Associated venous injury significantly complicates presentation, management, and outcomes of axillosubclavian arterial trauma

Long-term functional outcomes of upper extremity civilian vascular trauma

OBJECTIVE

Civilian analyses of long-term outcomes of upper extremity vascular trauma (UEVT) are limited. Our goal was to evaluate the management of UEVT in the civilian trauma population and explore the long-term functional consequences.

METHODS

A retrospective review and analysis was performed of patients with UEVT at an urban Level 1 trauma center (2001-2022). Management and long-term functional outcomes were analyzed.

RESULTS

There were 150 patients with UEVT. Mean age was 34 years, and 85% were male. There were 42% Black and 27% White patients. Mechanism was penetrating in 79%, blunt in 20%, and multifactorial in 1%. Within penetrating trauma, mechanism was from firearms in 30% of cases. Of blunt injuries, 27% were secondary to falls, 13% motorcycle collisions, 13% motor vehicle collisions, and 3% crush injuries. Injuries were isolated arterial in 62%, isolated venous in 13%, and combined in 25% of cases. Isolated arterial injuries included brachial (34%), radial (27%), ulnar (27%), axillary (8%), and subclavian (4%). The majority of arterial injuries (92%) underwent open repair with autologous vein bypass (34%), followed by primary repair (32%), vein patch (6.6%), and prosthetic graft (3.3%). There were 23% that underwent fasciotomies, 68% of which were prophylactic. Two patients were managed with endovascular interventions; one underwent covered stent placement and the other embolization. Perioperative reintervention occurred in 12% of patients. Concomitant injuries included nerves (35%), bones (17%), and ligaments (16%). Intensive care unit admission was required in 45%, with mean intensive care unit length of stay 1.6 days. Mean hospital length of stay was 6.7 days. Major amputation and in-hospital mortality rates were 1.3% and 4.6% respectively. The majority (72%) had >6-month follow-up, with a median follow-up period of 197 days. Trauma readmissions occurred in 19%. Many patients experienced chronic pain (56%), as well as motor (54%) and sensory (61%) deficits. Additionally, 41% had difficulty with activities of daily living. Of previously employed patients (57%), 39% experienced a >6-month delay in returning to work. Most patients (82%) were discharged with opioids; of these, 16% were using opioids at 6 months.

CONCLUSIONS

UEVT is associated with long-term functional impairments and opioid use. It is imperative to counsel patients prior to discharge and ensure appropriate follow-up and therapy.

Impact of Endovascular Stenting on Outcomes in Patients with Traumatic Subclavian Artery Injury

BACKGROUND

Traumatic subclavian artery injury (SAI) remains uncommon but can lead to significant morbidity and mortality. Although open and endovascular repair offer excellent limb salvage rates, their role in blunt and penetrating injuries is not well defined. The goal of this study was to examine the effect of mechanism of injury and type of repair on outcomes in patients with traumatic SAI.

STUDY DESIGN

Patients undergoing procedures for traumatic SAI were identified from the Trauma Quality Improvement Program database between 2015 and 2018. Demographics, severity of injury and shock, type of subclavian repair (open vs endovascular), morbidity, and mortality were recorded. Patients with SAI were stratified by mechanism and type of repair and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality.

RESULTS

Seven hundred thirty-seven patients undergoing procedures for SAI were identified. Of these, 39% were penetrating. The majority were male (80%) with a median age and Injury Severity Score (ISS) of 37 and 21, respectively. 58% of patients were managed endovascularly. For patients with blunt injury, the type of repair affected neither morbidity (25% vs 19%, p = 0.116) nor mortality (11% vs 10%, p = 0.70). For patients with penetrating injuries, endovascular repair had significantly lower morbidity (12% vs 22%, p = 0.028) and mortality (6% vs 21%, p = 0.001). MLR identified endovascular repair as the only modifiable risk factor associated with reduced mortality (odds ratio, 0.35; 95% confidence interval, 0.14 to 0.87, p = 0.02).

CONCLUSIONS

SAI results in significant morbidity and mortality regardless of mechanism. Although the type of repair did not affect mortality in patients with blunt injury, endovascular repair was identified as the only modifiable predictor of reduced mortality in patients with penetrating injuries.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries

The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Readmissions after Firearm Injury Requiring Vascular Repair

BACKGROUND

Firearm injuries can be morbid and potentially have high resource utilization. Historically, trauma and vascular surgery patients are at higher risk for readmissions. Our goal was to assess the risk for readmission among patients undergoing vascular repair after a firearm injury.

METHODS

The National Readmission Database was queried from 2011 to 2014. All firearm injuries with or without vascular repair were analyzed. Multivariable analysis was conducted to assess the effect of concurrent vascular repair on readmissions at 30, 90, and 180 days.

RESULTS

There were 42,184 firearm injury admissions identified, where 93.3% did not undergo vascular repair and 6.7% required vascular repair. The overall in-hospital death rate was 8.2%. Average age was 29.9 ± 0.2 years, and 89.2% were male. Intent was most frequently assault (61.2%) followed by unintentional injury (26.5%), suicide (5.2%), and legal intervention (3.1%). Patients with vascular repair compared to those without vascular repair were more frequently admitted at teaching hospitals (85.2% vs. 81.8%, P = 0.042), had higher Agency for Healthcare Research and Quality (AHRQ) extreme severity of illness, AHRQ risk of mortality, New Injury Severity Score (NISS), and had more diagnoses and procedures (P < 0.0001). Patients with vascular repair compared to those without vascular repair also more frequently sustained abdominal/pelvis injury (40.4% vs. 23.4%, P < 0.0001) and were more likely to have anemia (5.9% vs. 3.6%, P = 0.009). Patients undergoing vascular repair had a higher rate for 30-day (8.9% vs. 5.5%, P = 0.0001), 90-day (18.1% vs 9.5%, P < 0.0001), and 180-day (22.3% vs. 13%, P < 0.0001) readmission. Kaplan-Meier analysis of unadjusted data showed a higher readmission rate over time with vascular repair. Multivariable analysis demonstrated that vascular repair was not associated with higher 30-day readmission (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.92-1.72, P = 0.14) but was for 90-day (OR 1.38, 95% CI 1.14-1.68, P = 0.001) and 180-day readmission (OR 1.24, 95% CI 1.06-1.45, P = 0.009). Additional factors associated with 30-day readmission were higher NISS, discharge to a care facility, and Elixhauser score. Other factors associated with 90-day readmission were unintentional intent of injury, NISS, discharge to a care facility, and Elixhauser score. Factors also associated with 180-day readmission were insurance type, unintentional intent of injury, NISS, care facility discharge, and Elixhauser score.

CONCLUSIONS

Firearm injury resulting in vascular injury was associated with increased readmissions at 90 and 180 days. This study establishes baseline rates for readmission after vascular repair for firearm traumas and allows opportunity for improvement through targeted interventions for these patients. Vascular surgeons can have a more active role in managing this high-profile public health issue.

Humerus fracture and combined venous injury increases limb loss in axillary or subclavian artery injury

OBJECTIVE

Axillosubclavian vessel injury is rare, with most cases occurring after penetrating trauma. A prior database (2002-2006) analysis demonstrated an overall limb loss rate of 2.9%, with no difference between isolated arterial axillosubclavian vessel injury and combined artery/vein axillosubclavian vessel injury. Given increases in advanced vascular surgical techniques, as well as improved multidisciplinary care and expeditious diagnosis with computed tomography angiography, we hypothesized the national rate of limb loss in patients with arterial axillosubclavian vessel injury has decreased. In addition, we attempted to identify current predictors for limb loss in arterial axillosubclavian vessel injury. Finally, we hypothesized that combined artery/vein axillosubclavian vessel injury, as well as associated brachial plexus injury will have a higher risk for limb-loss and mortality compared to isolated arterial axillosubclavian vessel injury.

METHODS

A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. All patients ≥ 18 years of age with arterial axillosubclavian vessel injury were included. The primary outcome was limb loss. After a univariable logistic regression model identified significant covariates, we performed a multivariable logistic regression for analysis.

RESULTS

Of the total 5,494,609 trauma admissions, 3807 patients had arterial axillosubclavian vessel injury (<0.1%). Of these, 3137 (82.4%) had isolated arterial axillosubclavian vessel injury and 670 (17.6%) had combined artery/vein axillosubclavian vessel injury. The overall limb loss rate was 2.4% (from 2.9% in 2006, p = 0.47). After adjusting for covariates, independent risk factors for limb loss included a combined artery/vein axillosubclavian vessel injury (odds ratio = 3.54, confidence interval = 2.06-6.11, p < 0.001), blunt mechanism (odds ratio = 7.81, confidence interval = 4.21-14.48, p < 0.001), open repair (odds ratio = 2.37, confidence interval = 1.47-3.82, p < 0.001), and open proximal humerus fracture (odds ratio = 8.50, confidence interval = 4.97-14.54, p < 0.001). An associated brachial plexus injury was not associated with limb loss ( p = 0.37). Combined artery/vein axillosubclavian vessel injury was associated with higher risk for mortality compared to isolated arterial axillosubclavian vessel injury (odds ratio = 2.17, confidence interval = 1.73-2.71, p < 0.001).

CONCLUSIONS

The national rate of limb loss in trauma patients with arterial axillosubclavian vessel injury has not changed in the past decade. A combined artery/vein axillosubclavian vessel injury is an independent risk factor for limb loss, as well as open repair. However, the strongest risk factor is an open proximal humerus fracture. An associated brachial plexus injury is not associated with increased risk of limb loss. Patients with combined artery/vein axillosubclavian vessel injury have a twofold increased risk of death compared to patients with isolated arterial axillosubclavian vessel injury.