Limb salvage in extremity vascular trauma: Our experience

Arunagiri Viruthagiri

Senior Consultant Vascular and Endovascular Surgeon, Kauvery Hospitals, Trichy.

Aim

We analysed our limb salvage outcomes in patients who presented with extremity vascular trauma.

Material and methods

Place of study: Kauvery hospital, Trichy

Duration: 4 years (March 2019–March 2023)

Type: Retrospective analysis

Total number of patients: 82.

Results

1. Demographics

Adults-69

Total (M: F=64:5)

extremity-vascular-trauma-1

Paediatric – 13

Paediatric (M: F=10:3)

extremity-vascular-trauma-2

2. Mode of injury/investigation

extremity-vascular-trauma-3

3. Timing of surgery from presentation

extremity-vascular-trauma-4

4. Vascular injury/Vessel involved

Upper limb – 36

Lower limb – 46

5. Vascular procedure Performed

Interposition vein graft – 68 patients (82%)

Primary repair – 5 patients (6%)

Fasciotomy – 52 patients (63%)

Amputation – 8 (10%) Primary-5, Secondary-3

Ligation – 4 (5%)

6. Associated injuries

Skeletal fractures (66%)

  1. Compound – 26 patients
  2. Simple – 14 patients
  3. Supracondylar – 14 patients

Other injury

  1. Bladder – 2 patient
  2. Nerve – 9 (median nerve most common)

7. Associated procedures

 

Primary ortho procedure – 54
K wire 5
ORIF 15
Closed reduction 4
External fixator 30

Plastic surgery procedure – 44
SSG 24
Tendon and Nerve repair 12
Flap cover 6
Brachial plexus exploration 2

8. Limb Savage vs Amputation

extremity-vascular-trauma-5

9. Mortality – 3 patients (3.6%)

  1. Patient 1 and 2 run over by bus- multiple long bone injury with pelvic and perineal injury – lost to sepsis.(one was doctor)
  2. Patient 3- delayed presentation – crush injury – debridement with vascular repair and free flap- blow out on day 7 secondary to infection

Discussion

PROOVIT Registry

  1. The American Association for the Surgery of Trauma Prospective Observational Vascular Injury Treatment (PROOVIT) registry:
  2. Multicenter data on modern vascular injury diagnosis, management, and outcome
  3. A total of 542 injuries from 14 centers (13 American College of)
  4. Surgeons verified Level I and 1 American College of Surgeons verified
  5. Level II) have been captured since February 2013.
  6. Data for 1 year and 6 months.

criteria

Kauvery Hospitals (%)

PROOVIT registry (%)
Male 91 70.5
Blunt injuries 82 47
Extremity Vascular injury (n=82) 93 44
Skeletal injury 66 NA
Hypotension 16 11.8
CT angiogram 78 40
Injury pattern Transection 42 24.3
Occlusion 48 17.3
Ligation (Vein and Pseudo aneurysm) 5 5.7
IPVG ( GSV ) 82 23
Re-intervention 1 7.7
Amputation ( n= 8 ) 10 7.7
Mortality 3.6 12.7

Our Strategies

  1. Prefer Posterior approach for popliteal artery injury where P3 is reformed.
  2. Always autologous conduit in Trauma.
  3. Radical debridement.
  4. Soft tissue Cover- Plastic Surgeons involved.
  5. Skeletal stabilization- Upfront unless limb immediately threatened.

Conclusion

  1. Our experience Limb Salvage 90%
  2. Early intervention (Within 24 hr)
  3. Using autologous conduits (100%)
  4. Skeletal stabilization (Upfront) prior to repair.

Areas to introspect

  1. Functional outcome at 6 months and 1 year.
  2. PGs of Vascular, Orthopaedics and Plastic Surgery to jointly collect and contribute to data on Extremity Vascular Trauma prospectively.
  3. Monitor timelines from presentation to imaging to OR.

Acknowledgements

Orthopaedic team – Dr. PRR Sir, Dr SMC Sir and Dr. Kalaivannan.

Plastic team – Dr. Skanda, Dr. Murali.

Audit team – Dr. Ramu

Dr. Rajesh – Medical Admin.

Arunagiri-Viruthagiri

Dr. Arunagiri Viruthagiri

Senior Consultant Vascular and Endovascular Surgeon

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