Management of Lower Extremity Vascular Trauma

Acellular Dermal Matrices in Reconstructive Pediatric Complex Lower Limb Trauma: An Observational Study

BACKGROUND

Contemporary research has shown that acellular dermal matrices can benefit adult lower extremity traumatic injuries; however, its use in children has not been explored.

OBJECTIVE

This study aims to explore the use of acellular dermal matrices in pediatric complex lower extremity trauma.

METHODS

This single-center retrospective observational cohort study of children with complex lower extremity trauma treated with Pelnac™, commercial acellular dermal matrices, was conducted at a tertiary hospital in South Africa from 2010 to 2017. Demographic and clinical data were collected from medical records. The primary outcome was the rate and type of acellular dermal matrices-related complications. Secondary outcomes included the usage of negative pressure wound therapy.

RESULTS

A total of 54 children were studied; 30 (55%) were male, and the median age was six. Forty-five children healed without complications, while nine experienced complications - four acute and five chronic. Four patients had complete loss of acellular dermal matrices, and three developed acute infections. More than 30 days post-acellular dermal matrices application, five patients had hypertrophic scarring, four had joint contractures, and two had non-healing wounds. All patients who healed without complication received negative pressure wound therapy (n = 45), while those who did not (n = 5) developed complications. Three of the five patients without negative pressure wound therapy had acute acellular dermal matrices loss, compared to only one of the 49 patients who received negative pressure wound therapy.

CONCLUSION

Our findings suggest that acellular dermal matrices may be an effective and safe reconstructive adjunct or alternative when used with negative pressure wound therapy.

Management of pediatric lower extremity vascular trauma: adult vs pediatric level I trauma centers

BACKGROUND

Pediatric lower extremity vascular injury (PLEVI) is uncommon and the availability of granular data is sparse. This study evaluated the surgical management of PLEVIs between a Level I adult (ATC) vs pediatric (PTC) trauma center.

METHODS

We performed a retrospective review of PLEVIs (< 18 years) managed surgically between 01/2009-12/2022. Demographics and outcome data were obtained. Primary outcomes included amputation and fasciotomy rates. Secondary outcomes included type of vessel repair, mortality, and hospital length of stay.

RESULTS

Seventy-nine patients were identified, 41 at the ATC and 38 at the PTC, totaling 112 vessels injured. ATC patients were older (median years 16.0 vs 12.5) and almost exclusively (97.6% vs 29.0%) gunshot wounds. Vascular surgeons managed 50% of injuries at the ATC vs 73.7% at the PTC (p = 0.10). Amputations were uncommon and not significantly different between centers. Seventeen patients (44.7%) required fasciotomies at the PTC vs 21 (51.2%) at the ATC (p = 0.56). Rates of vessel repair, ligation, grafting, mortality, and hospital length of stay were not significantly different.

CONCLUSIONS

PLEVI can be managed safely at ATCs and PTCs with acceptable outcomes. However, important nuances in patient triage and management need to be considered. Multi-institutional comprehensive datasets are needed.

LEVEL OF EVIDENCE

 Level III.

Experience of vascular injuries at a military hospital in Korea

PURPOSE

Vascular injuries require immediate surgical treatment with standard vascular techniques. We aimed to identify pitfalls in vascular surgery for trauma team optimization and to suggest recommendations for trauma and vascular surgeons.

METHODS

We reviewed 28 victims and analyzed the patterns of injuries, methods of repair, and outcomes.

RESULTS

Ten patients had torso injuries, among whom three thoracic aorta injuries were repaired with thoracic endovascular aortic repair, one left hepatic artery pseudoaneurysm with embolization, and two inferior vena cava with venorrhaphy, three iliac arteries with patch angioplasty or embolization, and three common femoral arteries with bypass surgery or arterioplasty. Four patients had upper extremity injuries, among whom one brachial artery and vein was repaired with bypass surgery after temporary intravascular shunt perfusion, two radial arteries were repaired with anastomoses, and one ulnar artery was repaired with ligation. One radial artery under tension was occluded. Fourteen patients had lower extremity injuries, among whom one superficial femoral artery and vein was repaired with bypass and concomitant ligation of the deep femoral artery and vein, three superficial femoral arteries were repaired with bypass (two concomitant femoral veins with bypass or anastomosis), one deep femoral artery with embolization, two popliteal arteries with bypass or anastomosis, four infrapopliteal transected arteries, one arteriovenous fistula with ligation, and one pseudoaneurysm with bypass. However, one superficial femoral artery and all femoral veins were occluded. One leg replantation failed.

CONCLUSIONS

There are potential complications of vascular access during resuscitative endovascular balloon occlusion of the aorta procedures. Vascular repair should be performed without tension or spasm. Preservation of the harvested vein in papaverine solution and blood while using a temporary intravascular shunt is a method of eliminating spasms.

Systematic review and meta-analysis of endovascular therapy versus open surgical repair for the traumatic lower extremity arterial injury

OBJECTIVE

For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury.

METHODS

The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates.

RESULTS

A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21-0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20-0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75-1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%-27%).

CONCLUSION

Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.

Contemporary management and time to revascularization in upper extremity arterial injury

INTRODUCTION

Upper extremity arterial injury is associated with significant morbidity and mortality for trauma patients, but there is a paucity of data to guide the clinician in the management of these injuries. The goals of this review were to characterize the demographics, presentation, clinical management, and outcomes, and to evaluate how time to intervention associates with outcomes in trauma patients with upper extremity vascular injuries.

METHODS

The National Trauma Data Bank (NTDB) Research Data Set for the years 2007-2016 was queried in order to identify adult patients (age ≥ 18) with an upper extremity arterial injury. Patients with brachiocephalic, subclavian, axillary, or brachial artery injury using the 1998 and 2005 versions of the Abbreviated Injury Scale were included. Patients with non-survivable injuries to the brain, traumatic amputation, or other major arterial injuries to the torso or lower extremities were excluded.

RESULTS

The data from 7908 patients with upper extremity arterial injuries was reviewed. Of those, 5407 (68.4%) underwent repair of the injured artery. The median Injury Severity Score (ISS) was 10 (IQR = 7-18), and 7.7% of patients had a severe ISS (≥ 25). Median time to repair was 120 min (IQR = 60-240 min). Management was open repair in 52.3%, endovascular repair in 7.3%, and combined open and endovascular repairs in 8.8%; amputation occurred in 1.8% and non-operative management was used in 31.6% of patients. Blunt mechanism of injury, crush injury, concomitant fractures/dislocations, and nerve injuries were associated with amputation, whereas simultaneous venous injury was not. There was a significant decrease in the rate of amputation when patients undergoing surgical revascularization did so within 90 min of injury (P = 0.007).

CONCLUSION

Injuries to arteries of the upper extremity are managed with open repair, endovascular repair, and, rarely, amputation. Expeditious transport to the operating room for revascularization is the key for limb salvage.

Delayed revascularization of extremities following vascular injuries: Challenges and outcome

Purpose

In developing countries delayed presentation following major vascular injury is common due to limited vascular trauma units; delay in diagnosis and time lost in transit which pose a major challenge for limb salvage. Aim of this study was to assess limb survival and complications after delayed revascularization of extremity following major vascular injury.

Method

20 patients, (19 males and 1 female, mean age 31.55 years) with major extremity vascular injury who presented >8 h after vascular trauma were included in this study. All patients had road traffic accidents as the cause of extremity injury. These patients were operated by primary vascular repairs, thrombectomy and/or interposition vein graft along with fixation of concomitant skeletal trauma.

Results

The commonest vessel injured was popliteal artery. The mean time of limb revascularization was 30.8 h. Limb salvage rate was 95% and there was no perioperative mortality. 9 patients developed postoperative complications including sloughing of leg muscles (4), foot drop (3) pseudo aneurysm (1) and reperfusion injury (1). At 6 months follow-up all the patients were able to walk with full weight bearing and there was no chronic ischemia, pain or sinuses.

Conclusion

Limb salvage can be achieved with good results in patients with delayed revascularization in selected cases. However; delayed revascularization leads to long and protracted postoperative course with high chances of vascular and neurological complications.

Patency of arterial repairs from wartime extremity vascular injuries

BACKGROUND

Extremity vascular injury (EVI) causes significant disability in Veterans of the Afghanistan/Iraq conflicts. Advancements in acute trauma care improved survival and decreased amputations. The study of wartime EVI has relied on successful limb salvage as a surrogate for vascular repair. We used imaging studies as a specific measure of arterial repair durability.

METHODS

Service members with EVI were identified using the Department of Defense Trauma Registry and validated by chart abstraction. Inclusion criteria for the arterial patency subgroup included an initial repair attempt with subsequent imaging reports (duplex ultrasound, CT angiography, and angiogram) documenting initial patency.

RESULTS

The cohort of 527 included 140 Veterans with available imaging studies for 143 arterial repairs; median follow-up from injury time to last available imaging study was 19 months (Q1-Q3: 3-58; range: 1-175). Injury mechanism was predominantly explosions (52%) and gunshot wounds (42%). Of the 143 arterial repairs, 81% were vein grafts. Eight repairs were occluded, replaced or included in extremity amputations. One upper extremity and three transtibial late amputations were performed for chronic pain and poor function averaging 27 months (SD: 4; range: 24-32). Kaplan-Meier analysis estimated patency rates of 99%, 97%, 95%, 91% and 91% at 3, 6, 12, 24, and 36 months, respectively, with similar results for upper and lower extremity repairs. Explosive and gunshot wound injury mechanisms had similar patency rates and upper extremity injuries repaired with vein grafts had increased patency.

CONCLUSIONS

Arterial repair mid-term patency in combat-related extremity injuries is excellent based on imaging studies for 143 repairs. Assertive attempts at acute limb salvage and vascular repair are justified with decisions for amputation versus limb salvage based on the overall condition of the patient and degree of concomitant nerve, orthopedic and soft tissue injuries rather than the presence of arterial injuries.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Endovascular repair is a feasible option for superficial femoral artery injuries: a comparative effectiveness analysis

PURPOSE

To compare outcomes between open (OR) and endovascular repair following superficial femoral artery (SFA) injuries.

METHODS

This is a cross-sectional study querying the 2012-2014 National Inpatient Sample for SFA injuries. Patients were grouped into OR and stent-graft placement (SGP). Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), fasciotomy and amputation rate, and cost. Wilcoxon rank-sum, Kruskal-Wallis, Chi-squared test with Bonferroni adjustment were used as appropriate; p < 0.05 was significant.

RESULTS

255 Patients were identified. Mean age was 34.6 years and majority were males. OR was performed in 82.7%. Overall mortality rate was 3.7%. Median HLOS was 8 days. Fasciotomies were performed in 31% and lower limb amputations in 3.7%. Males more often underwent OR (89.0% vs. 73.1%, p < 0.01). SGP patients were significantly older (44.9 vs. 32.5 years; p < 0.01), and with Medicare insurance (20.5% vs. 6.5%; p < 0.01. Mortality, HLOS, and hospitalization cost were not significantly different. OR patients had higher rate of fasciotomy (35.4% vs. 15.4%; p < 0.01).

CONCLUSIONS

Endovascular management is not inferior to OR following SFA injuries and both carry a low amputation rate. OR is associated with a higher fasciotomy rate. Endovascular repair should be considered when technically feasible.

Endovascular Stenting for a Crush Injury of the Common Femoral Artery Followed by Open Repair of Unveiled External Iliac Vein Injury after a Horse Fall

Accurate diagnosis and management of a femoral vascular injury is important as it is a life-threatening injury with high morbidity and mortality. This is the case of a 75-year-old man admitted to the emergency room with trauma to the right groin due to a horse fall. Computed tomography showed active bleeding of the femoral artery without pelvic or femoral fracture. We inserted a stent-graft, but hypotension persisted. Exploration of the groin was completed, and the bleeding from the external iliac vein was identified and repaired. In conclusion, vascular injury is rare in groin trauma without associated fracture, however, arterial and venous injury should not be completely ruled out. Endovascular therapy is worth recommending as a quicker and safer management than surgery in patients with active bleeding in the femoral artery. However, the possibility of combined injury of the femoral vein should be suspected in case of ongoing hemodynamic instability.

Successful superselective embolization with n-butyl cyanoacrylate for hemorrhage from superficial femoral artery branches following blunt trauma: Three case reports

INTRODUCTION

In blunt traumatic superficial femoral arterial (SFA) injuries, hemorrhage from the branches without injury to the main artery is rare, but can lead to serious complications, such as compartment syndrome affecting the clinical outcomes. Although open surgical repair has been the standard approach to peripheral vascular injuries, endovascular treatment has become more refined and is now an alternative to open surgery, which potentially involves lower morbidity and mortality rates. However, management of arterial injuries, especially when they involve simple bleeding from small branches of the main artery, can be challenging, and the best treatment options for such injuries remains controversial.

PATIENT CONCERNS

Three cases suffered blunt trauma that resulted in hemorrhage from branches of the SFA.

DIAGNOSIS

All patients underwent selective angiography, which demonstrated active extravasation from branches of the SFA.

INTERVENTIONS

All patients were treated using embolization with n-butyl cyanoacrylate (NBCA).

OUTCOMES

A post-embolization angiography demonstrated successful hemostasis, with no complications.

CONCLUSION

Superselective catheterization using a coaxial technique with a 5-F curved catheter and the smallest caliber microcatheter, and using a permanent liquid embolic agent, such as NBCA, increases the success rate of embolization for cases of hemorrhage from SFA branches.