the incidence of reperfusion injury.


  Results Top


The present study involved 51 patients over a period of 2½ years. Six patients had primary amputation:

  1. Demographics: All patients were males with age range being 14–65 years and a mean of 32.6 years. Eighty percent of the patients were in economically productive age group of 20–50 years
  2. Mode of injury: Thirty-five patients (77.8%) sustained injury following road traffic accidents. Of these, 32 patients (91.4%) were on two-wheelers, whereas three patients were on a 4-wheeler vehicle. Further, of these 32 patients on two-wheelers, 30 patients (93.7%) were driving the vehicle themselves. Other causes included fall from height in five patients, occupational injury in four patients and altercations in one patient [Table 1]
  3. Vessels involved: Popliteal artery was most commonly involved vessel, seen in 19 of the 45 patients (42.2%). Femoral artery was involved in 13 patients (28.9%), posterior tibial artery in seven patients (15.5%), anterior tibial in three patients (6.7%), while dorsalis pedis, peroneal, and profunda femoris arteries were involved in one patient each. Right limb was involved in 32 patients (71.1%) and left limb was involved in 13 patients.
  4. Associated injuries: Forty three patients had associated orthopedic fractures. Only seven patients (15.5%) had associated traumatic brain injury. No patient had associated abdominal or chest injury
  5. Delays in admission/intervention: Of the total 45 patients, only 25 patients (55.5%) reached the hospital within the golden period of 6 h following injury. Of these only four patients reached within 4 h of injury. Seventeen patients (37.8%) reached in the time interval of 6–9 h following injury, while three patients reached 12 h after vascular injury. Following admission patients were investigated as needed and then shifted to emergency occupational therapy. CT angiography was done in seven patients [Figure 1] and [Figure 2] and CT head was done in patients suspected of head injury (seven patients). Only five patients (11.1%) underwent revascularization within 6 h of injury. Twelve patients (26.7%) underwent revascularization within 6–9 h, 15 patients (33.3%) within 9–12 h and 13 patients (28.9%) after 12 h of vascular injury
  6. Surgery performed: Before the commencement of vascular repair, all patients underwent fasciotomy and assessment of contractility of distal muscle groups. Only those patients who had muscle contractility underwent vessel repair. Of the 45 patients, 32 patients underwent end-to-end anastomosis of the involved vessel [Figure 3]. Reverse saphenous vein interposition graft was used in 13 patients. Of these 13 patients, venous graft was used for popliteal artery in 12 patients [Table 2]
  7. Reperfusion injuries: Reperfusion injury was observed in 14 of the 45 vascular injury patients. It occurred following femoral artery repair in one patient, following popliteal artery repair in seven patients, posterior tibial artery repair in four patients, and anterior tibial and dorsalis pedis artery repair in one patient each. The ischemia time was more than 12 h in nine patients (64.2%) and more than 6 h but <12 h in four patients (28.5%) and one patient had ischemia time of <4 h. All the patients with signs of reperfusion injury were shifted to intensive care units and underwent conservative management
  8. Complications: Two deaths were reported during the study. Both patients developed acute respiratory distress syndrome (ARDS) presumed to be the result of reperfusion injury. One patient had ischemia time of 8 h and the other had ischemia time of 12 h. There were three patients who underwent secondary amputation because of vascular thrombosis [Table 3].
Table 1: Description of patient's epidemiology and mode of injury

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Figure 1: Computed tomography angiogram revealing right popliteal artery transection at the level of femoral condyles

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Figure 2: Computed tomography angiogram revealing left popliteal artery injury

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Figure 3: Intraoperative image of popliteal artery repair with end-to-end anastomosis

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Table 2: Description of injury related factors

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Table 3: Description of complications associated with revascularization

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  Discussion Top


Arterial injuries present the most challenging and fascinating conditions in the field of surgery. Although rare, they can be associated with significant morbidity and devastating complications such as threat to the limb or the life. Many fail to reach the specialist in time and end up losing limbs or lives. Although well addressed elsewhere, it has received less attention in developing countries like India. There is a need to study these injuries from the perspective of countries like India. 6 h has been described as the golden period for revascularization in vascular injury. However, limited facilities to manage vascular injuries in some small hospitals, coupled with delays in diagnosis and transfer to large hospitals, pose major challenges with regard to optimum management of these injuries.[6]

All the patients in our study were males with a mean age of 32.6 years which correlates with the findings of other studies.[5],[7],[8] Majority of the patients were in economically productive age group of 20–50 years, most of whom were breadwinners of the family and and re-establish circulation was crucial.

Road traffic accidents happened to be the most common cause of vascular injury as noted in 35 patients (77.8%). Most of these patients (91.4%) were on a two-wheeler. Majority of the two-wheelers were motorcyles. Motorcyclists are more susceptible because of the high-energy trauma to the unprotected extremities. Popliteal artery (42.2%) was the most common artery involved followed by femoral artery (28.9%). These findings were consistent with other studies.[9],[10] The popliteal artery is very liable to injury due to its anatomical course, whereby it is anchored above and below the knee joint as it passes through the popliteal fossa.[9] However, in many studies from West, the popliteal artery injuries are <0.25%.[11]

Although described as the golden period,[12] only 55.5% of our cases presented within 6 h following injury. The mean duration of presentation to our tertiary care hospital was 6.35 h. This reveals the lack of awareness and recognition of vascular injuries. This highlights significant deficiences in the current trauma management system in India, an important reason would be the lack of vascular expertise availability in many centres.[13]

The role of angiographic evaluation is controversial and mostly limited to absent hard signs in high-suspicion situation like dislocations of the knee.[14] CT angiography was done in only seven patients with a 100% specificity and 100% sensitivity with regard to the location of arterial injury which were correlated with intraoperative findings. We strongly emphasize on the role of CT angiography in all patients where we suspect multilevel vascular injuries or where the diagnosis is uncertain prior to surgical intervention. Patients underwent orthopedic fixation/revascularization as per the status of the muscles.

Many authors have highlighted the importance of fasciotomy in the vascular reconstruction especially when the time of reconstruction exceeds 4 to 6 h post injury.[15] As a result, some scholars suggest that fasciotomy performed at the time of arterial repair may lower amputation rates especially in patients with long preoperative delays.[16] Likewise, in our study, before the commencement of vascular repair, all patients underwent fasciotomy and assessment of contractility of distal muscle groups and only those patients who had muscle contractility underwent vessel repair as done in a case series in which all patients needing emergency repairs for ischemia had a fasciotomy to assess limb viability.[6]

Thirty-two of our patients underwent end-to-end anastomosis of the involved vessel, while reverse saphenous vein interposition graft was used in 13 patients where end-to-end anastomosis was not possible. We did not use any synthetic graft in our study as autologous saphenous vein grafting have shown superior results in terms of better patency rate and resistance to infection.[17] We did not perform any endovascular interventions as all the cases were major injuries and surgically accessible areas and required many concomitant procedures. In our study, only five patients (11.1%) underwent revascularization within 6 h of injury. 88.9% underwent revascularization 6 h after injury.

The timing of orthopedic fixation in concomitant bone injury is debatable. Prior skeletal fixation is strongly advocated in some series,[18],[19] while more recent reports have highlighted the importance of reducing ischemia time by proceeding with vascular reconstruction first.[20],[21] In our study, patients underwent orthopedic fixation/revascularization as per the status of the muscles. Orthopedic fixation was done first without taking much time to provide a stable base followed by vascular repair in cases presenting within 6 h. In those presenting late, vascular repair was done first to prevent further prolongation of ischemia time.

The risk of reperfusion injury has been cited as a reason for conservative management in prolonged ischemia. Reperfusion injury was observed in 14 of the 45 who underwent vascular repair. The ischemia time was more than 12 h in 9 patients (64.2%) and more than 6 h but <12 h in four patients (28.5%) and one patient had ischemia time of <4 h. Reperfusion injury develops in delayed revascularization either as compartment syndrome, renal failure, or multiorgan dysfunction. The exact data of reperfusion injury following extremity revascularization are not available. In our series, there were 2 mortalities (4.4%), due to ARDS secondary to reperfusion injury. There were 3 (6.66%) patients who underwent secondary amputation because of vascular thrombosis. We had a limb salvage rate of 88.88% almost similar limb salvage rates of 90.1% reported by Joshi et al.[22] and 84% as reported by Hafez et al.[20] Our policy to revascularize all viable limbs with continued ischemia in otherwise stable patients even with long periods of ischemia seems justified.

Early diagnosis and immediate intervention are mandatory to save the extremities and lives of the patients.[23] Conventional logic dictates that longer the period of ischemia, the higher the chance of limb loss. However, to condemn limbs as unsalvageable purely on the basis of ischemia time alone needs to be reconsidered.

Huynh et al. concluded that even though prolonged ischemia has been a well-recognized predictor of cell death, the tolerance period varies from person to person, which depends on the severity of the ischemia and the presence of collateral flow.[24] Another study concluded that the greatest impact on decision-making between limb salvage and amputation depended on the severity of soft tissue injury and the level of arterial injury.[25] In addition, the time since injury may not necessarily reflect the actual period of ischemia because of the presence of collateral circulation. Subsequently, we suggest all viable limbs with continued ischemia be revascularized in otherwise stable patients even with long periods of ischemia.

Moreover, most of the studies available in the literature which recommend revascularization in injuries presenting beyond 6 h have reviewed the cases retrospectively. On the contrary, our study prospectively analyzes the outcome of delayed revascularization in patients with viable distal muscles. Limitation of this study is that it is a smaller series and a single surgeon experience.


  Conclusions Top


In a developing country like India, patients have to travel certain distances before they reach a tertiary care institute. Approximately 4–5 h of the golden period is wasted in making diagnosis, referral, and arriving in a tertiary hospital. Of the 40 patients, who underwent vascular reperfusion after 6 h of injury, 14 patients (35%) had reperfusion injury and there were 2 deaths reported.

Keeping these facts in mind, we recommend that decision to reperfuse the involved limb should not be solely based on the time elapsed (6 h). Other factors such as viability of the muscles and neurological status should also be taken into consideration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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Gustilo RB, Merkow RL, Templeman DA. The management of open fractures. J Bone Joint Surg Am 1990;72:299-304.  Back to cited text no. 3
    
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Kendall RW, Taylor DC, Salvian AJ, O'Brien PJ. The role of arteriography in assessing vascular injuries associated with dislocations of the knee. J Trauma 1993;35:875-8.  Back to cited text no. 14
    
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Dorigo W, Pulli R, Piffaretti G, Castelli P, Griselli F, Dorrucci V, et al. Results from an Italian multicentric registry comparing heparin-bonded ePTFE graft and autologous saphenous vein in below-knee femoro-popliteal bypasses. J Cardiovasc Surg (Torino) 2012;53:187-94.  Back to cited text no. 17
    
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25.
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    Figures

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

  [Table 1], [Table 2], [Table 3]



 

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