Epidemiology and outcomes of traumatic vascular injury repair by trauma surgeons and vascular surgeons in a collaborative model

BACKGROUND

Management roles for peripheral vascular injuries (PVI) are a source of ongoing debate given the concern for the loss of vascular skills among general surgeons and trauma surgeons (TS). We sought to analyze outcomes of PVI managed by TSs or vascular surgeons (VSs).

METHODS

This is a retrospective study of a single, Level I trauma center. Trauma patients with PVI who underwent repair from 2010 to 2021 were included. Patients were separated into groups by the surgical specialty (TS or VS) undertaking the first intervention of the injured vessel.

RESULTS

A total of 194 patients were included, with 101 (52%) PVI managed by TS and 93 (48%) by VS. The TS group had more penetrating injuries (84% vs. 63%, p < 0.01), were more often hypotensive (17% vs. 6%, p = 0.01), and had a higher median Injury Severity Score (10 vs. 9, p < 0.001). Time from arrival to operating room was lower in the TS group (77 vs. 257 minutes, p < 0.01), with no difference in rates of preoperative imaging. The TS group performed damage-control surgery (DCS) more frequently (21% vs. 1.1%, p < 0.01). There was no difference in reintervention rates between the two groups after excluding patients that required reintervention for definitive repair after DCS (13% vs. 9%, p = 0.34). Mortality was 8% in the TS group and 1% in the VS group ( p = 0.02) with no deaths related to the PVI repair in either group. There was no difference in PVI repair complication rates between the two groups (18% vs. 13%; p = 0.36).

CONCLUSION

In our collaborative model at a high-volume trauma center, a wide variety of PVI are surgically managed by TS with VS. immediately available for consultation or for definitive repair of more complex vascular injuries. Trauma surgeons performed more DCS on higher acuity patients. No difference in vascular-related complications was detected between groups.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Vascular Surgery Role in Vascular Trauma: 11-Year Analysis of Peripheral Vascular Trauma Management at a Level-1 Trauma Center

BACKGROUND

Vascular surgeons are increasingly relied upon in the management of complex peripheral vascular trauma. The degree however that vascular surgery (VS) is involved in vascular trauma care is not well established. We hypothesize that VS consultation is required in a high portion of complex lower extremity vascular trauma.

METHODS

A single-center retrospective review of all consecutive patients who sustained traumatic arterial injury of the lower extremity requiring open operative repair at a level-1 trauma center (from February 2009 to May 2020) was performed. Patients who underwent surgical repair were stratified by the service that performed the operation (VS versus trauma surgery [TS]). Secondary outcomes assessed included location of arterial injury, type of repair, and clinical outcomes.

RESULTS

A total of 111 patients underwent operative repair of lower extremity arterial injury (mean age 34.5 ± 15.5 years, 89% male). The most common vessels requiring intervention were the superficial femoral artery (n = 42, 38%), popliteal artery (n = 35, 31.5%), and tibial vessels (n = 19, 17.1%). The most common intervention required in patients was an autologous bypass (n = 85, 76.5%), followed by ligation (n = 9, 8.1%) and primary repair (n = 6, 5.4%). Most interventions overall required VS involvement (n = 95, 86%). VS performed a higher proportion of autologous graft procedures compared to TS (n = 79, 92.9% vs. n = 6, 7.1%). VS case load overall was likewise predominantly autologous grafts (n = 79/95, 83.2%). TS operated on a higher proportion of injuries to the tibial vessels (44% vs. 13%, P = 0.01), whereas VS intervened more frequently on popliteal injuries (36% vs. 6%, P = 0.02). With regard to the method of arterial repair, TS was more likely to perform ligation (38% vs. 3 %, P < 0.001) or primary repair (13% vs. 3%, P = 0.04) compared to VS. However, VS was more likely to perform repair with autologous graft (83% vs. 38%, P < 0.001). There were no significant differences in rates of mortality, limb loss, transfusions requirement, fasciotomy, deep venous thrombosis, hematoma formation, or length of stay between groups. Although, surgical site infections were more common in the TS group (38% vs. 15%, P = 0.04).

CONCLUSIONS

Vascular surgeons play a large role in managing complex lower extremity vascular trauma. In particular, VS remains integral for the management of more difficult injuries (e.g., popliteal injuries) and is more likely to provide more complex repairs (e.g., autologous grafts).

Trauma surgeon-performed peripheral arterial repairs are associated with equivalent outcomes when compared with vascular surgeons

BACKGROUND

Civilian extremity trauma with vascular injury carries a significant risk of morbidity, limb loss, and mortality. We aim to describe the trends in extremity vascular injury repair and compare outcomes between trauma and vascular surgeons.

METHODS

We performed a single-center retrospective review of patients 18 years or older with extremity vascular injury requiring surgical intervention between January 2009 and December 2019. Demographics, injury characteristics, operative course, and hospital course were analyzed. Descriptive statistics were used to examine management trends, and outcomes were compared for arterial repairs. Multivariate regression was used to evaluate surgeon specialty as a predictor of complications, readmission, vascular outcomes, and mortality.

RESULTS

A total of 231 patients met our inclusion criteria; 80% were male with a median age of 29 years. The femoral vessels were most commonly injured (39.4%), followed by the popliteal vessels (26.8%). Trauma surgeons performed the majority of femoral artery repairs (82%), while vascular surgeons repaired the majority of popliteal artery injuries (84%). Both had a similar share of brachial artery repairs (36% vs. 39%, respectively). There were no differences in complications, readmission, vascular outcomes, and mortality. Median time from arrival to operating room was significantly shorter for trauma surgeons. There was a significant downward trend between 2009 and 2017 in the proportion of total and femoral vascular procedures performed by trauma surgeons. On multivariate regression, surgical specialty was not a significant predictor of need for vascular reintervention, prophylactic or delayed fasciotomies, postoperative complications, or readmissions.

CONCLUSION

Traumas surgeons arrived quicker to the operating and had no difference in short-term clinical outcomes of brachial and femoral artery repairs compared with patients treated by vascular surgeons. Over the last decade, there has been a significant decline in the number of open vascular repairs done by trauma surgeons.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

Vascular Surgeons Carry an Increasing Responsibility in the Management of Lower Extremity Vascular Trauma

BACKGROUND

There is preliminary evidence that vascular surgeons are increasingly relied on nationally to assist with the management of lower extremity vascular trauma. Current trauma center verification, however, does not require any level of vascular surgery coverage. We sought to assess practice patterns regarding vascular surgery consultation and temporal trends in the surgical management of these patients.

METHODS

A retrospective analysis was performed on all patients who underwent surgical repair for vascular trauma of the lower extremity at a single, academic, public hospital from 2011 to 2018. Demographic data and procedural data were collected. Patients were assigned to a vascular surgery (VS) or nonvascular surgery (NV) group. The primary outcome measure was the rate of VS consultation. Secondary outcome measures included 30-day mortality, length-of-stay, and limb salvage.

RESULTS

One hundred eighty patients were identified (77 VS group, 103 NV group). There was an increase in the proportion of repairs done by VS from 2011 to 2018 (P < 0.05). There were significant management differences between the 2 groups, with vascular surgeons more likely to perform primary end-to-end anastomosis for both arterial (21.33% vs. 6.90%) and venous (19.15% vs. 5.26%) injuries (both P < 0.05). Patients in the VS group were less likely to have balloon embolectomy, fasciotomy, or intravascular shunting than the NV group (all P < 0.05). There were no significant differences in mortality (5.35% vs. 4.85%), length-of-stay (15.05 vs. 18.38 days), or limb salvage (94.81% vs. 95.15%).

CONCLUSIONS

Lower extremity vascular trauma is increasingly managed by vascular surgeons. Furthermore, vascular surgeons are more selective in the use of potentially unnecessary adjunctive maneuvers. Current accreditation guidelines should be revisited to mandate vascular surgery coverage in trauma centers that frequently treat this patient population.

Racial Disparities in Limb Amputations After Traumatic Vascular Injury

OBJECTIVES

The influence of race or ethnicity on limb loss after traumatic vascular injury is unclear. We sought to determine whether there were racial differences in rates of amputation between American Indians, blacks, Asians, and Hispanics compared to white patients following arterial axillosubclavian vessel injury (ASVI), femoral artery injury (FAI), or popliteal artery injury (PAI). As black race has been identified as an independent prognostic factor for postsurgical complication in trauma-associated lower extremity amputation, we further hypothesized that black race would be associated with a higher risk for limb loss after arterial ASVI, FAI, and PAI injury in a large national database.

METHODS

The National Trauma Data Bank was queried for patients ≥16-years-old with arterial ASVI, FAI, or PAI to determine the risk of arm, above knee amputation (AKA), and below knee amputation (BKA), respectively. Covariates were included in separate multivariable logistic regression models for analysis. The reference group included white trauma patients.

RESULTS

From 5,683,057 patients, 21,843 were identified with arterial ASVI, FAI, or PAI (<0.4%). For arterial ASVI, American Indian race was associated with higher risk for upper-extremity amputation as compared to white race (OR = 5.10, CI = 1.62-16.06, p < 0.05). For FAI, black race was associated with (OR = 0.66, CI = 0.49-0.89, p < 0.05) a lower risk of AKA, compared to white race. For PAI, race was not associated with risk for BKA.

CONCLUSION

Black race is associated with a lower risk of AKA after FAI, compared to whites. Race was not associated with a risk for limb loss after PAI. Future prospective studies examining socioeconomic factors and access to healthcare within this patient population is warranted to identify barriers and areas of improvement.