The Outcomes of Salvage Surgery for Vascular Injury in The Extremities: A Special Consideration For Delayed Revascularization

Abstract

A seven years retrospective study was performed in 45 consecutive vascular injuries in the extremities to investigate the pattern of injuries, managements and outcomes. Motor-vehicle accidents were the leading cause of injuries (80%), followed by industrial injuries (11.1%) and iatrogenic injuries (4.4%). Popliteal and brachial artery injuries were commonly involved (20%). Fifteen (33.3%) patients had fractures, dislocation or fracture dislocation around the knee joint and 6 (13.3%) patients had soft tissue injuries without fracture. Traumatic arterial transection accounted for 34 (75.6%) cases, followed by laceration in 7 (15.6%) and 9 (6.7%) contusions. Associated nerve injuries were seen in 8 (17.8 %) patients using intra-operative findings as the gold standard, both conventional angiogram (CA) and computerized tomography angiogram (CTA) had 100% specificity and 100% sensitivity in determining the site of arterial injuries.The mean ischemic time was 25.31 hours (4 - 278 hours). Thirty-three (73.3 %) patients were treated more than 6 hours after injury and 6 patients underwent revascularization after 24 hours; all had good collateral circulation without distal pulses or evidence of ischemic neurological deficit. The mean ischemic time in 39 patients who underwent revascularization within 24 hours was 13.2 hours. Delayed amputation was performed in 5 patients (11.1%). Of the 6 patients who underwent delayed revascularization, one patient had early amputation, one -had delayed amputation following infection and multiple flap procedures while the rest of the patients’ limbs survived. Joint stiffness was noted in 10 patients (22.2%) involving the knee joint, elbow and shoulder in two patients each. Infection was also noted in 5 patients (11.1%) with two of them were due to infected implants. Other complications encountered included nonunion (2 patients, 4.4%), delayed union (1 patient, 2.2%),limb length discrepancy (1 patient, 2.2%), hematoma (1 patient, 2.2%) and leaking anastomosis in one patient (2.2%). Volkmann’s ischemic contracture occurred in 3 (6.7%) patients. There was no complication noted in 8 (17.8%) patients Three patients (6.7%) died of whom two were not due to vascular causes. We conclude that early detection and revascularization of traumatic vascular injuries is important but delayed revascularization also produced acceptable results.

Outcome Assessments of Patients with Posttraumatic “Ultra-Time Vascular Injuries” of the Extremities

“…Akula et al 18 considered that lower limb reconstruction was more acceptable psychologically to patients with severe lower limb trauma compared with amputation, and that timely and regular functional training further improved patients’ lives 19 . For ultra-time vascular injuries, delayed revascularization of the limb is critical to the success of limb salvage, and it frequently involves the use of interposition grafting with autogenous saphenous vein grafts or end-to-end anastomoses 20 , and, as demonstrated by the three cases that required the establishment of individual management programs, the coordination of surgery and postoperative treatment can improve the limb preservation rate.…”

Successful limb salvage beyond the golden time following blunt traumatic open complete transection of the femoral artery and vein in a patient with cardiac arrest: a case report

“…Hence, even though the Mangled Extremity Severity Score of our patient was 12 [18], we carefully observed and assessed limb perfusion by Doppler and prioritized resuscitation of the patient. Although we bypassed the femoral vessels approximately 24 h after the injury, no reperfusion-related morbidities or signs of compartment syndrome were observed as recently reported elsewhere [14,19]. Even if there is no choice but to ligate the femoral vessels in an abbreviated surgery, the patient should be resuscitated from the viewpoint of careful assessment of whether the limb can be salvaged.…”

“…The golden time for revascularization of the extremities is considered to be within 6 to 8 h after the injury [14][15][16][17], but CECT and pulse Doppler examinations fortunately revealed collateral perfusion to the injured distal lower limb. Hence, even though the Mangled Extremity Severity Score of our patient was 12 [18], we carefully observed and assessed limb perfusion by Doppler and prioritized resuscitation of the patient.…”

Outcomes of Revascularization and Factors Associated With Major Amputation in Patients With Lower Limb Arterial Injury: A Single-Center Retrospective Analysis

“…Although, prolonged ischemia (>6 hours ) is associated with four times higher risk of secondary amputation. However, there is evidence of successful limb salvage following arterial injury in literature even after 24 hours of injury [17]. We assessed vascular injuries, the number of segments involved, and the availability of collateral by using readily available color Doppler ultrasound as it has 95% sensitivity and 99% specificity [18].…”