Nathan L Liang1, Louis H Alarcon2, Geetha Jeyabalan3, Efthymios D Avgerinos3, Michel S Makaroun3, Rabih A Chaer3. 1. Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address: liangnl@upmc.edu. 2. Division of Trauma and General Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. 3. Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Abstract
OBJECTIVE: Lower extremity arterial injury may result in limb loss after blunt or penetrating trauma. This study examined outcomes of civilian lower extremity arterial trauma and predictors of delayed amputation. METHODS: The records of patients presenting to a major level I trauma center from 2004 to 2014 with infrainguinal arterial injury were identified from a prospective institutional trauma registry, and outcomes were reviewed. Standard statistical methods were used for data analysis. RESULTS: We identified 149 patients (86% male; mean age, 33 ± 14 years,). Of these, 46% presented with blunt trauma: 19 (13%) had common femoral artery, 26 (17%) superficial femoral artery, 50 (33%) popliteal, and 54 (36%) tibial injury. Seven patients underwent primary amputation; of the remainder, 21 (15%) underwent ligation, 85 (59%) revascularization (80% bypass grafting, 20% primary repair), and the rest were observed. Delayed amputation was eventually required in 24 patients (17%): 20 (83%) were due to irreversible ischemia or extensive musculoskeletal damage, despite having adequate perfusion. Delayed amputation rates were 26% for popliteal, 20% for tibial, and 4.4% for common/superficial femoral artery injury. The delayed amputation group had significantly more (P < .05) blunt trauma (79% vs 30%), popliteal injury (46% vs 27%), compound fracture/dislocation (75% vs 33%), bypass graft (63% vs 43%), and fasciotomy (75% vs 43%), and a higher mangled extremity severity score (6.1 ± 1.8 vs 4.3 ± 1.6). Predictors of delayed amputation included younger age, higher injury severity score, popliteal or multiple tibial injury, blunt trauma, and pulseless examination on presentation. CONCLUSIONS: Individualized decision making based on age, mechanism, pulseless presentation, extent of musculoskeletal trauma, and location of injury should guide the intensity of revascularization strategies after extremity arterial trauma. Although patients presenting with vascular trauma in the setting of multiple negative prognostic factors should not be denied revascularization, expectations for limb salvage in the short-term and long-term periods should be carefully outlined.
OBJECTIVE: Lower extremity arterial injury may result in limb loss after blunt or penetrating trauma. This study examined outcomes of civilian lower extremity arterial trauma and predictors of delayed amputation. METHODS: The records of patients presenting to a major level I trauma center from 2004 to 2014 with infrainguinal arterial injury were identified from a prospective institutional trauma registry, and outcomes were reviewed. Standard statistical methods were used for data analysis. RESULTS: We identified 149 patients (86% male; mean age, 33 ± 14 years,). Of these, 46% presented with blunt trauma: 19 (13%) had common femoral artery, 26 (17%) superficial femoral artery, 50 (33%) popliteal, and 54 (36%) tibial injury. Seven patients underwent primary amputation; of the remainder, 21 (15%) underwent ligation, 85 (59%) revascularization (80% bypass grafting, 20% primary repair), and the rest were observed. Delayed amputation was eventually required in 24 patients (17%): 20 (83%) were due to irreversible ischemia or extensive musculoskeletal damage, despite having adequate perfusion. Delayed amputation rates were 26% for popliteal, 20% for tibial, and 4.4% for common/superficial femoral artery injury. The delayed amputation group had significantly more (P < .05) blunt trauma (79% vs 30%), popliteal injury (46% vs 27%), compound fracture/dislocation (75% vs 33%), bypass graft (63% vs 43%), and fasciotomy (75% vs 43%), and a higher mangled extremity severity score (6.1 ± 1.8 vs 4.3 ± 1.6). Predictors of delayed amputation included younger age, higher injury severity score, popliteal or multiple tibial injury, blunt trauma, and pulseless examination on presentation. CONCLUSIONS: Individualized decision making based on age, mechanism, pulseless presentation, extent of musculoskeletal trauma, and location of injury should guide the intensity of revascularization strategies after extremity arterial trauma. Although patients presenting with vascular trauma in the setting of multiple negative prognostic factors should not be denied revascularization, expectations for limb salvage in the short-term and long-term periods should be carefully outlined.
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