j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
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Applying peripheral vascular injury guidelines to penetrating trauma Vincent E. Chong, MD, Wayne S. Lee, MD, Emily Miraflor, MD, and Gregory P. Victorino, MD* Department of Surgery, University of California, San FranciscodEast Bay, Oakland, California
article info
abstract
Article history:
Introduction: Treatment of traumatic vascular injury is evolving because of endovascular
Received 2 January 2014
therapies. National guidelines advocate for embolization of injuries to lower extremity
Received in revised form
branch vessels, including pseudoaneurysms or arteriovenous fistulas, in hemodynamically
1 March 2014
normal patients without hard signs of vascular injury. However, patient stability and injury
Accepted 12 March 2014
type may limit endovascular applicability at some centers. We hypothesized that for
Available online xxx
penetrating trauma, indications for endovascular treatment of peripheral vascular injuries, as outlined by national guidelines, are infrequent.
Keywords:
Methods: We reviewed records of patients sustaining penetrating peripheral vascular
Trauma
injuries treated at our university-based urban trauma center from 2006e2010. Patient
Peripheral vascular injury
demographics and outcomes were analyzed.
Endovascular
Results: In 92 patients with penetrating peripheral vascular injuries, 82 were managed operatively and 10 were managed nonoperatively. Seventeen (18%) were hemodynamically unstable on arrival, 44 (48%) had multiple vessels injured, and 76 (83%) presented at night and/or on the weekend. No pseudoaneurysms or arteriovenous fistulas were seen initially or at follow-up. Applying national guidelines to our cohort, only two patients (2.2%) met recommended criteria for endovascular treatment. Conclusions: According to national guidelines, indications for endovascular treatment of penetrating peripheral vascular injury are infrequent. Nearly two-thirds of patients with penetrating peripheral vascular injuries were hemodynamically unstable or had multiple vessels injured, making endovascular repair less desirable. Additionally, over 80% presented at night and/or on the weekend, which could delay treatment at some centers due to mobilization of the endovascular team. Trauma centers need to consider their resources when incorporating national guidelines in their treatment algorithms of penetrating vascular trauma. ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
The standard approach to penetrating peripheral vascular injury requiring surgical intervention is open repair. However, the role of endovascular therapy in the setting of trauma
continues to evolve [1e5]. As reported in two different reviews of the National Trauma Data Bank, the incidence of endovascular approaches to vascular trauma has been on the rise in the past two decades [6,7]. From 1994e2003, 2.2% of all traumatic vascular injuries were approached endovascularly,
* Corresponding author. Department of Surgery, Highland Hospital, University of California, San FranciscodEast Bay, 1411 East 31st Street, Oakland, California, 94602. Tel.: þ1 510 437 8370; fax þ1 510 437 5127. E-mail address: [email protected] (G.P. Victorino). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.03.035
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
compared with 6% from 2007e2009 [6,7]. In 2003, endovascular techniques comprised 8.1% of all surgical interventions for vascular trauma, although this also included nonextremity injuries [6]. Despite the increasing popularity of endovascular approaches to peripheral vascular trauma, its indications and utility are still controversial. This is, in part, because of a lack of a strong evidence base. Although the literature does support the effectiveness of endovascular approaches to cervical and thoracic vascular injuries [3,8], the evidence in peripheral vascular trauma is based almost solely on case reports and expert opinion. As such, guidelines published by two leading national trauma organizations indicate that endovascular techniques may only be appropriate in selective circumstances, namely for embolization of injuries to extremity branch vessels, such as the profunda femoris and infrapopliteal trifurcation [9,10]. Beyond anatomic location, there are other contraindications to an endovascular approach. An absolute contraindication would be an inability to cross the traumatic lesion with a wire, whereas relative contraindications include uncontrolled hemorrhage and hemodynamic instability [3]. Other limitations to the applicability of endovascular techniques include any factors that would result in unnecessary delays in definitive treatment, such as lack of staff training and familiarity with endovascular equipment, long wait times for activation of an endovascular team, and long distances between the interventional and operative suites [3]. These limitations could effectively transform relative contraindications, such as hemodynamic instability, into absolute contraindications. To explore the applicability of currently published indications for endovascular treatment of peripheral vascular trauma, we conducted a retrospective review of the trauma registry at our university-based urban trauma center. We focused on penetrating injuries, which make up the overwhelming majority of peripheral vascular trauma at our institution. We hypothesized that patients with peripheral vascular injuries from penetrating trauma rarely meet indications for endovascular treatment based on current national guidelines.
2.
3.
Results
During the study period, 10,103 patients were activated into our trauma system. Of these, there were 92 patients who sustained a penetrating peripheral vascular injury (Fig. 1). The mean age of our cohort was 30 y old, with a range from 14e57 y old. There were 87 men and five women. Firearm trauma was the mechanism of injury for 66 patients (72%), whereas 26 patients (28%) sustained stab wounds. At presentation, 17 patients (18%) were hemodynamically unstable, defined by systolic blood pressure 105 beats per minute. The average injury severity score of our cohort was 15 0.9. In regards to time of presentation, 76 patients (83%) presented to our trauma center either at night and/or on the weekend. Figure 2 illustrates how our cohort of 92 patients was managed after arrival at our trauma center. Seventy-one patients (77%) presented with either hard signs of vascular injury or thoracoabdominal injuries requiring emergency surgery, including 17 patients with hemodynamic instability. The hard signs of vascular injury included the following: pulsatile bleeding (n ¼ 26), expanding hematoma (n ¼ 2), and loss of pulse (n ¼ 37). All 71 patients underwent open operative intervention. Patients who presented with soft signs of vascular injury underwent further diagnostic imaging with either computed tomography angiography or duplex ultrasonography. From this subset of patients, 10 were found to have injuries amenable to nonoperative management, such as arterial vasospasm or injury to superficial lower extremity branch vessels requiring only bedside ligation or observation. Observation encompassed pulse checks, Doppler ultrasonography, and ankle-brachial index measurements while hospitalized or as outpatients. The other 11 patients required intervention for major injuries to named extremity arteries. In the 82 patients who required operative intervention for their injuries, there were 28 (34%) patients with upper extremity injuries and 54 (66%) with lower extremity injuries (Table; Fig. 4). The anatomic breakdown of lower extremity arterial injuries is as follows: five common femoral, four deep femoral, 25 superficial femoral, 13 popliteal, three anterior
Methods
Approval for the study was obtained from our Institutional Review Board. Patients were selected for inclusion in this study from our university-based urban trauma center’s database if they had a documented extremity arterial or venous injury due to penetrating mechanism during the 5-y period from 2006e2010. The following data were extracted from the records: patient demographics, presenting vital signs, injury severity scores, vascular structures injured, associated injuries, preoperative imaging evaluation, type of repair performed, secondary procedures, patency of repair, and final functional status of the injured limb. Descriptive statistics were calculated with Microsoft Excel (Microsoft, Redmond, WA). Results are presented as mean standard error of the mean.
Fig. 1 e Peripheral vascular injuries, 2006e2010. Our study sample consisted of 92 patients with penetrating peripheral vascular injuries. Of these, 10 were managed nonoperatively, whereas 82 required surgery.
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
Fig. 2 e Management algorithm for peripheral vascular injuries. Of the patients who presented with penetrating peripheral vascular injury, 71 underwent immediate operation because of hard signs of vascular injury, concomitant thoracoabdominal injuries, and/or hemodynamic instability. Further diagnostic testing was done for 21 patients with soft signs of vascular injury, leading to either open operation (n [ 11) or nonoperative management (n [ 10).
tibial, and one posterior tibial. Additionally, there were three injuries of unnamed vessels, of which one was in the calf distal to the trifurcation. Looking specifically at the 11 patients who required operative intervention after presenting with soft signs of vascular injury, the anatomic breakdown of arterial injuries is as follows: one anterior tibial, one peroneal, three axillary, one brachial, two popliteal, and one superficial femoral. All operations were performed by in-house attending trauma surgeons and surgical house staff. Figure 3 illustrates the number of penetrating peripheral vascular injuries that required surgery, by year. Arterial injuries were primarily repaired in 15 patients, and 22 patients received ligation. Vein patch was used in two patients. Interposition graft with autogenous vein was performed in 16 patients, whereas 27 patients received polytetrafluoroethylene
3
Fig. 3 e Number of penetrating peripheral vascular injuries requiring surgery. The annual number of patients with penetrating peripheral vascular injuries that required surgery ranged from 12e23.
grafts. Venous injuries were either primarily repaired (n ¼ 11) or ligated (n ¼ 33). Other operations performed in this cohort include the following: fasciotomy (n ¼ 26), thoracotomy (n ¼ 2), exploratory laparotomy (n ¼ 5), and splitthickness skin graft (n ¼ 8). Of the patients who were managed operatively, 54 (66%) had more than one injury. These other injuries included 21 orthopedic injuries, seven intra-abdominal injuries, and 44 venous injuries. Multiple arterial injuries occurred in five patients. Finally, there were three deaths (3%), all of which were attributed to associated thoracoabdominal vascular injuries and overwhelming hemorrhage. Other complications observed in our cohort include wound infections (n ¼ 6), deep venous thrombosis (n ¼ 4), transfusion reaction (n ¼ 1), acute renal failure requiring temporary dialysis (n ¼ 3), and graft thrombosis and/or occlusion (n ¼ 3). All graft occlusions occurred in the postoperative period in patients who received polytetrafluoroethylene grafts. These graft occlusions were managed by thrombectomy (n ¼ 1), graft revision (n ¼ 1), or extra-anatomic saphenous vein bypass (n ¼ 1).
Table e Vessels injured in trauma patients with penetrating vascular injury needing operative treatment from 2006e2010. Vessel name Axillary Brachial Ulnar Radial Common femoral Profunda femoral Superficial femoral Popliteal Anterior tibial Posterior tibial Peroneal Unnamed UE vessel Unnamed LE vessel
Artery
Vein
6 8 9 2 5 4 25 13 3 1 d 3 3
6 5 d d 13 d 11 7 1 d 1 d 1
LE ¼ lower extremity; UE ¼ upper extremity.
Fig. 4 e Anatomic location of arterial injury (%). CFA [ common femoral artery; SFA [ superficial femoral artery. *Of the nine patients (11%) with lower extremity branch vessel injuries, seven presented with hemodynamic instability, hard signs of vascular injury, or an associated abdominal injury requiring emergency surgery.
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j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
Postdischarge follow-up data were available for 73 of the 82 patients (89%) who underwent operative intervention, with an average follow-up duration of 252 40 d. Patients were assessed with pulse checks, Doppler ultrasonography, and ankle-brachial index measurements. Deficiencies in any of these three were investigated with further imaging by computed tomography angiography or duplex ultrasonography. There were no traumatic pseudoaneurysms or arteriovenous fistulas identified at follow-up.
4.
Discussion
Endovascular therapy has dramatically changed the treatment of both elective and emergency vascular pathologies. Likewise, endovascular techniques have become invaluable in the management of many trauma situations, including hemorrhage due to solid organ injury or pelvic fracture, injury to the thoracic aorta, and vascular injuries in the cervical and thoracic outlet [8,11e14]. The role of endovascular therapy in the setting of penetrating peripheral vascular trauma, however, is still evolving. Guidelines issued by the Western Trauma Association and the Eastern Association for the Surgery of Trauma [9,10] state that endovascular embolization should be applied selectively to hemodynamically stable patients without hard signs of vascular injury who have injuries to lower extremity branch vessels. When applying these guidelines to our cohort of penetrating peripheral vascular injury patients in retrospect, only two of 92 patients (2.2%) over a 5-y period met criteria for embolization. Specifically, following our management algorithm in Figure 2, 71 patients were excluded from endovascular therapy because they required emergency operative intervention for hard signs of vascular injury or thoracoabdominal injuries. Ten patients who underwent diagnostic imaging for soft signs of vascular injury were successfully managed nonoperatively. Of the remaining 11 patients, nine had injuries to major vessels. As such, two patients with injuries to the anterior tibial and peroneal arteries should have received endovascular embolization according to these guidelines. A review of the vascular trauma literature, however, reveals several case series that suggest anatomic locations other than those detailed in the previously mentioned guidelines that may be amenable to endovascular therapy. For example, embolization of axillary artery branches, such as the humeral circumflex arteries, has been done safely and effectively [14,15]. Also in the upper extremity, brachial artery injuries have been successfully managed endovascularly; Lonn et al. [16] describe thrombectomy and angioplasty for thrombosis and intimal disruption and Maynar et al. [17] discuss stent-graft repair of a brachial artery transection. In the lower extremity, stent-grafting has been used for more proximal injuries to the common and superficial femoral artery, mostly for dissections, pseudoaneurysms, and arteriovenous fistulas [5,18,19]. Some authors have also argued against hemodynamic instability as a contraindication to endovascular intervention. In a small series of eight patients undergoing treatment of traumatic injuries to the subclavian and axillary arteries, endovascular repair was successfully performed despite
hemodynamic instability [20]. The same was true of brachial artery injuries as described by Maynar et al. [17]. Despite these series that highlight the feasibility of endovascular techniques that were applied beyond the boundaries of published guidelines, there are still concerns and disagreement. For example, issues of durability [19] and longterm follow-up requirements [6] have been proposed as disadvantages that endovascular approaches face in comparison with standard open surgery. This may be particularly true for a trauma population that is generally young, healthy, and unpredictable in regards to long-term follow-up. Furthermore, there is lack of consensus regarding which anatomic locations, other than the lower extremity branch vessels, may be approached endovascularly. As an example, Risberg and Lonn [5] state that endovascular interventions are not useful in the femoral region, which contrasts with Franz et al. [19] who claim that stent-grafting is most useful in the superficial femoral artery. In addition, endovascular intervention in these case series is often used for findings that are more likely to be present after blunt trauma, such as vessel thrombosis due to intimal disruptions, dissection, pseudoaneurysm, and arteriovenous fistula. Apart from wartime injuries, which have a higher number of pseudoaneuryms and arteriovenous fistulas from shrapnel injuries, these lesions are exceedingly rare in the civilian penetrating trauma population [8,21]. Indeed, in our 5-y cohort of penetrating trauma patients, there were no pseudoaneurysms or arteriovenous fistulas identified on presentation. As such, application of these series to a penetrating trauma population should be done with caution. Finally, although endovascular techniques have been successfully employed despite hemodynamic instability, this is unlikely to be applicable to all trauma centers. The effectiveness and timeliness of endovascular therapy depend on the rapid activation and expertise of an endovascular team. Although hemodynamic instability alone may not preclude an initial endovascular approach to peripheral vascular injury if an endovascular team is immediately available, Johnson [3] and Risberg [5] discuss how delays in treatment may occur if the endovascular team needs to be activated from off-site or if an operating room team that is immediately available is not trained in endovascular support. This variability in trauma center resources should be considered when taking into account published national guidelines. Our trauma surgeons have minimal endovascular skills and rely on the interventional radiology team for endovascular services. At our center, an on-call interventional radiologist is available 24-h a day, and they have access to a full interventional suite equipped with a trained endovascular support team. This resource is immediately available to the trauma team during the day. During the night and weekends, the interventional team is available within 30 min of activation. In our present study, 83% of all penetrating peripheral vascular injuries occurred during the nighttime or on the weekend, which combined with the large number of patients with hemodynamic instability and multiple vessel injuries, introduces a factor that may limit the applicability of an endovascular approach to penetrating peripheral vascular trauma in our cohort.
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
In summary, we found that during a 5-y period at our urban trauma center, there were 92 peripheral vascular injuries due to penetrating trauma, including 82 that required operative management. Nearly two-thirds of the patients were either hemodynamically unstable on arrival to the trauma center or had multiple vessels injured, making endovascular repair less desirable. Furthermore, activation of an endovascular team would have delayed definitive treatment for 83% of our cohort who presented during the night or on the weekend, thereby limiting the effectiveness of an endovascular approach. Finally, two of the major indications for endovascular repair, pseudoaneurysms and arteriovenous fistulas, are rare in the civilian trauma patient population, which further emphasizes the need for open vascular surgical skills. In light of the previously mentioned discussion, each trauma center needs to consider their resources when incorporating national guidelines in their treatment algorithms of penetrating vascular trauma. Nevertheless, the published guidelines still represent the summation of the best available evidence for treatment of peripheral vascular injury due to penetrating trauma, and deviations from this should be considered only on a case-bycase or center-by-center basis.
Acknowledgment V.C. contributed to the analysis and interpretations, writing the article, and critical revisions; W.L. to the analysis and interpretations and critical revisions; E.M. to the conception and design, data collection, analysis and interpretation, and writing the article; and G.V. to the conception and design, data collection, analysis and interpretation, and critical revisions.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
[1] Donas KP, Torsello GF. Endovascular surgery as a bridge solution for selected vascular emergencies. J Cardiovasc Surg (Torino) 2010;51:337. [2] Doody O, Given MF, Lyon SM. Extremitieseindications and techniques for treatment of extremity vascular injuries. Injury 2008;39:1295. [3] Johnson CA. Endovascular management of peripheral vascular trauma. Semin Intervent Radiol 2010;27:38.
5
[4] Reed AB. Advances in the endovascular management of acute injury. Perspect Vasc Surg Endovasc Ther 2011;23:58. [5] Risberg B, Lo¨nn L. Management of vascular injuries using endovascular techniques. Eur J Surg 2000;166:196. [6] Reuben BC, Whitten MG, Sarfati M, Kraiss LW. Increasing use of endovascular therapy in acute arterial injuries: analysis of the National Trauma Data Bank. J Vasc Surg 2007;46:1222. [7] Worni M, Scarborough JE, Gandhi M, Pietrobon R, Shortell CK. Use of endovascular therapy for peripheral arterial lesions: an analysis of the National Trauma Data Bank from 2007 to 2009. Ann Vasc Surg 2013;27:299. [8] Starnes BW, Arthurs ZM. Endovascular management of vascular trauma. Perspect Vasc Surg Endovasc Ther 2006;18: 114. [9] Feliciano DV, Moore FA, Moore EE, et al. Evaluation and management of peripheral vascular injury. Part 1. Western Trauma Association/critical decisions in trauma. J Trauma 2011;70:1551. [10] Fox N, Rajani RR, Bokhari F, et al. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73: S315. [11] Parodi JC, Scho¨nholz C, Ferreira LM, Bergan J. Endovascular stent-graft treatment of traumatic arterial lesions. Ann Vasc Surg 1999;13:121. [12] Mirza A, Ellis T. Initial management of pelvic and femoral fractures in the multiply injured patient. Crit Care Clin 2004; 20:159. [13] Arthurs ZM, Sohn VY, Starnes BW. Vascular trauma: endovascular management and techniques. Surg Clin North Am 2007;87:1179. x-xi. [14] Scalea TM, Sclafani S. Interventional techniques in vascular trauma. Surg Clin North Am 2001;81:1281. xii. [15] Naidoo NM, Corr PD, Robbs JV, Maharaj J, Nair R. Angiographic embolisation in arterial trauma. Eur J Vasc Endovasc Surg 2000;19:77. [16] Lo¨nn L, Delle M, Karlstro¨m L, Risberg B. Should blunt arterial trauma to the extremities be treated with endovascular techniques? J Trauma 2005;59:1224. [17] Maynar M, Baro M, Qian Z, et al. Endovascular repair of brachial artery transection associated with trauma. J Trauma 2004;56:1336. discussion 1341. [18] Piffaretti G, Tozzi M, Lomazzi C, et al. Endovascular treatment for traumatic injuries of the peripheral arteries following blunt trauma. Injury 2007;38:1091. [19] Franz RW, Shah KJ, Halaharvi D, Franz ET, Hartman JF, Wright ML. A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center. J Vasc Surg 2011;53:1604. [20] Gilani R, Tsai PI, Wall MJ, Mattox KL. Overcoming challenges of endovascular treatment of complex subclavian and axillary artery injuries in hypotensive patients. J Trauma Acute Care Surg 2012;73:771. [21] Khoury G, Sfeir R, Nabbout G, Jabbour-Khoury S, Fahl M. Traumatic arteriovenous fistulae: “the Lebanese war experience”. Eur J Vasc Surg 1994;8:171.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Applying peripheral vascular injury guidelines to penetrating trauma Vincent E. Chong, MD, Wayne S. Lee, MD, Emily Miraflor, MD, and Gregory P. Victorino, MD* Department of Surgery, University of California, San FranciscodEast Bay, Oakland, California
article info
abstract
Article history:
Introduction: Treatment of traumatic vascular injury is evolving because of endovascular
Received 2 January 2014
therapies. National guidelines advocate for embolization of injuries to lower extremity
Received in revised form
branch vessels, including pseudoaneurysms or arteriovenous fistulas, in hemodynamically
1 March 2014
normal patients without hard signs of vascular injury. However, patient stability and injury
Accepted 12 March 2014
type may limit endovascular applicability at some centers. We hypothesized that for
Available online xxx
penetrating trauma, indications for endovascular treatment of peripheral vascular injuries, as outlined by national guidelines, are infrequent.
Keywords:
Methods: We reviewed records of patients sustaining penetrating peripheral vascular
Trauma
injuries treated at our university-based urban trauma center from 2006e2010. Patient
Peripheral vascular injury
demographics and outcomes were analyzed.
Endovascular
Results: In 92 patients with penetrating peripheral vascular injuries, 82 were managed operatively and 10 were managed nonoperatively. Seventeen (18%) were hemodynamically unstable on arrival, 44 (48%) had multiple vessels injured, and 76 (83%) presented at night and/or on the weekend. No pseudoaneurysms or arteriovenous fistulas were seen initially or at follow-up. Applying national guidelines to our cohort, only two patients (2.2%) met recommended criteria for endovascular treatment. Conclusions: According to national guidelines, indications for endovascular treatment of penetrating peripheral vascular injury are infrequent. Nearly two-thirds of patients with penetrating peripheral vascular injuries were hemodynamically unstable or had multiple vessels injured, making endovascular repair less desirable. Additionally, over 80% presented at night and/or on the weekend, which could delay treatment at some centers due to mobilization of the endovascular team. Trauma centers need to consider their resources when incorporating national guidelines in their treatment algorithms of penetrating vascular trauma. ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
The standard approach to penetrating peripheral vascular injury requiring surgical intervention is open repair. However, the role of endovascular therapy in the setting of trauma
continues to evolve [1e5]. As reported in two different reviews of the National Trauma Data Bank, the incidence of endovascular approaches to vascular trauma has been on the rise in the past two decades [6,7]. From 1994e2003, 2.2% of all traumatic vascular injuries were approached endovascularly,
* Corresponding author. Department of Surgery, Highland Hospital, University of California, San FranciscodEast Bay, 1411 East 31st Street, Oakland, California, 94602. Tel.: þ1 510 437 8370; fax þ1 510 437 5127. E-mail address: [email protected] (G.P. Victorino). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.03.035
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
compared with 6% from 2007e2009 [6,7]. In 2003, endovascular techniques comprised 8.1% of all surgical interventions for vascular trauma, although this also included nonextremity injuries [6]. Despite the increasing popularity of endovascular approaches to peripheral vascular trauma, its indications and utility are still controversial. This is, in part, because of a lack of a strong evidence base. Although the literature does support the effectiveness of endovascular approaches to cervical and thoracic vascular injuries [3,8], the evidence in peripheral vascular trauma is based almost solely on case reports and expert opinion. As such, guidelines published by two leading national trauma organizations indicate that endovascular techniques may only be appropriate in selective circumstances, namely for embolization of injuries to extremity branch vessels, such as the profunda femoris and infrapopliteal trifurcation [9,10]. Beyond anatomic location, there are other contraindications to an endovascular approach. An absolute contraindication would be an inability to cross the traumatic lesion with a wire, whereas relative contraindications include uncontrolled hemorrhage and hemodynamic instability [3]. Other limitations to the applicability of endovascular techniques include any factors that would result in unnecessary delays in definitive treatment, such as lack of staff training and familiarity with endovascular equipment, long wait times for activation of an endovascular team, and long distances between the interventional and operative suites [3]. These limitations could effectively transform relative contraindications, such as hemodynamic instability, into absolute contraindications. To explore the applicability of currently published indications for endovascular treatment of peripheral vascular trauma, we conducted a retrospective review of the trauma registry at our university-based urban trauma center. We focused on penetrating injuries, which make up the overwhelming majority of peripheral vascular trauma at our institution. We hypothesized that patients with peripheral vascular injuries from penetrating trauma rarely meet indications for endovascular treatment based on current national guidelines.
2.
3.
Results
During the study period, 10,103 patients were activated into our trauma system. Of these, there were 92 patients who sustained a penetrating peripheral vascular injury (Fig. 1). The mean age of our cohort was 30 y old, with a range from 14e57 y old. There were 87 men and five women. Firearm trauma was the mechanism of injury for 66 patients (72%), whereas 26 patients (28%) sustained stab wounds. At presentation, 17 patients (18%) were hemodynamically unstable, defined by systolic blood pressure 105 beats per minute. The average injury severity score of our cohort was 15 0.9. In regards to time of presentation, 76 patients (83%) presented to our trauma center either at night and/or on the weekend. Figure 2 illustrates how our cohort of 92 patients was managed after arrival at our trauma center. Seventy-one patients (77%) presented with either hard signs of vascular injury or thoracoabdominal injuries requiring emergency surgery, including 17 patients with hemodynamic instability. The hard signs of vascular injury included the following: pulsatile bleeding (n ¼ 26), expanding hematoma (n ¼ 2), and loss of pulse (n ¼ 37). All 71 patients underwent open operative intervention. Patients who presented with soft signs of vascular injury underwent further diagnostic imaging with either computed tomography angiography or duplex ultrasonography. From this subset of patients, 10 were found to have injuries amenable to nonoperative management, such as arterial vasospasm or injury to superficial lower extremity branch vessels requiring only bedside ligation or observation. Observation encompassed pulse checks, Doppler ultrasonography, and ankle-brachial index measurements while hospitalized or as outpatients. The other 11 patients required intervention for major injuries to named extremity arteries. In the 82 patients who required operative intervention for their injuries, there were 28 (34%) patients with upper extremity injuries and 54 (66%) with lower extremity injuries (Table; Fig. 4). The anatomic breakdown of lower extremity arterial injuries is as follows: five common femoral, four deep femoral, 25 superficial femoral, 13 popliteal, three anterior
Methods
Approval for the study was obtained from our Institutional Review Board. Patients were selected for inclusion in this study from our university-based urban trauma center’s database if they had a documented extremity arterial or venous injury due to penetrating mechanism during the 5-y period from 2006e2010. The following data were extracted from the records: patient demographics, presenting vital signs, injury severity scores, vascular structures injured, associated injuries, preoperative imaging evaluation, type of repair performed, secondary procedures, patency of repair, and final functional status of the injured limb. Descriptive statistics were calculated with Microsoft Excel (Microsoft, Redmond, WA). Results are presented as mean standard error of the mean.
Fig. 1 e Peripheral vascular injuries, 2006e2010. Our study sample consisted of 92 patients with penetrating peripheral vascular injuries. Of these, 10 were managed nonoperatively, whereas 82 required surgery.
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
Fig. 2 e Management algorithm for peripheral vascular injuries. Of the patients who presented with penetrating peripheral vascular injury, 71 underwent immediate operation because of hard signs of vascular injury, concomitant thoracoabdominal injuries, and/or hemodynamic instability. Further diagnostic testing was done for 21 patients with soft signs of vascular injury, leading to either open operation (n [ 11) or nonoperative management (n [ 10).
tibial, and one posterior tibial. Additionally, there were three injuries of unnamed vessels, of which one was in the calf distal to the trifurcation. Looking specifically at the 11 patients who required operative intervention after presenting with soft signs of vascular injury, the anatomic breakdown of arterial injuries is as follows: one anterior tibial, one peroneal, three axillary, one brachial, two popliteal, and one superficial femoral. All operations were performed by in-house attending trauma surgeons and surgical house staff. Figure 3 illustrates the number of penetrating peripheral vascular injuries that required surgery, by year. Arterial injuries were primarily repaired in 15 patients, and 22 patients received ligation. Vein patch was used in two patients. Interposition graft with autogenous vein was performed in 16 patients, whereas 27 patients received polytetrafluoroethylene
3
Fig. 3 e Number of penetrating peripheral vascular injuries requiring surgery. The annual number of patients with penetrating peripheral vascular injuries that required surgery ranged from 12e23.
grafts. Venous injuries were either primarily repaired (n ¼ 11) or ligated (n ¼ 33). Other operations performed in this cohort include the following: fasciotomy (n ¼ 26), thoracotomy (n ¼ 2), exploratory laparotomy (n ¼ 5), and splitthickness skin graft (n ¼ 8). Of the patients who were managed operatively, 54 (66%) had more than one injury. These other injuries included 21 orthopedic injuries, seven intra-abdominal injuries, and 44 venous injuries. Multiple arterial injuries occurred in five patients. Finally, there were three deaths (3%), all of which were attributed to associated thoracoabdominal vascular injuries and overwhelming hemorrhage. Other complications observed in our cohort include wound infections (n ¼ 6), deep venous thrombosis (n ¼ 4), transfusion reaction (n ¼ 1), acute renal failure requiring temporary dialysis (n ¼ 3), and graft thrombosis and/or occlusion (n ¼ 3). All graft occlusions occurred in the postoperative period in patients who received polytetrafluoroethylene grafts. These graft occlusions were managed by thrombectomy (n ¼ 1), graft revision (n ¼ 1), or extra-anatomic saphenous vein bypass (n ¼ 1).
Table e Vessels injured in trauma patients with penetrating vascular injury needing operative treatment from 2006e2010. Vessel name Axillary Brachial Ulnar Radial Common femoral Profunda femoral Superficial femoral Popliteal Anterior tibial Posterior tibial Peroneal Unnamed UE vessel Unnamed LE vessel
Artery
Vein
6 8 9 2 5 4 25 13 3 1 d 3 3
6 5 d d 13 d 11 7 1 d 1 d 1
LE ¼ lower extremity; UE ¼ upper extremity.
Fig. 4 e Anatomic location of arterial injury (%). CFA [ common femoral artery; SFA [ superficial femoral artery. *Of the nine patients (11%) with lower extremity branch vessel injuries, seven presented with hemodynamic instability, hard signs of vascular injury, or an associated abdominal injury requiring emergency surgery.
4
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
Postdischarge follow-up data were available for 73 of the 82 patients (89%) who underwent operative intervention, with an average follow-up duration of 252 40 d. Patients were assessed with pulse checks, Doppler ultrasonography, and ankle-brachial index measurements. Deficiencies in any of these three were investigated with further imaging by computed tomography angiography or duplex ultrasonography. There were no traumatic pseudoaneurysms or arteriovenous fistulas identified at follow-up.
4.
Discussion
Endovascular therapy has dramatically changed the treatment of both elective and emergency vascular pathologies. Likewise, endovascular techniques have become invaluable in the management of many trauma situations, including hemorrhage due to solid organ injury or pelvic fracture, injury to the thoracic aorta, and vascular injuries in the cervical and thoracic outlet [8,11e14]. The role of endovascular therapy in the setting of penetrating peripheral vascular trauma, however, is still evolving. Guidelines issued by the Western Trauma Association and the Eastern Association for the Surgery of Trauma [9,10] state that endovascular embolization should be applied selectively to hemodynamically stable patients without hard signs of vascular injury who have injuries to lower extremity branch vessels. When applying these guidelines to our cohort of penetrating peripheral vascular injury patients in retrospect, only two of 92 patients (2.2%) over a 5-y period met criteria for embolization. Specifically, following our management algorithm in Figure 2, 71 patients were excluded from endovascular therapy because they required emergency operative intervention for hard signs of vascular injury or thoracoabdominal injuries. Ten patients who underwent diagnostic imaging for soft signs of vascular injury were successfully managed nonoperatively. Of the remaining 11 patients, nine had injuries to major vessels. As such, two patients with injuries to the anterior tibial and peroneal arteries should have received endovascular embolization according to these guidelines. A review of the vascular trauma literature, however, reveals several case series that suggest anatomic locations other than those detailed in the previously mentioned guidelines that may be amenable to endovascular therapy. For example, embolization of axillary artery branches, such as the humeral circumflex arteries, has been done safely and effectively [14,15]. Also in the upper extremity, brachial artery injuries have been successfully managed endovascularly; Lonn et al. [16] describe thrombectomy and angioplasty for thrombosis and intimal disruption and Maynar et al. [17] discuss stent-graft repair of a brachial artery transection. In the lower extremity, stent-grafting has been used for more proximal injuries to the common and superficial femoral artery, mostly for dissections, pseudoaneurysms, and arteriovenous fistulas [5,18,19]. Some authors have also argued against hemodynamic instability as a contraindication to endovascular intervention. In a small series of eight patients undergoing treatment of traumatic injuries to the subclavian and axillary arteries, endovascular repair was successfully performed despite
hemodynamic instability [20]. The same was true of brachial artery injuries as described by Maynar et al. [17]. Despite these series that highlight the feasibility of endovascular techniques that were applied beyond the boundaries of published guidelines, there are still concerns and disagreement. For example, issues of durability [19] and longterm follow-up requirements [6] have been proposed as disadvantages that endovascular approaches face in comparison with standard open surgery. This may be particularly true for a trauma population that is generally young, healthy, and unpredictable in regards to long-term follow-up. Furthermore, there is lack of consensus regarding which anatomic locations, other than the lower extremity branch vessels, may be approached endovascularly. As an example, Risberg and Lonn [5] state that endovascular interventions are not useful in the femoral region, which contrasts with Franz et al. [19] who claim that stent-grafting is most useful in the superficial femoral artery. In addition, endovascular intervention in these case series is often used for findings that are more likely to be present after blunt trauma, such as vessel thrombosis due to intimal disruptions, dissection, pseudoaneurysm, and arteriovenous fistula. Apart from wartime injuries, which have a higher number of pseudoaneuryms and arteriovenous fistulas from shrapnel injuries, these lesions are exceedingly rare in the civilian penetrating trauma population [8,21]. Indeed, in our 5-y cohort of penetrating trauma patients, there were no pseudoaneurysms or arteriovenous fistulas identified on presentation. As such, application of these series to a penetrating trauma population should be done with caution. Finally, although endovascular techniques have been successfully employed despite hemodynamic instability, this is unlikely to be applicable to all trauma centers. The effectiveness and timeliness of endovascular therapy depend on the rapid activation and expertise of an endovascular team. Although hemodynamic instability alone may not preclude an initial endovascular approach to peripheral vascular injury if an endovascular team is immediately available, Johnson [3] and Risberg [5] discuss how delays in treatment may occur if the endovascular team needs to be activated from off-site or if an operating room team that is immediately available is not trained in endovascular support. This variability in trauma center resources should be considered when taking into account published national guidelines. Our trauma surgeons have minimal endovascular skills and rely on the interventional radiology team for endovascular services. At our center, an on-call interventional radiologist is available 24-h a day, and they have access to a full interventional suite equipped with a trained endovascular support team. This resource is immediately available to the trauma team during the day. During the night and weekends, the interventional team is available within 30 min of activation. In our present study, 83% of all penetrating peripheral vascular injuries occurred during the nighttime or on the weekend, which combined with the large number of patients with hemodynamic instability and multiple vessel injuries, introduces a factor that may limit the applicability of an endovascular approach to penetrating peripheral vascular trauma in our cohort.
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
In summary, we found that during a 5-y period at our urban trauma center, there were 92 peripheral vascular injuries due to penetrating trauma, including 82 that required operative management. Nearly two-thirds of the patients were either hemodynamically unstable on arrival to the trauma center or had multiple vessels injured, making endovascular repair less desirable. Furthermore, activation of an endovascular team would have delayed definitive treatment for 83% of our cohort who presented during the night or on the weekend, thereby limiting the effectiveness of an endovascular approach. Finally, two of the major indications for endovascular repair, pseudoaneurysms and arteriovenous fistulas, are rare in the civilian trauma patient population, which further emphasizes the need for open vascular surgical skills. In light of the previously mentioned discussion, each trauma center needs to consider their resources when incorporating national guidelines in their treatment algorithms of penetrating vascular trauma. Nevertheless, the published guidelines still represent the summation of the best available evidence for treatment of peripheral vascular injury due to penetrating trauma, and deviations from this should be considered only on a case-bycase or center-by-center basis.
Acknowledgment V.C. contributed to the analysis and interpretations, writing the article, and critical revisions; W.L. to the analysis and interpretations and critical revisions; E.M. to the conception and design, data collection, analysis and interpretation, and writing the article; and G.V. to the conception and design, data collection, analysis and interpretation, and critical revisions.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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