Vascular Reconstruction and Limb Loss in Military Tibial Artery Injuries.

BACKGROUND: Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma. METHODS: A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least 1 tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (1, T1; 2, T2; 3, T3). RESULTS: Two hundred twenty one limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P < 0.001). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P = 0.59). T3 received greater blood transfusion volume (P = 0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P = 0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P = 0.16), and amputation was not significantly predicted by arterial ligation in T1 (P = 0.08) or T2 (P = 0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, P = 0.02), but other limb complication rates were similar. CONCLUSIONS: In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all 3 tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in 1-vessel and 2-vessel injuries, suggesting that selective reconstruction in these cases is advisable.

Association between time to revascularization and limb loss in military femoropopliteal arterial injuries.

OBJECTIVE: Expeditious revascularization is key to limb salvage after arterial injuries, but the relationship between time to revascularization and amputation risk is not well-defined. We aimed to explore amputation risk based on time to revascularization in a cohort of military femoropopliteal arterial injuries. METHODS: A database of vascular injuries from Iraq and Afghanistan casualties (2004-2012) was queried for femoral (common, superficial, or deep) and/or popliteal arterial injuries that underwent revascularization. Time from injury to initial revascularization (via shunt or reconstruction) was divided into groups of <3 hours, 3 to 6 hours, 6 to 9 hours, and >9 hours, and bivariate comparisons were performed. RESULTS: Revascularization times were available for 120 cases. Injury and treatment characteristics by time group were generally similar between time groups. Shunting and vein injuries were more common in limbs revascularized earlier, whereas blast mechanism and fasciotomy were more common with later revascularization. Ten cases (8%) underwent revascularization in less than 3 hours, 63 (53%) were revascularized in 3 to 6 hours, 33 (28%) in 6 to 9 hours, and 14 (12%) after 9 hours. Amputation rates within the cohorts were 10%, 21%, 24%, and 50%, respectively (P = .085, χ2 of amputation rates across time groups). The mean ± standard deviation revascularization time for amputated limbs was 442 ± 348 minutes vs 347 ± 183 minutes for salvaged limbs (P = .057). Amputation was performed in 19% of limbs revascularized in <6 hours and in 32% revascularized >6 hours from injury (P = .112). The >9-hour group, however, had a 50% amputation rate vs 21% for those with revascularization in <9 hours (P = .016). Fractures were more common in >9-hour limbs than <9-hour limbs (79% vs 44%; P = .016), but other limb injury characteristics were similar, with no difference in limb injury severity scores. Among 91 salvaged limbs, neither vascular nor other complications were predicted by time to revascularization. All seven >9-hour limbs had a limb complication, most commonly infection (71%), and three (42%) required a skin graft to close their fasciotomies. CONCLUSIONS: Increasing time from injury to initial revascularization was associated with increasing rates of limb loss. Revascularization within 3 hours of injury resulted in a low amputation rate, whereas one-half of limbs treated after 9 hours were amputated. Arterial shunting was associated with earlier revascularization and should be considered a mainstay of combat casualty vascular care. Forward-deployed surgical assets play a pivotal role in providing early revascularization and reducing rates of limb loss in modern combat casualty care.

Arterial Access Complications Following Percutaneous Femoral Access in 24-Hour Resuscitative Endovascular Balloon Occlusion of the Aorta Survivors.

INTRODUCTION: With the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) comes the potential for vascular access site complications (VASCs) and limb ischemic sequelae. We aimed to determine the prevalence of VASC and associated clinical and technical factors. METHODS: A retrospective cohort analysis of 24-h survivors undergoing percutaneous REBOA via the femoral artery in the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute care surgery registry between Oct 2013 and Sep 2021 was performed. The primary outcome was VASC, defined as at least one of the following: hematoma, pseudoaneurysm, arteriovenous fistula, arterial stenosis, or the use of patch angioplasty for arterial closure. Associated clinical and procedural variables were examined. Data were analyzed using Fisher exact test, Mann-Whitney-U tests, and linear regression. RESULTS: There were 34 (7%) cases with VASC among 485 meeting inclusion criteria. Hematoma (40%) was the most common, followed by pseudoaneurysm (26%) and patch angioplasty (21%). No differences in demographics or injury/shock severity were noted between cases with and without VASC. The use of ultrasound (US) was protective (VASC, 35% versus no VASC, 51%; P = 0.05). The VASC rate in US cases was 12/242 (5%) versus 22/240 (9.2%) without US. Arterial sheath size >7 Fr was not associated with VASC. US use increased over time (R2 = 0.94, P < 0.001) with a stable rate of VASC (R2 = 0.78, P = 0.61). VASC were associated with limb ischemia (VASC, 15% versus no VASC, 4%; P = 0.006) and arterial bypass procedures (VASC 3% versus no VASC 0%; P < 0.001) but amputation was uncommon (VASC, 3% versus no VASC, 0.4%; P = 0.07). CONCLUSIONS: Percutaneous femoral REBOA had a 7% VASC rate which was stable over time. VASC are associated with limb ischemia but need for surgical intervention and/or amputation is rare. The use of US-guided access appears to be protective against VASC and is recommended for use in all percutaneous femoral REBOA procedures.

The Characteristics and Results of Endovascular Devices in Trauma (CREDiT) study: Multi-institutional results.

INTRODUCTION: Endovascular techniques are increasingly used to repair major traumatic vascular injuries, but most endovascular implants are not designed/approved for trauma-specific indications. No inventory guidelines exist for the devices used in these procedures. We aimed to describe the use and characteristics of endovascular implants used for repair of vascular injuries to allow for better inventory management. METHODS: This CREDiT study is a six-year retrospective cohort analysis of endovascular procedures performed for repair of traumatic arterial injuries at five participating US trauma centers. For each treated vessel, procedural and device details were recorded and outcomes assessed with the aim of defining the range of implants and sizes used for these interventions. RESULTS: A total of 94 cases were identified; 58 (61%) were descending thoracic aorta, 14 (15%) axillosubclavian, 5 carotid, 4 abdominal aortic, 4 common iliac, 7 femoropopliteal, and 1 renal. Vascular surgeons performed 54% of cases, trauma surgeons 17%, IR/CT Surgery 29%. Systemic heparin was administered in 68% and procedures were performed a median of 9 h after arrival (IQR 3-24 h). Primary arterial access was femoral in 93% of cases, 49% were bilateral. Brachial/radial access was used primarily in 6 cases, and secondary to femoral in 9. The most common implant was self-expanding stent graft; 18% used >1 stent. Implants ranged in diameter and length based on vessel size. Five of 94 implants underwent reintervention (1 open surgery) at a median of 4d postop (range 2-60d). Two occlusions and 1 stenosis were present at follow-up at a median of 1 month (range 0-72 m). CONCLUSIONS: Endovascular reconstruction of injured arteries requires a broad range of implant types, diameters, and lengths which should be readily available in trauma centers. Stent occlusions/stenoses are rare and can typically be managed by endovascular means.