Penetrating injuries of the iliac arteries: a South African experience

Fatal penetrating iliac wound: A case report with determination of physical activity and time to collapse

A case of fatal left iliac penetrating wound in a thirty-year-old man, during a fight, was presented. The medical file described a transfixing five-centimeter large wound on the left iliac vein and a puncture wound on the left iliac artery. After performing an autopsy, we concluded that the death was secondary to multivisceral failure, secondary to hemorrhagic shock. The judge investigating the case requested a detailed forensic medical reconstructive opinion focusing on the sequence of events leading to the fatal blow. Our having access to the videorecording and the photographs of the crime scene, added to the testimonies of witnesses proved to be a great help to the investigation. The data from the crime scene video recordings allowed us to estimate the victim's physical activity after the fatal stabbing (running between 20 and 140 meters) and the time when he collapsed (between 32s and 1 min) after the stabbing which is rarely described with methods using Closed-Circuit Television material, especially in cases of fatal vascular injuries. Those data are usually estimated from eyewitnesses' accounts, which remain an unreliable method.

Repair of the Iliac Arterial Injury in Trauma: An Endovascular Operation?

BACKGROUND

Endovascular therapy is effective for non-traumatic iliac arterial diseases. The role of endovascular surgery in traumatic iliac lesions is unclear. The aim of this study is to compare outcomes for open versus endovascular management of traumatic iliac injuries.

MATERIALS AND METHODS

The National Trauma Data Bank was searched for patients from 2002to 2016 with iliac arterial injury. Patients were sorted by treatment modality (open versus endo) and mechanism (blunt versus penetrating) and matched using mangled extremity score variables. The proportion of patients undergoing amputation were compared using the chi-square test.

RESULTS

In the blunt group, 1550 (82%) had endovascular and 342 (18%) had open repair. Endovascular repair was associated with a significantly lower amputation rate than open repair (0.6% versus 3.6%, P = 0.015) despite higher incidence of concomitant injuries. Venous injury was more frequent in the open group (13.7% versus 1.8%, P < 0.001). Within the penetrating group, 209 (22%) had endovascular and 755 (78%) had open repair. Again endovascular repair was associated with a lower amputation rate (0% versus 5.1%, P = 0.004). Patients undergoing endovascular repair had more severe extremity/orthopedic injury, with venous injury again associated with open repair (48.5% versus 37.4%, P = 0.03).

CONCLUSIONS

Endovascular repair of iliac injuries was associated with a significantly lower rate of amputation than open surgery. Endovascular repair was associated with a higher incidence of several injuries, although open repair was associated with concomitant venous injury. Further work is required to delineate the benefit of endovascular intervention and role of venous injury in limb salvage.

Characterization and Outcomes of Iliac Vessel Injury in the 21st Century

Introduction:

Iliac vessel trauma (IVT) is traditionally associated with high mortality. We evaluated a modern series of patients with IVT to assess current outcomes and endovascular therapy use.

Methods:

We performed a retrospective review of the National Trauma Data Bank. Patients with IVT were stratified by blunt and penetrating mechanism and arterial and venous injury.

Results:

In blunt IVT, there was no significant difference in mortality between those with and without pelvic fractures (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.36-1.06). In penetrating IVT, combined arterial and venous IVT was associated with higher mortality (OR 1.70, 95% CI 1.06-2.70) compared to isolated arterial IVT. Isolated venous IVT was associated with lower mortality (OR 0.55, 95% CI 0.35-0.85) compared to isolated arterial IVT. Endovascular stenting was utilized in 11.3% of blunt IVT with pelvic fractures, 6.3% of blunt IVT without pelvic fractures, and 1.8% of penetrating IVT.

Conclusion:

Iliac Vessel Trauma has significant mortality. Endovascular intervention for IVT is applied sparingly.

A heuristic approach and heretic view on the technical issues and pitfalls in the management of penetrating abdominal injuries

There is a general decline in penetrating abdominal trauma throughout the western world. As a result of that, there is a significant loss of expertise in dealing with this type of injury particularly when the patient presents to theatre with physiological instability. A significant percentage of these patients will not be operated by a trauma surgeon but, by the "occasional trauma surgeon", who is usually trained as a general surgeon. Most general surgeons have a general knowledge of operating penetrating trauma, knowledge originating from their training years and possibly enhanced by reading operative surgery textbooks. Unfortunately, the details included in most of these books are not extensive enough to provide them with enough armamentaria to tackle the difficult case. In this scenario, their operative dexterity and knowledge cannot be compared to that of their trauma surgeon colleagues, something that is taken for granted in the trauma textbooks. Techniques that are considered basic and easy by the trauma surgeons can be unfamiliar and difficult to general surgeons. Knowing the danger points and pitfalls that will be encountered in penetrating trauma to the abdomen, will help the occasional trauma surgeons to avoid intraoperative errors and improve patient care. This manuscript provides a heuristic approach from surgeons working in a high volume penetrating trauma centers in South African. Some of the statements could be considered heretic by the "accepted" trauma literature. We believe that this heuristic ("rule of thumb" approach, that originating from "try and error" experience) can help surgical trainees or less experienced in penetrating trauma surgeons to improve their surgical decision making and technique, resulting in better patient outcome.

Damage control techniques for common and external iliac artery injuries: have temporary intravascular shunts replaced the need for ligation?

BACKGROUND

Trauma to the common or external iliac arteries has a mortality rate of 24% to 60%. "Damage control" options for these severely injured vessels are either ligation or temporary intravascular shunts (TIVSs). Complications of ligation include a 50% amputation rate and up to 90% mortality. The primary goal of this study was to identify the consequences of using ligation versus TIVS for common or external iliac artery injuries in damage control scenarios.

METHODS

All patients with injuries to an iliac artery (1995-2008) at a Level I trauma center were reviewed. Demographics and outcomes were analyzed using standard statistical methodology.

RESULTS

Iliac artery injuries were present in 88 patients (71 external and 17 common; 72% penetrating; median Injury Severity Score, 25; mean hospital stay, 28 days). Most nonsurvivors (73%) died of refractory shock within the first 24 hours after presenting with hemodynamic instability (66%). Ligation was required in one (6%) common and 14 (20%) external iliac arteries. TIVS was used in two (12%) common and five (7%) external iliac arteries. Patients requiring ligation (1995-2005) or TIVS (2005-2008) for their common or external iliac arteries had similar demographics and injuries (p > 0.05). Compared with patients who underwent ligation, patients receiving TIVS required fewer amputations (47% vs. 0%) and fasciotomies (93% vs. 43%; p < 0.05). Mortality in the ligation group was 73%, versus 43% in the TIVS cohort.

CONCLUSIONS

TIVSs have replaced ligation as the primary damage control procedure for injuries to common and external iliac arteries. As a result, the high incidence of subsequent amputation has been virtually eliminated. With increased TIVS experience, an improvement in survival is likely.

[Treatment of limb injuries at a regional center]

INTRODUCTION

The objective of the study was to analyse the causes of injury, surgical approaches, outcome, and complications with vascular trauma in patients operated on over a period between 1986-2006.

MATERIAL AND METHODS

In 128 patients with peripheral arterial injuries the mechanism was direct penetration in 90 cases and blunt injury in 30 cases. In 8 cases a chronic damage (false aneurysm, AV fistula) was observed. Isolated vascular trauma was present in 97 patients (75.8%), 31 cases (24.2%) were complicated by concomitant bone fractures,and nerve or soft tissue damage. Most frequently injured vessels were the superficial femoral (22.6%) crural (22.6%),and ulnar and radial (13.2%) arteries.

RESULTS

In 132 cases operation had to be performed. Direct suture 26, interposition in arterial injuries 26, interposition in venous injuries 5, end to end anastomosis in 12 cases, venous patches in 7 cases were the operation method. In 28 cases non-reconstructive operation was carried out, and there were 4 endovascular procedures. Five secondary amputations were performed and five patients died. The limb salvage rate was 95%.

DISCUSSION

Most vascular injuries of the extremities can be managed successfully unless associated with severe concomitant damage of the bones, nerves and soft tissues.

[Penetrating injuries to the pelvis]

As criminality and weapon use increase, general and military surgeons are increasingly confronted with penetrating pelvic injuries both at home and on peacekeeping missions. Penetrating injuries to the iliac vascular axis are associated with considerable mortality, and thus the majority of these emergency patients arrive in a state of deep hypovolemic shock. Concomitant bowel injuries are present in one of five cases, resulting in contamination of the damaged area. Surgical options are simple lateral repair, ligation of the veins, temporary shunt insertion, and prosthetic graft interposition in the injured artery. In extremis ligation of the common or external iliac artery may be the only option to save the patient's life. Surgeons must be aware that damage control surgery and related methods may be needed early on to enable patient survival.

Factors associated with mortality in patients with penetrating abdominal vascular trauma

OBJECTIVE

Prehospital transport, resuscitation, and operative intervention are all critical to the care of the penetrating trauma victim. We determined which factors most affected mortality in patients with penetrating abdominal vascular injuries.

METHODS

Consecutive patients with penetrating abdominal vascular injuries from an urban Level I trauma center from January 1993 to December 1998 were identified from the trauma registry and their charts reviewed. All patients who died prior to operative intervention were excluded. Data collected included mortality, age, scene time (ST), EMS transport time (TT), time in the emergency department (ED), initial systolic blood pressure in the ED (BP), operating time, intraoperative estimated blood loss (EBL), and worst base deficit in the first 24 h (BD). These variables were compared between nonsurvivors and survivors by univariate ANOVA. Multivariate ANOVA (MANOVA) determined independent effects on mortality.

RESULTS

Forty-six penetrating abdominal vascular injuries were identified in 31 patients, 11 of whom died (38.7%). Examining prehospital parameters, mean ST averaged 16.5 +/- 3.6 min, while TT was 31.8 +/- 7.1 min. For ED parameters, initial BP was 94.8 +/- 6.4 mm Hg and initial heart rate was 109 +/- 7 beats per minute. Mean operative EBL for all patients was 3518 +/- 433 ml. The mean BD for all patients was -12.9 +/- 1.8. Significant differences were noted in the univariate analysis between survivors and nonsurvivors for BD (P < 0.0001), BP (P = 0.0062) and EBL (P = 0.0002). MANOVA revealed that only base deficit (P < 0.0001) had an independent effect on mortality.

CONCLUSIONS

In patients with penetrating abdominal vascular injuries who survive their ED stay, adverse physiologic parameters reflecting the adequacy of resuscitation are more predictive of mortality than identifiable prehospital parameters.

Iliac vessel injuries

Trauma to the iliac vasculature continues to pose a significant challenge to management. In several large series, mortality for penetrating injuries is reported as approaching 40%. Uncontrollable hemorrhage originating from an anatomically inaccessible source and multiple associated injuries often contribute to this high mortality rate. This article discusses the current existing management strategies and the controversial role of PTFE in vascular reconstruction within a contaminated field. Concomitant injuries to the enteric viscera and genitourinary system are also addressed. Postoperative management including anticoagulation and the complications of liberal fasciotomy are mentioned. The evolving role of endovascular therapy as an adjunctive modality in the armamentarium of the trauma surgeon is also presented briefly.

Penetrating vascular trauma in Johannesburg, South Africa

An awareness that time crucially affects outcome underpins the principles of management of vascular injury. Patients with hard signs of vascular injury should undergo urgent exploration. Soft signs mandate investigation, and arteriography is still the standard of care. Noninvasive vascular imaging may prove its worth in the future. All patients with penetrating arterial injury should receive broad-spectrum antibiotic prophylaxis. Early repair of carotid artery injury provides the best likelihood of a neurologically intact survivor. There is a definite and emerging role of endovascular therapy both for difficult access injuries and for the later complications of vascular injury, such as false aneurysm and arteriovenous fistulas. The experimental and clinical evidence for the use of intraluminal shunts in peripheral vascular injury is compelling, and experience in their use is accumulating. Vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment; resuscitation and prompt revascularization are likely to lead to satisfactory outcomes. The major trauma load in South Africa represents an unparalleled experience in management of vascular injury, which seems likely to continue for the foreseeable future.

Vascular injuries of the limbs: a fifteen-year Georgian experience

OBJECTIVES

to analyse the causes of injury, surgical approaches, outcome and complication of vascular trauma of the upper and lower limbs in patients with vascular injuries operated on over a period between 1981 and 1995.

PATIENTS

in 157 patients, the injuries were penetrating in 136 cases and blunt in 21. Isolated vascular trauma was present in 92 (58.6%) patients, 65 cases (41.4%) were aggrevated by concomitant bone fractures, severe nerve and soft tissue damage. The most frequently injured vessels were the superficial femoral (20. 6%) and brachial (19.1%) arteries.

RESULTS

saphenous vein interposition grafting was applied with good results in 34 patients, polytetrafluoroethylene grafts were used in three cases, end-to-end anastomoses in 42 cases, venous bypasses in five cases, and venous patches in seven cases. Seventeen patients underwent arterial repair and nine, venous repair. Fasciotomy was used in 18 cases, and vessels were ligated in 14 cases. Blood flow was restored in 91 patients (58.0%), and collaterals compensated in 31 cases (19.7%). Fourteen primary and nine secondary amputations were performed. Twelve patients died. The limb salvage rate was 77.7% (84.1% among surviving patients).

CONCLUSIONS

most vascular injuries associated with limb trauma can be managed successfully unless associated by severe concomitant damage to bones, nerves and soft tissues.

Alternatives in the management of penetrating injuries to the iliac vessels

BACKGROUND

The high mortality and morbidity rates after iliac vessel injuries remain a challenging problem for trauma surgeons. Several controversial issues surround the management of iliac vessel injuries, including the value of abbreviated laparotomy, the role of extra-anatomic bypass reconstruction (EABR), the use of vascular prostheses in the presence of contamination, and the need and timing for fasciotomy.

METHODS

Retrospective review of the records of patients who sustained an injury to the iliac vessel between 1987 and 1996.

RESULTS

A total of 64 patients were treated, including 23 with isolated iliac vein injuries, 17 with arterial injuries, and 24 with combined arteriovenous injuries. Vascular prostheses were placed in 17 patients with arterial injuries, including 12 with associated intestinal wounds. Graft infection did not occur. Of the 24 patients with combined injuries, 11 underwent abbreviated laparotomy and 1 died. Five deaths, however, occurred in 13 patients in whom no attempts were made for damage control laparotomy. Significant differences between survivors and nonsurvivors included final arterial pH, final prothrombin time, length of hypotension, and number of transfusions. Arterial ligation with EABR was performed in five patients and failed in two. Deep venous thrombosis and pulmonary embolism occurred in four patients, in three of them after venous injuries were ligated. The overall mortality rate was 23%.

CONCLUSION

Our findings show that (1) abbreviated laparotomy reduces mortality in iliac injuries; (2) EABR should be performed early after stabilization to prevent limb ischemia; (3) the use of vascular prostheses with associated intestinal injuries did not appear to increase the incidence of graft infection; and (4) after vein ligation, early fasciotomy and prophylaxis against extremity swelling, deep venous thrombosis, and pulmonary embolism should be considered.