Management of distal femoral and popliteal arterial injuries: an update.

BACKGROUND: The management of combined arterial and musculoskeletal injuries to the lower extremity remains controversial, particularly with regard to the initial order of intervention and the use of intravascular shunting. In this study, we review the contemporary management and outcome of patients treated for acute traumatic distal femoropopliteal arterial injuries. METHODS: From January 2001 to January 2006, we repaired 57 acute traumatic lower-extremity arterial injuries in a level 1 trauma center. Our approach was to perform surgical revascularization without intraluminal shunting as soon as the arterial injury was recognized. There were 44 men (77%). Mean age was 31 years (range, 5-68). The mechanism of injury was blunt in 42 of 57 (74%) patients. Vascular reconstruction was achieved by using an autogenous saphenous vein graft in 52 of 57 (91%), a vein patch in 3 of 57 (5%), or primarily in 2 of 57 (4%) patients. RESULTS: The limb-salvage rate was 92% (53/57). Thirty-six patients (63%) had associated orthopedic fixation: 12 of 36 (33%) before and 24 of 36 (67%) after revascularization. Twenty-one of 57 patients (37%) had vascular repair only without orthopedic fixation. Thirty-four patients (60%) required fasciotomy. Four patients had subsequent above-knee amputation: 3 because of wound complications despite successful revascularization and 1 because of failed revascularization. There were no complications related to the arterial repairs that were performed before orthopedic fixation. CONCLUSION: Our study shows that arterial reconstruction for acute traumatic lower-limb injuries results in a good limb-salvage rate. We advocate prompt vascular repair before orthopedic intervention for combined vascular and skeletal injuries of the lower extremity, without using intravascular shunting.

Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage.

BACKGROUND: The benefit of distal aortic perfusion and cerebrospinal fluid drainage over the "clamp and sew" technique during repairs of the descending thoracic aorta is still being debated. The purpose of this report is to analyze our experience with regard to neurologic deficit (paraplegia and paraparesis) and mortality using the adjuncts of distal aortic perfusion and cerebrospinal fluid drainage. METHODS: Between February 1991 and September 2004, we repaired 355 descending thoracic aortic aneurysms. Excluded from analysis were 29 patients who required profound hypothermic circulatory arrest as a result of transverse arch involvement and 26 patients with aortic rupture, leaving a group of 300 patients for which outcomes were analyzed. Mean patient age was 67 years, and 102 (34%) of the patients were women. The adjunct group of distal aortic perfusion and cerebrospinal fluid drainage used in 238 (79.3%) patients was compared with a group of 62 patients who underwent simple cross-clamp with or without the addition of a single adjunct. Multivariable data were analyzed by Cox regression. RESULTS: The incidence of neurologic deficit after all repairs was 2.3% (7 of 300 patients). The incidence of neurologic deficit (immediate and delayed) in the adjunct group was 1.3% (3 of 238 patients), and in the nonadjunct group was 6.5% (4 of 62 patients; p < 0.02). One case of delayed paraplegia occurred in each group. All neurologic deficits occurred in patients with aneurysmal involvement of the entire descending thoracic aorta (extent C; p < 0.02). Statistically significant predictors for neurologic deficit were the use of the adjunct (odds ratio [OR], 0.19; p = 0.02), previous repaired abdominal aortic aneurysm (OR, 7.0; p = 0.005), type C aneurysm (OR, 13.73; p = 0.02), and cerebrovascular disease history (OR, 4.7; p < 0.03). Thirty-day mortality was 8% (24 of 300 patients). Significant multivariate predictors of 30-day mortality were preoperative renal dysfunction (OR, 4.6; p < 0.01) and female sex (OR, 2.9; p < 0.03). CONCLUSIONS: Repairs of the descending thoracic aorta using the adjunct of distal aortic perfusion and cerebrospinal fluid drainage can be performed with a low incidence of neurologic deficit and an acceptable mortality. The use of the adjuncts should be considered during elective repairs of the descending thoracic aorta.