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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 9  |  Page : 1221-1228

Evaluation of extremity vascular injuries and treatment approaches


1 Department of Cardiovascular Surgery, Adıyaman Univesity, Adıyaman, Turkey
2 Department of Forensic Medicine, Adıyaman Univesity, Adıyaman, Turkey

Date of Submission19-Dec-2018
Date of Acceptance04-Jul-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Dr. H Kafadar
Department of Forensic Medicine, Adıyaman Univesity, Adıyaman - 416100
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_656_18

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   Abstract 


Background: Vascular injuries are commonly seen in both emergency services and forensic medicine practise. They are often life-threatening, with high morbidity and mortality rates. Aims: This study aimed to retrospectively evaluate extremity vascular injuries and the associated treatment approaches. Methods: After obtaining approval from the ethics committee of the university, those patients admitted to the emergency department of Adiyaman between 1 February 2013 and 31 August 2018 were included in this study. The patients' data were obtained through the electronic records system, and the cases were evaluated according to the age, gender and cause of injury, including blunt force trauma injuries (accidents, traffic accidents, crush injuries and occupational accidents) and penetrating injuries (stabbing, gunshot wounds, suicide attempts and assaults). Additionally, the injuries were evaluated based on the extremity, according to the anatomical location and whether the injury was life-threatening. Results: This study included 76 patients with extremity vascular injuries; 65 were males (85.52%), 11 were females (14.48%) and their average age was 33.24 ± 15.85 years. Forty-five (59.2%) of the patients had upper extremity vascular injuries, and 31 (40.3%) had lower extremity vascular injuries. In addition to arterial injuries, 26 (34.21%) of the patients had venous injuries and 22 (28.94%) had nerve injuries. Nine of these patients had neurological deficits due to their nerve injuries. All of the patients were revascularized within 3–5 hours, and none of the patients required amputations. Conclusion: The primary goals in extremity vessel injury cases are to prevent mortality, especially after major vascular injuries, and save the extremity from amputation. With a fast, effective and multi-disciplinary approach, an accurate diagnosis and effective surgical intervention can prevent morbidity and mortality as well as reduce the rate of undesirable complications.

Keywords: Forensic medicine, injury, revascularization, vascular injury


How to cite this article:
Guven C, Kafadar H. Evaluation of extremity vascular injuries and treatment approaches. Niger J Clin Pract 2020;23:1221-8

How to cite this URL:
Guven C, Kafadar H. Evaluation of extremity vascular injuries and treatment approaches. Niger J Clin Pract [serial online] 2020 [cited 2020 Sep 27];23:1221-8. Available from: http://www.njcponline.com/text.asp?2020/23/9/1221/294686




   Introduction Top


Extremity vascular injuries exhibit a variety of aetiologies, including blunt and/or penetrating injuries, but they frequently occur in the form of penetrating injuries, such as cutting tool punctures and gunshot wounds.[1],[2],[3] Recently, however, non-combat studies have shown that patients with extremity vascular injuries are more commonly referred to the emergency services for blunt injuries rather than penetrating injuries.[1] Extremity vascular injuries can occur with various blunt trauma, such as traffic accidents, falls from heights, natural disasters, beatings and crush injuries.[1],[2],[3] It has been reported that 2%–3% of all patients with trauma admitted to the emergency department exhibit vascular injuries, and these patients are among the first cases requiring emergency surgery.[1],[2],[3],[4],[5]

Vascular injuries exhibit high morbidity and mortality rates because they usually involve life-threatening bleeding. Isolated vascular injuries are easier to diagnose, and they have a higher success rate in surgical treatment.[1],[2],[3] However, if a patient presents with multiple injuries, various imaging techniques, including radiography, focused assessment with sonography for trauma (FAST), Doppler ultrasonography (US), and computed tomography angiography (CTA), may be required for the diagnosis and treatment planning. Of these, CTA imaging can provide faster and more accurate results in certain patients with vascular injuries.[3] With the correct diagnosis and appropriate surgical method, it is possible to save the extremity and reduce patient mortality.[3],[4],[5],[6],[7] This requires a multidisciplinary approach to minimize the ischemia time, determine the treatment priorities and plan urgent and proper vascular repair.[3]

Severe vascular injuries indicate haemorrhaging or ischemia. The loss of blood can occur externally or internally and cause hypovolemic shock, which can result in mortality and/or the loss of the extremity. Therefore, the surgeon's main goal should be an attempt to save the patient's life. In order to prevent the loss of an extremity (amputation), the damaged vessel(s) should be repaired and revascularization should be provided.[3],[8],[9],[10],[11]

Extremity vascular injuries are frequently associated with bone fractures and adjacent nerve injuries. Therefore a multidisciplinary approach is very important when dealing with multiple injuries (such as in crush injuries) and the adjacent tissues and organs. This type of approach is more likely to result in successful diagnosis and treatment.[3],[5],[6],[7],[8],[11]

When interdisciplinary and multidisciplinary approaches are applied to all vascular injuries, rapid diagnoses and treatments can reduce both the mortality and the amputation rates. Therefore, we designed this study to contribute to the literature on peripheral vascular injuries because they are encountered frequently in emergency and forensic medicine. These are life-threatening injuries that require urgent surgical interventions (revascularizations).


   Materials and Methods Top


This study began after receiving the approval of the university ethics committee. The cases of those patients who were admitted to the emergency department of Adiyaman, and who underwent surgery between 1 February 2013 and 31 August 2018, were retrospectively analysed. The patient data were obtained from the electronic hospital records, and the cases were evaluated in terms of the age, gender and cause of injury, including accidents, traffic accidents, falls, blunt force trauma, penetrating injuries, gunshot wounds, crush injuries from work accidents, suicide attempts and assaults. The number and anatomical locations of the extremity injuries were determined, and any differences between the vascular injuries to the upper and lower extremities and the most frequently injured vessels were elucidated. Additionally, in terms of the practice of forensic medicine, we established whether or not the injuries were life-threatening.

Statistical analysis

The statistical analysis was performed using IBM SPSS Statistics for Windows (version 22.0; IBM Corp., Armonk, NY, USA). The categorical variables were grouped, the percentages were calculated, and Pearson's Chi-squared test or Fisher's exact test was used to compare the frequencies based on the suitability. The relationships or differences between the groups were explained statistically, and a P value of <0.05 was accepted as statistically significant.

In this study, the categorical variables were given as frequencies and percentages, while the descriptive statistics and continuous variables were given as the means ± the standard deviations.


   Results Top


Data analysis

A total of 76 patients who met the study criteria were identified; 65 of the patients were males (85.52%), 11 (14.48%) were females and their mean age was 33.24 ± 15.85 years. When the cases were examined in terms of the injured anatomical regions, 45 (59.2%) of the patients exhibited upper extremity vascular injuries and 31 (40.3%) exhibited lower extremity vascular injuries [Table 1]. There were more upper extremity vascular injuries than lower extremity vascular injuries, but the difference was not statistically significant (P > 0.005).
Table 1: Arterial injury causes and revascularization types

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All of the patients exhibited arterial injuries, with the most frequently injured artery being the radial artery (28 cases, 36.84%), and 21 of them had isolated injuries. Additionally, ulnar artery injuries were identified in 7 (9.3%) of the patients. Popliteal artery injuries were the second most common (16 cases, 21.1%), and popliteal vein injuries were also found in 14 (18.4%) of the patients. A total of 16 patients (21.05%) had ulnar artery injuries; 9 of them had single-vessel injuries and 7 (9.3%) had combined injuries. Crush injuries were seen in two patients due to a wall collapsing on them [Table 1].

When the cases were examined in terms of the injury causes, the most common cause was a sharp and penetrating object injury (52 patients, 68.4%); nine (11.9%) of them were gunshot wounds, five (6.6%) were Circular saw injuries, four (5.3%) fell from heights, three (3.9%) were traffic accidents, two (2.6%) were crush injuries and one (1.3%) was a horse bite injury. Compared to the other types of injuries, the sharp and penetrating object injuries were the most commonly seen extremity vascular injuries, and this difference was statistically significant. Additionally, the number of extremity vascular injuries in the assault and murder cases was statistically significantly higher than in the accident and suicide cases [Table 2].
Table 2: Vascular injury causes

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In addition to the arterial injuries, venous injuries were also detected in 26 (34.21%) of the patients [Table 3]. Two of the patients with common iliac vein and popliteal vein injuries were treated with synthetic grafts. In seven of the patients with venous injuries that could not be repaired primarily, the veins were ligated. In five of the nine firearm injury cases, in addition to an arterial injury, a venous injury was detected. Four of these patients were shot in the knee with shotguns, and one (1.3%) patient attempted suicide with a close shot distance. Saphenous graft revascularizations were performed in these cases.
Table 3: Venous injuries, causes and repair methods

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The surgical repair methods included end-to-end anastomoses in 44 patients (57.9%), saphenous vein graft interpositions in 11 patients (14.5%), synthetic grafts in 4 (5.2%), patients, primary repairs in 16 (21.0%), patients and ligation in 1 (1.3%), patient [Table 4]. A statistically significant difference was found between the number of end-to-end anastomoses and the other surgical repair methods (P < 0.005).
Table 4: Surgical methods used for the arterial repairs

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Additional pathologies associated with the vascular injuries were found in 47 (61.84%) of the 76 patients included in this study. These pathologies included nerve injuries in 22 patients (46.80%), muscle and/or tendon damage in 16 patients (34.05%) and bone fractures in 9 patients (19.14%), [Table 5].
Table 5: Additional pathologies associated with the vascular injuries

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The surgical treatment success rate was the highest in the patients with sharp and penetrating object injuries. In other words, the least amount of dysfunction was seen in this patient group.

[Figure 1] shows an image of a patient who presented to the emergency department with a horse bite injury. This patient had extensive soft tissue loss, fractures of the radius and ulna, and radial and ulnar artery injuries. After undergoing a saphenous graft interposition of the radial artery and primary repair of the ulnar artery under general anaesthesia, the radius and ulna fractures were repaired by external fixation during the same session in the orthopaedics department. This patient was transferred to the plastic and reconstructive surgery department for soft tissue reconstruction one week later [Figure 2]. Two months later, the patient underwent internal fixation surgery with a plate and screws placed on the distal ends of the fractured radius and ulna in the orthopaedics department. Six months later, the patient exhibited a 'claw hand' deformity due to the median and ulnar nerve damage.
Figure 1: Tissue loss from a horse bite on the right forearm of a patient

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Figure 2: The same patient after the tissue reconstruction

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It was determined all of the patients were revascularized in emergency conditions, and none of the patients required amputations. In addition to the vascular injuries, nerve injuries occurred in 22 of the patients. Of them, 9 (40.9%) developed neurological deficits due to the nerve injuries.

In these patients, the time between the vascular injury occurrence and revascularization did not exceed the duration of warm ischemia (6 hours), and all of them were revascularized within 3–5 hours. There were less ischemic symptoms, especially in the upper extremities in the distal forearm injuries, due to the widespread collaterals.

Undesirable sequelae, including prolonged hospitalization durations, increased surgical interventions and excessive tissue damage, were seen more often and in direct proportion to the vascular injuries that were accompanied by other pathologies.

In these patients, the time to hospital admission was 30–150 minutes, and the revascularization time was not more than 5 hours. These may be two of the most important factors in reducing the mortality and the sequelae due to excessive blood loss. For example, one patient presented with a close-range hunting rifle injury to a lower extremity with a large amount of tissue loss. A venous interposition graft was used to treat this patient. The patient was discharged after 3 days in the intensive care unit and 47 days of follow-up and treatment. This patient was followed up in the hospital for the longest period.

Rapid and accurate diagnosis is vital to the successful treatment of an extremity vascular injury. It is possible to diagnose these injuries with a physical examination in most of the isolated injury cases, such as a cutting tool injury; 65% of the cases were diagnosed based on a physical examination. In order to determine the presence of additional pathologies, several different imaging methods were used; radiology department US examinations were used in the stable patients and CTA examinations were conducted in those cases with tissue loss.

One patient presented with a knee injury from a shotgun, and the physical examination showed that the capillary filling time and pulse were within normal limits. The CTA examination was normal because of the dense artefact [Figure 3]. However, this patient underwent emergency surgery due to late bleeding from the popliteal artery and vein, which were injured due to a corrosive effect.
Figure 3: Computed tomography angiography image that was evaluated as normal because of the intensive artefact

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   Discussion Top


Vascular injuries are common during combat, and they constitute 2%–5% of all injuries.[3],[12] Rai et al. reported that the peripheral vascular injury rate was 3.1%. Combat-related vascular injuries are caused mostly by penetrating injuries, with 80%–90% caused by firearms.[8],[11],[12],[13],[14],[15] Additionally, Peck et al. reported that penetrating injuries were responsible for 88% of the vascular injuries sustained during the Iraq war (2004–2006), and they determined that only 3% of the cases were from blunt trauma vascular injuries. According to those authors, the penetrating vascular injuries were caused most commonly by explosive devices and firearms.[16]

In this study, penetrating injuries were found in the majority of the cases (80.3%) when compared to nonpenetrating injuries (19.7%), and these results were consistent with the literature. However, 68.4% of the extremity vascular penetrating injuries were caused by sharp and penetrating objects, and 11.9% of the injuries were caused by firearms. This difference was found to be statistically significant, but these results were not compatible with the literature. The reason for this could be that during the years in which this study was carried out (2013–2018), there were no wars or armed conflicts in our region, so none of these cases were admitted to our hospital.

When examining the extremity vascular injuries in terms of the anatomical regions, the lower extremity vascular injury rate was higher in the literature.[1],[2],[3],[8],[16] For instance, Peck et al. reported a lower extremity vascular injury rate of 70.1% and an upper extremity rate of 29.9%.[16] In our study, the upper extremity vascular injury rate was 59.2% and the lower extremity rate was 40.3%. In the upper extremities, the radial artery was the most commonly injured vessel, while the popliteal artery was the most commonly injured vessel in the lower extremities. However, these results were not compatible with the literature. as most of the studies in the literature evaluated gunshot wounds and/or explosive injuries during combat. In our study, the majority of the patients presented with sharp and penetrating object injuries.

Most often, the diagnosis of an extremity artery injury is made by using the physical examination findings, including pulsatile bleeding, a rapidly expanding hematoma and a non-palpable artery distal from the lesion. In a stable patient, FAST US, Colour Doppler US and CTA evaluations are very useful for obtaining an accurate diagnosis.[8],[16],[17],[18] However, CTA is the preferred method in emergency conditions.[8]

In this study, 42 of the cases (65%) were diagnosed based on a physical examination. In order to establish the presence of additional pathologies, several different imaging methods were used; Colour Doppler US examinations were used in stable patients, and CTA examinations were used in those patients with tissue loss.

In the literature, the most common symptom of a peripheral vascular injury was haemorrhagic shock, at a rate of 80%, and it is the most important factor for determining mortality. In vascular injuries, the initial aim should be to save the patient's life. The secondary aim should be to protect the affected extremity against ischemic damage.[3],[11] This requires a multidisciplinary and professional approach to the transfer of the patient from the scene of the accident to the emergency department for the initial evaluation[3],[11] As this process is often a race against time, a fast transfer and timely intervention are required to save the patient's life and protect the extremity from ischemic damage. The type of injury, anatomical localization and presence of additional tissue damage are the other factors affecting the mortality and morbidity rates in these patients.[1],[3],[11],[12],[13]

Maintaining appropriate haemostasis and combating hypovolemic shock should be the main targets when awaiting surgery in extremity arterial injuries. In those patients with haemorrhages, direct pressure to the bleeding area or the use of a tourniquet in the proximal haemorrhage area may be effective. The literature review showed that the use of tourniquets in all of the major military studies prevented mortality. Moreover, it has been shown that the use of a tourniquet has no permanent side effects in many large case series that included amputations.[4],[6],[7] If direct pressure is not sufficient to control the bleeding, a tourniquet is recommended until definitive surgical control can be achieved.[19]

In the data obtained from our patients, no deaths or amputations were reported in those patients that were brought to the hospital and underwent surgery in the cardiovascular surgery department. This may have been because the time taken to bring the patients to the hospital varied between 30 and 150 minutes, and the period until revascularization did not exceed 5 hours. These were also considered to be the most important factors for reducing the mortality and sequelae due to excessive blood loss.

The skin, soft tissue (muscle/tendon) and/or nerve damage associated with bone fractures is frequently associated with complex extremity vascular injuries, which exhibit a high risk of amputation. In these patients, the primary objective is to correct the acute damage and improve hemodynamic status. Then, the prevention of functional loss can be taken into account.[19]

Additional pathologies associated with the vascular injuries were found in 61.84% of the cases presented in this study. Nerve injuries (n = 22) were observed in 46.80% of the cases, muscle and/or tendon damage (n = 6) was observed in 34.05% of the cases, and concomitant bone fractures were seen in 19.15% of the cases.

The most common type to repair in the peripheral vascular injury cases was a primary repair, although this varied according to the lesion characteristics. In those cases in which a primary repair was impossible, saphenous vein grafts were preferred due to the long-term circulation and resistance to infection.[19],[20],[21],[22],[23]

Primary repairs were performed in 21% of our cases, the end-to-end anastomoses were performed in 57.9%, saphenous vein graft interpositions were performed in 14.5%, synthetic grafts were performed in 5.26% cases and a ligation was performed in 1.3% patient. These results were compatible with the literature.

[Table 6] shows the review of the main papers published in the literature during the last 5 years [Table 6].[11],[24],[25],[26],[27]
Table 6: A review of the main papers published in the literature during the last 5 years

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   Conclusion Top


Peripheral vascular injuries are commonly encountered in emergency medicine. They are often life-threatening, and they must be repaired urgent surgically (revascularization). In all vascular injury cases, interdisciplinary and multidisciplinary approaches can help to reduce the mortality rate with rapid diagnosis and treatment. They can also reduce the functional loss and amputation rates.

Ethical approval

The study was approved by Adiyaman University ethical committee. The study was approvedby Adiyaman University ethical committee (20.11.2018 Date and Number: 2018/8-3).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Management of combat vascular injuries using modern imaging: Are we getting better&? Emerg Med Int 2013;1-6. doi: 10.1155/2013/689473.  Back to cited text no. 3
    
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Kragh JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 2008;64:38-49.  Back to cited text no. 5
    
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Kragh JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 2009;249:1-7.  Back to cited text no. 6
    
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Kragh JF, O'Neill ML, Walters TJ, Jones JA, Baer DG, Gershman LK, et al. Minor morbidity with emergency tourniquet use to stop bleeding in severe limb trauma: Research, history, and reconciling advocates and abolitionists. Mil Med 2011;176:817-23.  Back to cited text no. 7
    
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Peck MA, Clouse WD, Cox MW, Bowser AN, Eliason JL, Jenkins DH, et al. The complete management of extremity vascular injury in a local population: A wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base, Iraq. J Vasc Surg 2007;45:1197-204.  Back to cited text no. 16
    
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Conrad MF, Patton JH Jr, Parikshak M, Kralovich KA. Evaluation of vascular injury in penetrating extremity trauma: Angiographers stay home. Am J Surg 2002;68:269-74.  Back to cited text no. 18
    
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Rush RM, Arrington ED, Hsu JR. Management of complex extremity injuries: Tourniquets, compartment syndrome detection, fasciotomy, and amputation care. Surg Clin North Am 2012;92:987-1007.  Back to cited text no. 19
    
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Dereli Y, Özdemir R, Kayalar N, Aǧrış M, Hoşgör K, Özdiş AS. Penetrating peripheral vascular injuries. JAEM 2012;11:15-8.  Back to cited text no. 20
    
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Perkins ZB, Yet B, Glasgow S, Cole E, Marsh W, Brohi K, et al. Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma. Br J Surg 2015;102:436-50.  Back to cited text no. 22
    
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Gifford SM, Aidinian G, Clouse WD, Fox CJ, Porras CA, W Tracey Jones, et al. Effect of temporary shunting on extremity vascular injury: An outcome analysis from the Global War on Terror vascular injury initiative. J Vasc Surg 2009;50:549-55.  Back to cited text no. 23
    
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Usman R, Jamil M, Anwer MF. Evaluation, surgical management and outcome of traumatic extremity vascular injuries: A 5-year Level-1 trauma centres experience. Ann Vasc Dis 2018;11:312-7.  Back to cited text no. 24
    
25.
De Ayala-Hillman R, Crespo-Martínez NA, García-Rodríguez O, Ramos-Meléndez EO, Rodriguez-Ortiz P. Traumatic vascular injury and its management with temporary intravascular shunts: Puerto Rico trauma hospital's experience. P R Health Sci J 2018;37:220-3.  Back to cited text no. 25
    
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Jagdish K, Paiman M, Nawfar A, Yusof M, Zulmi W, Azman W, et al. The outcomes of salvage surgery for vascular injury in the extremities: A special consideration for delayed revascularization. Malays Orthop J 2014;8:14-20.  Back to cited text no. 26
    
27.
DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb JB, et al. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: Multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg 2015;78:215-22.  Back to cited text no. 27
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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