검색
검색 팝업 닫기

Advanced search

Article

Split Viewer

Korean J Thorac Cardiovasc Surg 2020; 53(5): 291-296

Published online October 5, 2020 https://doi.org/10.5090/kjtcs.19.087

Copyright © Journal of Chest Surgery.

Traumatic Peripheral Arterial Injury with Open Repair: A 10-Year Single-Institutional Analysis

Hoseong Cho, M.D.1 , Up Huh, M.D.1 , Chung Won Lee, M.D.1 , Seunghwan Song, M.D.1 , Seon Hee Kim, M.D.2 , Sung Woon Chung, M.D.1

Departments of 1Thoracic and Cardiovascular Surgery and 2Trauma Surgery, Pusan National University Hospital, Biomedical Research Institute, Pusan National University School of Medicine, Busan, Korea

Correspondence to:Up Huh
Tel 82-51-240-7267
Fax 82-51-243-9389
E-mail tymfoo82@gmail.com
ORCID https://orcid.org/0000-0002-7739-3979

Received: November 13, 2019; Revised: March 18, 2020; Accepted: April 12, 2020

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properlycited.

Background: We report our 10-year experience with traumatic peripheral arterial injury repair at an urban level I trauma center.
Methods: Between January 2007 and December 2016, 28 adult trauma patients presented with traumatic peripheral arterial injuries. Data were retrospectively collected on demographic characteristics, the mechanism of injury, the type of vascular injury, and physiological status on initial assessment. The analysis also included the Mangled Extremity Severity Score (MESS), Injury Severity Score, surgical procedures, and outcome variables including limb salvage, hospital stay, intensive care unit stay, and postoperative vascular complications.
Results: Four (14.3%) patients required amputation due to failed revascularization. MESS significantly differed between patients with blunt and penetrating trauma (8.2±2.2 vs. 5.8±1.3, respectively; p=0.005). The amputation rate was not significantly different between patients with blunt and penetrating trauma (20% vs. 0%, respectively; p=0.295). The overall mortality rate was 3.6% (1 patient).
Conclusion: Blunt trauma was associated with higher MESS than penetrating trauma, and amputation was more frequent. In particular, patients with blunt trauma had significantly higher MESS than patients with penetrating trauma (8.2±2.2 vs. 5.8±1.3, respectively; p=0.005), and amputation was performed when revascularization failed in cases of blunt trauma of the lower extremity. Therefore, particular care is needed in making treatment decisions for patients with peripheral arterial injuries caused by blunt trauma.

Keywords: Blunt trauma, Penetrating trauma, Arteries, Revascularization

Peripheral arterial injuries constitute approximately 4%–6% of all major traumas [1,2]. However, they comprise 80% of vascular injuries that manifest as fatal hemorrhage or limb-threatening ischemia [3]. Peripheral arterial injury in trauma patients can potentially progress to ischemia and amputation unless it is immediately diagnosed and revascularized.

The causes of peripheral arterial injuries are divided into penetrating trauma (e.g., bullets and knives) and blunt trauma (e.g., traffic accidents and falling down). Unlike in some other countries, the main cause of peripheral arterial injuries in Korea is blunt trauma, since individual firearms are prohibited. Therefore, research on penetrating peripheral arterial injuries caused by gunshot wounds in Korea is very rare.

The aim of the present retrospective study was to analyze the prognosis of penetrating and blunt trauma, based on our 10-year experience with the repair of traumatic peripheral arterial injuries in an urban level I trauma center in Korea.

Patients

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board at Pusan National University Hospital (reference no., H-1909-018-083). Informed consent was waived. Between January 2007 and December 2016, 28 adult patients presented to an urban level I trauma center with traumatic peripheral arterial injuries. Data were retrospectively collected by a single investigator and included basic demographic characteristics, mechanism of injury, type of vascular injury, and physiological status on initial assessment. The analysis also included the Mangled Extremity Severity Score (MESS), Injury Severity Score (ISS), surgical procedures, and outcome variables, such as limb salvage, hospital stay, intensive care unit stay, and postoperative vascular complications.

The response system of our trauma center consists of a team of specialists from the disciplines of emergency medicine, cardiovascular surgery, general surgery, orthopedic surgery, and neurosurgery. Members of all disciplines remain at the trauma center at all times and are activated immediately after receiving a transfer request. Criteria for considering primary amputation include dense ischemia (Rutherford class 3) with an ischemic time of greater than 6 hours, or bone or soft tissue defects that are considered impossible to reconstruct by the orthopedic surgeon. Nonetheless, despite these guidelines, the final decision is made on a case-by-case basis after discussing treatment options with the patient, the patient’s family, and the interdisciplinary team.

The diagnosis of peripheral arterial injury is established using enhanced computed tomography (CT) angiography. There is an emergency room in the trauma center, and the CT room of the trauma center is always ready for trauma patients. Therefore, if their vital signs were stable, all patients suspected of vascular damage underwent CT to diagnose vascular damage. At our trauma center, the choice between limb relief and primary amputation is made after evaluation by the full team.

The intervention was classified as surgical ligation, primary repair, or surgical bypass of the main bleeding branch. Surgical ligation was performed between the proximal and distal ends of the arterial injury. Primary repair was performed through resection and re-anastomosis in patients with local arterial injuries that required resection of <2 cm of vessels with appropriate residual length to avoid undesirable tension. The opposite veins were used for surgical bypass, and prosthetic conduits were used without veins. In combined vascular and orthopedic procedures, vascular repair was performed first, unless decided otherwise by the multidisciplinary team. The need for fasciotomy was assessed at the end of the period of vascular regeneration based on a physical examination.

Statistical analysis

The patients were divided into 2 groups according to the mechanism of injury and compared. The Wilcoxon rank-sum test was used for continuous variables and the Fisher exact test was used for categorical variables. All analyses were performed using SAS ver. 9.3 (SAS Institute Inc., Cary, NC, USA) and a p-value <0.05 was considered to indicate statistical significance.

Demographics

During the 10-year period, 28 patients were identified and treated at our institution. Their mean age was 40.8± 17.0 years (range, 7–72 years), and the majority of patients were male (n=21, 75%). The basic demographic data of patients are summarized in Table 1. There were 20 patients (71.4%) with blunt trauma and 8 patients (28.6%) with penetrating trauma. The most common causes of blunt trauma included auto-pedestrian collisions (28.6%) and crush injuries (21.5%). The majority of cases of penetrating trauma involved stab wounds by a knife or broken glass (Table 2). No statistically significant differences were found in the demographic variables, ISS, GCS, intensive care unit stay, and mortality rates between those with blunt and penetrating trauma. There were statistically significant differences in the concomitant injuries, including associated fractures (16% versus 0%, respectively; p=0.00) and major soft tissue disruption (60% versus 12.5%, respectively; p=0.038) between those with blunt and penetrating trauma. Statistically significant differences between patients with blunt and penetrating trauma were found in the trauma-to-operation time (426.0±313.5 minutes versus 296.00±406.3 minutes, respectively; p=0.029) and hospital stay (96.5±86.9 days versus 28.6±35.3 days, respectively; p=0.004).

Vascular injuries

There were 28 peripheral artery injuries, including 11 (39.3%) in the popliteal artery, 7 (25%) in the femoral artery, 5 (17.9%) in the axillary artery, 3 (10.7%) in the brachial artery, and 2 (7.1%) in the ulnar or radial artery. The surgical procedures for each injury are summarized in Table 3. Amputation was performed in 4 cases (3 of 11 cases of popliteal artery injury and 1 of 7 cases of femoral artery injury). Amputation was not performed in any cases of peripheral artery injuries of the upper limb. Vascular interventions included primary repair (n=9, 32.1%), saphenous vein graft (SVG) interposition (n=7, 25.0%), polytetrafluoroethylene (PTFE) graft interposition (n=9, 32.1%), and arterial ligation (n=3, 10.7%). The types of arterial injury according to the mechanism of injury are summarized in Table 4. In blunt trauma, occlusion was observed in 9 cases (45%), and transection was observed in all cases of penetrating injuries.

Outcomes

Four patients (14.3%) required amputation due to failed revascularization. The details of these patients are summarized in Table 5. There was a statistically significant difference in MESS (8.2±2.2 versus 5.8±1.3, respectively; p=0.005) between patients with blunt and penetrating trauma. However, no statistically significant difference was found in the amputation rate between those with blunt and penetrating trauma (n=4, 20% versus n=0, 0%, respectively; p=0.295) (Table 1). In 1 case, amputation was performed due to rhabdomyolysis secondary to reperfusion injury, and in 3 cases, amputation was performed due to postoperative necrosis. Amputation was performed in both cases of ligation of the popliteal artery where vascular reconstruction was impossible due to a severe degloving injury, and in 2 cases without ligation that were accompanied by deep vein damage.

The overall mortality rate in this series was 3.6% (1 patient). This patient was placed in a forklift truck and arrived with pulseless electrical activity; spontaneous circulation was achieved with aggressive fluid resuscitation and the advanced cardiac life support protocol. He underwent primary repair of the superficial femoral artery and external fixation of a femur fracture; he died on postoperative day 7 due to septic shock from late-diagnosed severe bowel necrosis.

The incidence of vascular trauma has increased in recent years [4-7]. Nevertheless, deciding on a treatment approach is challenging, because there can be damage to several organs. This study presents 10 years of experience with peripheral artery trauma at the largest independent trauma center in Korea.

In this study, blunt trauma (n=20, 71.4%) was more common than penetrating trauma (n=8, 28.6%). In many studies outside of Korea [8-10], the most common cause of vascular trauma was penetrating trauma caused by gunshots. This difference may be due to the fact that guns are illegal in Korea, so there are few gun accidents. In this study, there were no cases of penetrating trauma due to firearms; instead, the most common causes of penetrating trauma were injuries due to knives (n=4) and glass (n=4).

The amputation rate was 14.3% (n=4), which is similar to the results of previous studies. Although the reported range of amputation rate is 2%–33%, the mechanisms and sites of injury vary among studies [11,12]. The amputation rate in cases of blunt trauma was higher than in cases of penetrating trauma in this study; however, the difference was not statistically significant. According to Liang et al. [13], blunt trauma has a higher rate of delayed amputation, with a rate of 23% for in-hospital amputations and 30% if eventual elective amputations are considered. This may partly be attributable to the high proportion of high-energy blunt trauma within the blunt injury group, which represents a cohort with greater overall injury severity. In this study, associated fractures and major soft tissue disruptions were more common in those with blunt trauma than in those with penetrating trauma. Therefore, the higher-energy damage in blunt trauma could result in a higher amputation rate. In a meta-analysis of more than 3,100 patients undergoing vascular repair Perkins et al. [11] showed that major soft tissue damage, compartment syndrome, multiple arterial damage, ischemic duration of more than 6 hours, associated fractures, blast or blunt damage mechanism, age, the ISS, and iliac or patellar injuries were associated with increased amputation rates, while shock and nerve or vein injuries were not.

The MESS is the most commonly used method to assess the severity of mangled extremities in vascular trauma [14]. The MESS was higher in cases of blunt trauma than in cases of penetrating trauma, because the trauma-to-operation time in cases of blunt trauma was longer than 6 hours (426±313.5 minutes), a statistically significant difference from that in cases of penetrating trauma. Burkhardt et al. [14] studied the relationship between flow recovery time and functional extremity salvage in a large animal model. Neuromuscular recovery in animals with an initial recovery of flow (<3 hours) was almost complete, but not if the flow stopped for 6 hours. Histopathological changes in degeneration, necrosis, and fibrosis are associated with reperfusion time. The long trauma-to-operation time in patients with blunt trauma occurred because many of these patients did not come directly to our hospital after trauma, but were referred by other hospitals or from remote areas. No statistically significant difference was found in the ISS; however, because the ISS was higher in cases of blunt trauma than in cases of penetrating trauma, the preoperative resuscitation time and evaluation of other injuries would have been more time-consuming.

Additionally, all cases of penetrating trauma involved low-energy injuries. In this study, MESS was statistically significantly higher in patients with blunt trauma than in patients with penetrating trauma (8.2±2.2 versus 5.8±1.3, respectively; p=0.005); it tended to be greater than 7 in those with blunt trauma, while it was less than 7 in those with penetrating trauma. The MESS was introduced by Johansen et al. [15] in 1990, and a cutoff score of 7 has classically been used to predict the future viability of limb salvage procedures. In all cases of amputation, the MESS was higher than 7. To date, however, no study has found that a MESS >7 can predict amputation with absolute certainty [16]. MESS can quantify the overall severity of limb injuries and aid in decision-making regarding management; however, limb salvage decisions should also consider the patient’s overall condition. Even in cases of severe limb trauma, we now have a variety of functional structures available that could not have been conceived in 1990. For instance, various new forms of fracture fixation have been introduced [17], as have negative-pressure devices [18] and free tissue transfers [19] to treat what would previously have been unmanageable soft tissue defects. Further innovations include successful major nerve reanastomoses [20] and the revascularization of traumatized limbs by endovascular methods [21].

When vascular reconstruction is performed in patients with trauma, it is very difficult to achieve tension-free end-to-end anastomosis. As this is the most common repair method for SVG interposition, it is preferable to use the SVG in the non-traumatic part [22]. In this study, penetrating trauma was the more common mechanism of injury to the brachial and ulnar or radial arteries. As a result, primary repair could be performed in relatively many cases. PTFE graft interposition is typically avoided due to the low patency rate and increased risk of infection [23,24]. In this study, however, due to the accompanying damage, adequate SVG interposition could not be achieved in many cases, resulting in a relatively high rate of PTFE graft interposition (32.1%) and a relatively low rate of SVG interposition (25%). Nonetheless, the amputation rate was not higher than that reported in previous studies.

The limitations of this study include the small number of cases of vascular trauma, the presence of fewer cases of penetrating trauma than of blunt trauma, and the non-randomized, retrospective, observational design of the study. Of particular note, the amputation rate was higher in patients with blunt trauma than that in patients with penetrating trauma; however, this difference was not statistically significant. Further studies may be needed to analyze the long trauma-to-operation time and to review the causes of low SVG interposition and high PTFE graft interposition in vascular reconstruction.

In conclusion, in this study, blunt trauma caused a higher proportion of peripheral arterial injuries than in reports from other countries. Blunt trauma was associated with a higher MESS than penetrating trauma, and amputation was more frequent. Specifically, patients with blunt trauma had a MESS higher than 7, and amputation resulted when revascularization failed in cases of blunt trauma of the lower extremity. Therefore, particular care is needed in making treatment decisions for patients with peripheral arterial injuries caused by blunt trauma.

No potential conflict of interest relevant to this article was reported.

This work was supported by clinical research grant from Pusan National University Hospital in 2020.

Comparison of variables according to the mechanism of injury

Characteristic Total (n=28) Blunt Penetrating p-value
Total 28 20 (71.4) 8 (28.6)
Age (yr) 40.8±17.0 42.7±17.4 35.9±16.1 0.34
Male sex 21 (75.0) 15 (75.0) 6 (75.0) 1.0
Associated fracture 16 (57.1) 16 (80.0) 0 0.000
Associated major soft tissue disruption 13 (46.4) 12 (60.0) 1 (12.5) 0.038
Trauma-to-operation time (min) 388.9±339.9 426.0±313.5 296.0±406.3 0.029
Injury Severity Score at presentation 19.7±14.9 22.4±15.6 13.1±11.4 0.089
Mangled Extremity Severity Score at presentation 7.5±2.3 8.2±2.2 5.8±1.3 0.005
Glasgow Coma Scale score at presentation 13.5±2.2 13.7±2.2 13.0±2.3 0.412
Hospital stay (day) 77.1±81.3 96.5±86.9 28.6±35.3 0.004
Intensive care unit time (day) 6.3±6.8 7.7±7.4 2.8±3.6 0.086
Amputation 4 (14.3) 4 (20.0) 0 0.295
Mortality 1 (3.6) 1 (5.0) 0 1.0

Values are presented as number (%) or mean±standard deviation. Bold type is statistically significant.


Mechanisms of injury

Mechanism No. (%)
Penetrating 8 (28.6)
Stab wound (knife) 4 (14.3)
Stab wound (broken glass) 4 (14.3)
Blunt 20 (71.4)
Auto-pedestrian collision 8 (28.6)
Motorcycle collision 2 (7.2)
Motor vehicle collision 2 (7.2)
Fall 2 (7.2)
Crush injury 6 (21.5)

Vascular reconstruction

Artery injured Blunt/penetrating Procedures (n)

Primary repair SVG interposition PTFE graft interposition Ligation Postoperative amputation
Axillary 5/0 0 2 3
Brachial 1/2 2 1
Ulnar or radial 0/2 1 1
Femoral 6/1 3 1a) 3 1
Popliteal 8/3 3 3 (1a)) 3 2a) 3
Total 20/8 9 7 9 3 4

SVG, saphenous vein graft; PTFE, polytetrafluoroethylene.

a)Amputation.


Types of arterial injury

Type of arterial injury Total Blunt trauma Penetrating injury
Occlusion 9 (32.1) 9 (45.0) 0
Partial transection 6 (21.4) 4 (20.0) 2 (25.0)
Complete transection 13 (46.4) 7 (35.0) 6 (75.0)

Values are presented as number (%).


  1. Kauvar DS, Sarfati MR, Kraiss LW. National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma. J Vasc Surg 2011;53:1598-603.
    Pubmed CrossRef
  2. Sciarretta JD, Perez-Alonso AJ, Ebler DJ, Mazzini FN, Petrone P, Asensio-Gonzalez JA. Popliteal vessel injuries: complex anatomy, difficult problems and surgical challenges. Eur J Trauma Emerg Surg 2012;38:373-91.
    Pubmed CrossRef
  3. Baghi I, Herfatkar MR, Shokrgozar L, Poor-Rasuli Z, Aghajani F. Assessment of vascular injuries and reconstruction. Trauma Mon 2015;20:e30469.
    CrossRef
  4. Rana SH, Farani TM, Jamal Y, Afzal M. Peripheral vascular injuries; epidemiology and management. Prof Med J 2008;15:54-60.
  5. Singh D, Pinjala RK. Management of peripheral vascular trauma: our experience. Int J Surg 2005;7:1-7.
    CrossRef
  6. Menakuru SR, Behera A, Jindal R, Kaman L, Doley R, Venkatesan R. Extremity vascular trauma in civilian population: a seven-year review from North India. Injury 2005;36:400-6.
    Pubmed CrossRef
  7. Iriz E, Kolbakir F, Sarac A, Akar H, Keceligil HT, Demirag MK. Retrospective assessment of vascular injuries: 23 years of experience. Ann Thorac Cardiovasc Surg 2004;10:373-8.
    Pubmed
  8. Franz RW, Goodwin RB, Hartman JF, Wright ML. Management of upper extremity arterial injuries at an urban level I trauma center. Ann Vasc Surg 2009;23:8-16.
    Pubmed CrossRef
  9. Thomson I, Muduioa G, Gray A. Vascular trauma in New Zealand: an 11-year review of NZVASC, the New Zealand Society of Vascular Surgeons' audit database. N Z Med J 2004;117:U1048.
    Pubmed
  10. Sultanov DD, Usmanov NU, Baratov AK, Gaibov AD, Kurbanov UA, Kurbanov NR. Traumatic injuries of the popliteal and tibial arteries: limb ischemia and problems of surgical management. Angiol Sosud Khir 2004;10:104-13.
    Pubmed
  11. Perkins ZB, Yet B, Glasgow S, et al. Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma. Br J Surg 2015;102:436-50.
    Pubmed CrossRef
  12. Hafez HM, Woolgar J, Robbs JV. Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. J Vasc Surg 2001;33:1212-9.
    Pubmed CrossRef
  13. Liang NL, Alarcon LH, Jeyabalan G, Avgerinos ED, Makaroun MS, Chaer RA. Contemporary outcomes of civilian lower extremity arterial trauma. J Vasc Surg 2016;64:731-6.
    Pubmed KoreaMed CrossRef
  14. Burkhardt GE, Gifford SM, Propper B, et al. The impact of ischemic intervals on neuromuscular recovery in a porcine (Sus scrofa) survival model of extremity vascular injury. J Vasc Surg 2011;53:165-73.
    Pubmed CrossRef
  15. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568-72.
    Pubmed CrossRef
  16. Fodor L, Sobec R, Sita-Alb L, Fodor M, Ciuce C. Mangled lower extremity: can we trust the amputation scores? Int J Burns Trauma 2012;2:51-8.
    Pubmed KoreaMed
  17. Ozturkmen Y, Karamehmetoglu M, Karadeniz H, Azboy I, Caniklioglu M. Acute treatment of segmental tibial fractures with the Ilizarov method. Injury 2009;40:321-6.
    Pubmed CrossRef
  18. Hinck D, Franke A, Gatzka F. Use of vacuum-assisted closure negative pressure wound therapy in combat-related injuries: literature review. Mil Med 2010;175:173-81.
    Pubmed CrossRef
  19. Germann G, Steinau HU. Functional soft-tissue coverage in skeletonizing injuries of the upper extremity using the ipsilateral latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1995;96:1130-5.
    Pubmed CrossRef
  20. Schmidhammer R, Dorninger L, Huber W, Haller H, Kropfl A. Simultaneous reimplantation of both lower legs: 5-year follow-up. Unfallchirurg 2003;106:161-5.
    Pubmed CrossRef
  21. Shalhub S, Starnes BW, Tran NT. Endovascular treatment of axillosubclavian arterial transection in patients with blunt traumatic injury. J Vasc Surg 2011;53:1141-4.
    Pubmed CrossRef
  22. Macedo FI, Sciarretta JD, Chausse S, Sleeman D, Pizano LR, Namias N. Vascular reconstruction is not warranted in most civilian traumatic shank vascular injuries. Ann Vasc Surg 2016;35:38-45.
    Pubmed CrossRef
  23. Martin LC, McKenney MG, Sosa JL, et al. Management of lower extremity arterial trauma. J Trauma 1994;37:591-8.
    Pubmed CrossRef
  24. Keen RR, Meyer JP, Durham JR, et al. Autogenous vein graft repair of injured extremity arteries: early and late results with 134 consecutive patients. J Vasc Surg 1991;13:664-8.
    Pubmed CrossRef

Article

Clinical Research

Korean J Thorac Cardiovasc Surg 2020; 53(5): 291-296

Published online October 5, 2020 https://doi.org/10.5090/kjtcs.19.087

Copyright © Journal of Chest Surgery.

Traumatic Peripheral Arterial Injury with Open Repair: A 10-Year Single-Institutional Analysis

Hoseong Cho, M.D.1 , Up Huh, M.D.1 , Chung Won Lee, M.D.1 , Seunghwan Song, M.D.1 , Seon Hee Kim, M.D.2 , Sung Woon Chung, M.D.1

Departments of 1Thoracic and Cardiovascular Surgery and 2Trauma Surgery, Pusan National University Hospital, Biomedical Research Institute, Pusan National University School of Medicine, Busan, Korea

Correspondence to:Up Huh
Tel 82-51-240-7267
Fax 82-51-243-9389
E-mail tymfoo82@gmail.com
ORCID https://orcid.org/0000-0002-7739-3979

Received: November 13, 2019; Revised: March 18, 2020; Accepted: April 12, 2020

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properlycited.

Abstract

Background: We report our 10-year experience with traumatic peripheral arterial injury repair at an urban level I trauma center.
Methods: Between January 2007 and December 2016, 28 adult trauma patients presented with traumatic peripheral arterial injuries. Data were retrospectively collected on demographic characteristics, the mechanism of injury, the type of vascular injury, and physiological status on initial assessment. The analysis also included the Mangled Extremity Severity Score (MESS), Injury Severity Score, surgical procedures, and outcome variables including limb salvage, hospital stay, intensive care unit stay, and postoperative vascular complications.
Results: Four (14.3%) patients required amputation due to failed revascularization. MESS significantly differed between patients with blunt and penetrating trauma (8.2±2.2 vs. 5.8±1.3, respectively; p=0.005). The amputation rate was not significantly different between patients with blunt and penetrating trauma (20% vs. 0%, respectively; p=0.295). The overall mortality rate was 3.6% (1 patient).
Conclusion: Blunt trauma was associated with higher MESS than penetrating trauma, and amputation was more frequent. In particular, patients with blunt trauma had significantly higher MESS than patients with penetrating trauma (8.2±2.2 vs. 5.8±1.3, respectively; p=0.005), and amputation was performed when revascularization failed in cases of blunt trauma of the lower extremity. Therefore, particular care is needed in making treatment decisions for patients with peripheral arterial injuries caused by blunt trauma.

Keywords: Blunt trauma, Penetrating trauma, Arteries, Revascularization

Introduction

Peripheral arterial injuries constitute approximately 4%–6% of all major traumas [1,2]. However, they comprise 80% of vascular injuries that manifest as fatal hemorrhage or limb-threatening ischemia [3]. Peripheral arterial injury in trauma patients can potentially progress to ischemia and amputation unless it is immediately diagnosed and revascularized.

The causes of peripheral arterial injuries are divided into penetrating trauma (e.g., bullets and knives) and blunt trauma (e.g., traffic accidents and falling down). Unlike in some other countries, the main cause of peripheral arterial injuries in Korea is blunt trauma, since individual firearms are prohibited. Therefore, research on penetrating peripheral arterial injuries caused by gunshot wounds in Korea is very rare.

The aim of the present retrospective study was to analyze the prognosis of penetrating and blunt trauma, based on our 10-year experience with the repair of traumatic peripheral arterial injuries in an urban level I trauma center in Korea.

Methods

Patients

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board at Pusan National University Hospital (reference no., H-1909-018-083). Informed consent was waived. Between January 2007 and December 2016, 28 adult patients presented to an urban level I trauma center with traumatic peripheral arterial injuries. Data were retrospectively collected by a single investigator and included basic demographic characteristics, mechanism of injury, type of vascular injury, and physiological status on initial assessment. The analysis also included the Mangled Extremity Severity Score (MESS), Injury Severity Score (ISS), surgical procedures, and outcome variables, such as limb salvage, hospital stay, intensive care unit stay, and postoperative vascular complications.

The response system of our trauma center consists of a team of specialists from the disciplines of emergency medicine, cardiovascular surgery, general surgery, orthopedic surgery, and neurosurgery. Members of all disciplines remain at the trauma center at all times and are activated immediately after receiving a transfer request. Criteria for considering primary amputation include dense ischemia (Rutherford class 3) with an ischemic time of greater than 6 hours, or bone or soft tissue defects that are considered impossible to reconstruct by the orthopedic surgeon. Nonetheless, despite these guidelines, the final decision is made on a case-by-case basis after discussing treatment options with the patient, the patient’s family, and the interdisciplinary team.

The diagnosis of peripheral arterial injury is established using enhanced computed tomography (CT) angiography. There is an emergency room in the trauma center, and the CT room of the trauma center is always ready for trauma patients. Therefore, if their vital signs were stable, all patients suspected of vascular damage underwent CT to diagnose vascular damage. At our trauma center, the choice between limb relief and primary amputation is made after evaluation by the full team.

The intervention was classified as surgical ligation, primary repair, or surgical bypass of the main bleeding branch. Surgical ligation was performed between the proximal and distal ends of the arterial injury. Primary repair was performed through resection and re-anastomosis in patients with local arterial injuries that required resection of <2 cm of vessels with appropriate residual length to avoid undesirable tension. The opposite veins were used for surgical bypass, and prosthetic conduits were used without veins. In combined vascular and orthopedic procedures, vascular repair was performed first, unless decided otherwise by the multidisciplinary team. The need for fasciotomy was assessed at the end of the period of vascular regeneration based on a physical examination.

Statistical analysis

The patients were divided into 2 groups according to the mechanism of injury and compared. The Wilcoxon rank-sum test was used for continuous variables and the Fisher exact test was used for categorical variables. All analyses were performed using SAS ver. 9.3 (SAS Institute Inc., Cary, NC, USA) and a p-value <0.05 was considered to indicate statistical significance.

Results

Demographics

During the 10-year period, 28 patients were identified and treated at our institution. Their mean age was 40.8± 17.0 years (range, 7–72 years), and the majority of patients were male (n=21, 75%). The basic demographic data of patients are summarized in Table 1. There were 20 patients (71.4%) with blunt trauma and 8 patients (28.6%) with penetrating trauma. The most common causes of blunt trauma included auto-pedestrian collisions (28.6%) and crush injuries (21.5%). The majority of cases of penetrating trauma involved stab wounds by a knife or broken glass (Table 2). No statistically significant differences were found in the demographic variables, ISS, GCS, intensive care unit stay, and mortality rates between those with blunt and penetrating trauma. There were statistically significant differences in the concomitant injuries, including associated fractures (16% versus 0%, respectively; p=0.00) and major soft tissue disruption (60% versus 12.5%, respectively; p=0.038) between those with blunt and penetrating trauma. Statistically significant differences between patients with blunt and penetrating trauma were found in the trauma-to-operation time (426.0±313.5 minutes versus 296.00±406.3 minutes, respectively; p=0.029) and hospital stay (96.5±86.9 days versus 28.6±35.3 days, respectively; p=0.004).

Vascular injuries

There were 28 peripheral artery injuries, including 11 (39.3%) in the popliteal artery, 7 (25%) in the femoral artery, 5 (17.9%) in the axillary artery, 3 (10.7%) in the brachial artery, and 2 (7.1%) in the ulnar or radial artery. The surgical procedures for each injury are summarized in Table 3. Amputation was performed in 4 cases (3 of 11 cases of popliteal artery injury and 1 of 7 cases of femoral artery injury). Amputation was not performed in any cases of peripheral artery injuries of the upper limb. Vascular interventions included primary repair (n=9, 32.1%), saphenous vein graft (SVG) interposition (n=7, 25.0%), polytetrafluoroethylene (PTFE) graft interposition (n=9, 32.1%), and arterial ligation (n=3, 10.7%). The types of arterial injury according to the mechanism of injury are summarized in Table 4. In blunt trauma, occlusion was observed in 9 cases (45%), and transection was observed in all cases of penetrating injuries.

Outcomes

Four patients (14.3%) required amputation due to failed revascularization. The details of these patients are summarized in Table 5. There was a statistically significant difference in MESS (8.2±2.2 versus 5.8±1.3, respectively; p=0.005) between patients with blunt and penetrating trauma. However, no statistically significant difference was found in the amputation rate between those with blunt and penetrating trauma (n=4, 20% versus n=0, 0%, respectively; p=0.295) (Table 1). In 1 case, amputation was performed due to rhabdomyolysis secondary to reperfusion injury, and in 3 cases, amputation was performed due to postoperative necrosis. Amputation was performed in both cases of ligation of the popliteal artery where vascular reconstruction was impossible due to a severe degloving injury, and in 2 cases without ligation that were accompanied by deep vein damage.

The overall mortality rate in this series was 3.6% (1 patient). This patient was placed in a forklift truck and arrived with pulseless electrical activity; spontaneous circulation was achieved with aggressive fluid resuscitation and the advanced cardiac life support protocol. He underwent primary repair of the superficial femoral artery and external fixation of a femur fracture; he died on postoperative day 7 due to septic shock from late-diagnosed severe bowel necrosis.

Discussion

The incidence of vascular trauma has increased in recent years [4-7]. Nevertheless, deciding on a treatment approach is challenging, because there can be damage to several organs. This study presents 10 years of experience with peripheral artery trauma at the largest independent trauma center in Korea.

In this study, blunt trauma (n=20, 71.4%) was more common than penetrating trauma (n=8, 28.6%). In many studies outside of Korea [8-10], the most common cause of vascular trauma was penetrating trauma caused by gunshots. This difference may be due to the fact that guns are illegal in Korea, so there are few gun accidents. In this study, there were no cases of penetrating trauma due to firearms; instead, the most common causes of penetrating trauma were injuries due to knives (n=4) and glass (n=4).

The amputation rate was 14.3% (n=4), which is similar to the results of previous studies. Although the reported range of amputation rate is 2%–33%, the mechanisms and sites of injury vary among studies [11,12]. The amputation rate in cases of blunt trauma was higher than in cases of penetrating trauma in this study; however, the difference was not statistically significant. According to Liang et al. [13], blunt trauma has a higher rate of delayed amputation, with a rate of 23% for in-hospital amputations and 30% if eventual elective amputations are considered. This may partly be attributable to the high proportion of high-energy blunt trauma within the blunt injury group, which represents a cohort with greater overall injury severity. In this study, associated fractures and major soft tissue disruptions were more common in those with blunt trauma than in those with penetrating trauma. Therefore, the higher-energy damage in blunt trauma could result in a higher amputation rate. In a meta-analysis of more than 3,100 patients undergoing vascular repair Perkins et al. [11] showed that major soft tissue damage, compartment syndrome, multiple arterial damage, ischemic duration of more than 6 hours, associated fractures, blast or blunt damage mechanism, age, the ISS, and iliac or patellar injuries were associated with increased amputation rates, while shock and nerve or vein injuries were not.

The MESS is the most commonly used method to assess the severity of mangled extremities in vascular trauma [14]. The MESS was higher in cases of blunt trauma than in cases of penetrating trauma, because the trauma-to-operation time in cases of blunt trauma was longer than 6 hours (426±313.5 minutes), a statistically significant difference from that in cases of penetrating trauma. Burkhardt et al. [14] studied the relationship between flow recovery time and functional extremity salvage in a large animal model. Neuromuscular recovery in animals with an initial recovery of flow (<3 hours) was almost complete, but not if the flow stopped for 6 hours. Histopathological changes in degeneration, necrosis, and fibrosis are associated with reperfusion time. The long trauma-to-operation time in patients with blunt trauma occurred because many of these patients did not come directly to our hospital after trauma, but were referred by other hospitals or from remote areas. No statistically significant difference was found in the ISS; however, because the ISS was higher in cases of blunt trauma than in cases of penetrating trauma, the preoperative resuscitation time and evaluation of other injuries would have been more time-consuming.

Additionally, all cases of penetrating trauma involved low-energy injuries. In this study, MESS was statistically significantly higher in patients with blunt trauma than in patients with penetrating trauma (8.2±2.2 versus 5.8±1.3, respectively; p=0.005); it tended to be greater than 7 in those with blunt trauma, while it was less than 7 in those with penetrating trauma. The MESS was introduced by Johansen et al. [15] in 1990, and a cutoff score of 7 has classically been used to predict the future viability of limb salvage procedures. In all cases of amputation, the MESS was higher than 7. To date, however, no study has found that a MESS >7 can predict amputation with absolute certainty [16]. MESS can quantify the overall severity of limb injuries and aid in decision-making regarding management; however, limb salvage decisions should also consider the patient’s overall condition. Even in cases of severe limb trauma, we now have a variety of functional structures available that could not have been conceived in 1990. For instance, various new forms of fracture fixation have been introduced [17], as have negative-pressure devices [18] and free tissue transfers [19] to treat what would previously have been unmanageable soft tissue defects. Further innovations include successful major nerve reanastomoses [20] and the revascularization of traumatized limbs by endovascular methods [21].

When vascular reconstruction is performed in patients with trauma, it is very difficult to achieve tension-free end-to-end anastomosis. As this is the most common repair method for SVG interposition, it is preferable to use the SVG in the non-traumatic part [22]. In this study, penetrating trauma was the more common mechanism of injury to the brachial and ulnar or radial arteries. As a result, primary repair could be performed in relatively many cases. PTFE graft interposition is typically avoided due to the low patency rate and increased risk of infection [23,24]. In this study, however, due to the accompanying damage, adequate SVG interposition could not be achieved in many cases, resulting in a relatively high rate of PTFE graft interposition (32.1%) and a relatively low rate of SVG interposition (25%). Nonetheless, the amputation rate was not higher than that reported in previous studies.

The limitations of this study include the small number of cases of vascular trauma, the presence of fewer cases of penetrating trauma than of blunt trauma, and the non-randomized, retrospective, observational design of the study. Of particular note, the amputation rate was higher in patients with blunt trauma than that in patients with penetrating trauma; however, this difference was not statistically significant. Further studies may be needed to analyze the long trauma-to-operation time and to review the causes of low SVG interposition and high PTFE graft interposition in vascular reconstruction.

In conclusion, in this study, blunt trauma caused a higher proportion of peripheral arterial injuries than in reports from other countries. Blunt trauma was associated with a higher MESS than penetrating trauma, and amputation was more frequent. Specifically, patients with blunt trauma had a MESS higher than 7, and amputation resulted when revascularization failed in cases of blunt trauma of the lower extremity. Therefore, particular care is needed in making treatment decisions for patients with peripheral arterial injuries caused by blunt trauma.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Acknowledgments

This work was supported by clinical research grant from Pusan National University Hospital in 2020.

There is no Figure.

Table 1 . Comparison of variables according to the mechanism of injury.

CharacteristicTotal (n=28)BluntPenetratingp-value
Total2820 (71.4)8 (28.6)
Age (yr)40.8±17.042.7±17.435.9±16.10.34
Male sex21 (75.0)15 (75.0)6 (75.0)1.0
Associated fracture16 (57.1)16 (80.0)00.000
Associated major soft tissue disruption13 (46.4)12 (60.0)1 (12.5)0.038
Trauma-to-operation time (min)388.9±339.9426.0±313.5296.0±406.30.029
Injury Severity Score at presentation19.7±14.922.4±15.613.1±11.40.089
Mangled Extremity Severity Score at presentation7.5±2.38.2±2.25.8±1.30.005
Glasgow Coma Scale score at presentation13.5±2.213.7±2.213.0±2.30.412
Hospital stay (day)77.1±81.396.5±86.928.6±35.30.004
Intensive care unit time (day)6.3±6.87.7±7.42.8±3.60.086
Amputation4 (14.3)4 (20.0)00.295
Mortality1 (3.6)1 (5.0)01.0

Values are presented as number (%) or mean±standard deviation. Bold type is statistically significant..


Table 2 . Mechanisms of injury.

MechanismNo. (%)
Penetrating8 (28.6)
Stab wound (knife)4 (14.3)
Stab wound (broken glass)4 (14.3)
Blunt20 (71.4)
Auto-pedestrian collision8 (28.6)
Motorcycle collision2 (7.2)
Motor vehicle collision2 (7.2)
Fall2 (7.2)
Crush injury6 (21.5)

Table 3 . Vascular reconstruction.

Artery injuredBlunt/penetratingProcedures (n)

Primary repairSVG interpositionPTFE graft interpositionLigationPostoperative amputation
Axillary5/0023
Brachial1/221
Ulnar or radial0/211
Femoral6/131a)31
Popliteal8/333 (1a))32a)3
Total20/897934

SVG, saphenous vein graft; PTFE, polytetrafluoroethylene..

a)Amputation..


Table 4 . Types of arterial injury.

Type of arterial injuryTotalBlunt traumaPenetrating injury
Occlusion9 (32.1)9 (45.0)0
Partial transection6 (21.4)4 (20.0)2 (25.0)
Complete transection13 (46.4)7 (35.0)6 (75.0)

Values are presented as number (%)..


References

  1. Kauvar DS, Sarfati MR, Kraiss LW. National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma. J Vasc Surg 2011;53:1598-603.
    Pubmed CrossRef
  2. Sciarretta JD, Perez-Alonso AJ, Ebler DJ, Mazzini FN, Petrone P, Asensio-Gonzalez JA. Popliteal vessel injuries: complex anatomy, difficult problems and surgical challenges. Eur J Trauma Emerg Surg 2012;38:373-91.
    Pubmed CrossRef
  3. Baghi I, Herfatkar MR, Shokrgozar L, Poor-Rasuli Z, Aghajani F. Assessment of vascular injuries and reconstruction. Trauma Mon 2015;20:e30469.
    CrossRef
  4. Rana SH, Farani TM, Jamal Y, Afzal M. Peripheral vascular injuries; epidemiology and management. Prof Med J 2008;15:54-60.
  5. Singh D, Pinjala RK. Management of peripheral vascular trauma: our experience. Int J Surg 2005;7:1-7.
    CrossRef
  6. Menakuru SR, Behera A, Jindal R, Kaman L, Doley R, Venkatesan R. Extremity vascular trauma in civilian population: a seven-year review from North India. Injury 2005;36:400-6.
    Pubmed CrossRef
  7. Iriz E, Kolbakir F, Sarac A, Akar H, Keceligil HT, Demirag MK. Retrospective assessment of vascular injuries: 23 years of experience. Ann Thorac Cardiovasc Surg 2004;10:373-8.
    Pubmed
  8. Franz RW, Goodwin RB, Hartman JF, Wright ML. Management of upper extremity arterial injuries at an urban level I trauma center. Ann Vasc Surg 2009;23:8-16.
    Pubmed CrossRef
  9. Thomson I, Muduioa G, Gray A. Vascular trauma in New Zealand: an 11-year review of NZVASC, the New Zealand Society of Vascular Surgeons' audit database. N Z Med J 2004;117:U1048.
    Pubmed
  10. Sultanov DD, Usmanov NU, Baratov AK, Gaibov AD, Kurbanov UA, Kurbanov NR. Traumatic injuries of the popliteal and tibial arteries: limb ischemia and problems of surgical management. Angiol Sosud Khir 2004;10:104-13.
    Pubmed
  11. Perkins ZB, Yet B, Glasgow S, et al. Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma. Br J Surg 2015;102:436-50.
    Pubmed CrossRef
  12. Hafez HM, Woolgar J, Robbs JV. Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. J Vasc Surg 2001;33:1212-9.
    Pubmed CrossRef
  13. Liang NL, Alarcon LH, Jeyabalan G, Avgerinos ED, Makaroun MS, Chaer RA. Contemporary outcomes of civilian lower extremity arterial trauma. J Vasc Surg 2016;64:731-6.
    Pubmed KoreaMed CrossRef
  14. Burkhardt GE, Gifford SM, Propper B, et al. The impact of ischemic intervals on neuromuscular recovery in a porcine (Sus scrofa) survival model of extremity vascular injury. J Vasc Surg 2011;53:165-73.
    Pubmed CrossRef
  15. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568-72.
    Pubmed CrossRef
  16. Fodor L, Sobec R, Sita-Alb L, Fodor M, Ciuce C. Mangled lower extremity: can we trust the amputation scores? Int J Burns Trauma 2012;2:51-8.
    Pubmed KoreaMed
  17. Ozturkmen Y, Karamehmetoglu M, Karadeniz H, Azboy I, Caniklioglu M. Acute treatment of segmental tibial fractures with the Ilizarov method. Injury 2009;40:321-6.
    Pubmed CrossRef
  18. Hinck D, Franke A, Gatzka F. Use of vacuum-assisted closure negative pressure wound therapy in combat-related injuries: literature review. Mil Med 2010;175:173-81.
    Pubmed CrossRef
  19. Germann G, Steinau HU. Functional soft-tissue coverage in skeletonizing injuries of the upper extremity using the ipsilateral latissimus dorsi myocutaneous flap. Plast Reconstr Surg 1995;96:1130-5.
    Pubmed CrossRef
  20. Schmidhammer R, Dorninger L, Huber W, Haller H, Kropfl A. Simultaneous reimplantation of both lower legs: 5-year follow-up. Unfallchirurg 2003;106:161-5.
    Pubmed CrossRef
  21. Shalhub S, Starnes BW, Tran NT. Endovascular treatment of axillosubclavian arterial transection in patients with blunt traumatic injury. J Vasc Surg 2011;53:1141-4.
    Pubmed CrossRef
  22. Macedo FI, Sciarretta JD, Chausse S, Sleeman D, Pizano LR, Namias N. Vascular reconstruction is not warranted in most civilian traumatic shank vascular injuries. Ann Vasc Surg 2016;35:38-45.
    Pubmed CrossRef
  23. Martin LC, McKenney MG, Sosa JL, et al. Management of lower extremity arterial trauma. J Trauma 1994;37:591-8.
    Pubmed CrossRef
  24. Keen RR, Meyer JP, Durham JR, et al. Autogenous vein graft repair of injured extremity arteries: early and late results with 134 consecutive patients. J Vasc Surg 1991;13:664-8.
    Pubmed CrossRef

Stats or Metrics

Share this article on :

  • line