Challenges in the management of extremity vascular injuries: A wartime experience from a tertiary centre in Sri Lanka

Abstract

BackgroundManagement of peripheral vascular injuries often present critical challenges in resource limited settings of developing countries. The additional burden from a military conflict poses further challenges. Delays in presentation often result in the loss of limb and even life, in what is usually a young active population. The objective of this report is to analyse the early outcome of vascular intervention at a tertiary referral centre in Sri Lanka.MethodsA retrospective descriptive review of eighty one consecutive extremity vascular injuries in seventy patients during a seven month period was performed with regards to the cause of injury, types of presentations, ischaemia time, interventional procedures, complications and early outcome.ResultsMean age was 31.2 years (9-72 years) and 96% were males. Injuries were caused by blasts in 41%, cuts in 26%, gunshots in 17% and road traffic injuries in 9%. Indications for revascularization were acute ischaemia in 44%, active bleeding in 43% and pseudo-aneurysms in 13%. Six patients underwent primary amputations due to non-viable limbs. 64 patients underwent vascular intervention. Fifty one percent needed vein grafts while 46% had direct repairs. Bleeding was often (73%) from upper extremity injuries. Median time to revascularization was 5.5 (2-16) hours with all limbs salvaged. Acute ischaemia (40%) was often from popliteal injuries. Median time to revascularization was 10 (5-18) hours and viability was prejudged at fasciotomy. 92% of revascularized limbs were salvaged. There was no perioperative mortality.ConclusionsResults from vascular repairs are encouraging despite significant delays.

Difficulties in the Management of Civilian Peripheral Vascular Trauma and their Complications at the University Teaching Hospital of Yaoundé, Cameroon

“…Male predominance due to the predominance of trauma in general in men compared to women is the same as in the literature [1][2][3][4][5][6][7][8]. The young age of our patients is also found in several studies.…”

“…However, we noted 3 cases of amputations in the 2 patients with popliteal lesions and the patient with brachial artery injury. The rate of amputation was 100% in acute setting very far from the one reported in the literature [1,3,8,10,11]. Revascularization procedure failed because patients came in late, they were operated more than 20 hours after the injury, there was no Fogarty catheter to remove distal clots.…”

“…These patients had associated injuries, bone lesions for the first two and nerve for the third and were operated beyond the recommended time. The association with other lesions, particularly bones and nerves and the delay of treatment are the main risk factors for amputation found in the literature [1,3,8,10,12]. Some lesions as popliteal artery injury have a high risk of amputation that may exceed 50% in the study of Li et al [10].…”

“…We have found only 3 cases associated with bone and nerve lesions. Bone and nerve lesions have been the most commonly reported associated lesions in several publications [1,2,7,8]. Aduful et al in Ghana [1] found further significant muscle injuries in 21.2% of cases.…”

“…If endovascular techniques (embolization, stenting) are widely used in the Western world for some vascular injuries [18], open surgery keeps a place of choice for many authors with good results [6][7][8][9]. However, endovascular techniques in properly selected patients offer many advantages.…”