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Vascular OnlineFirst, published on May 25, 2015 as doi:10.1177/1708538115589251
Original Article
Popliteal vein repair may not impact amputation rates in combined popliteal artery and vein injury
Vascular 0(0) 1–5 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538115589251 vas.sagepub.com
Anahita Dua1, Sapan S Desai2, Fadwa Ali1, Kai Yang1 and Cheong Lee1
Abstract Introduction: This study aimed to determine the incidence, management, and outcomes of popliteal artery injury, popliteal vein injury, and concomitant popliteal artery injury and vein injury. Methods: A retrospective analysis was completed using the 2000–2010 Nationwide Inpatient Sample utilizing International Classification of Diseases-9 codes to select patients with isolated popliteal artery injury (904.41), isolated popliteal vein injury (904.42), and isolated concomitant popliteal artery and vein injury (958.92). Variables included demographics, procedure type, and outcome during hospital course. Statistical analysis was with chi-square, Fisher exact test, and multivariate analysis. Results: A total of 2216 patients presented with injury to the popliteal system; 71% (1568) presented with isolated popliteal artery injury, 14% (306) with isolated popliteal vein injury, and 15% (342) with concomitant popliteal artery and vein injury. Amputation was significantly increased in popliteal artery injury and concomitant popliteal artery and vein injury (P < 0.001) as compared to popliteal vein injury. Ligation of the vein was more common in concomitant popliteal artery and vein injury when compared to popliteal vein injury (P < 0.05). The rate of amputation was 9.8% for popliteal artery injury, significantly greater than for popliteal vein injury (0.7%, P < 0.001) but not different than for concomitant popliteal artery and vein injury (8.2%, P ¼ NS). Conclusion: Evidence-based management of popliteal vasculature may increase rates of limb salvage. Within the limitations of the data set used, conclusions appear to be that patients with popliteal vein injury or concomitant popliteal artery and vein injury may be managed with vein ligation without increased amputation rates as compared to popliteal artery injury.
Keywords Popliteal injury, revascularization, popliteal trauma
Introduction Traumatic popliteal injury is an uncommon but potentially devastating problem that carries the highest amputation rates among all peripheral vascular injuries.1 Prior studies consist of retrospective case series of popliteal vessel injury among military and civilian populations.2 Although rates of amputation remain high in both military and civilian groups at 30% and 20%, respectively, exact surgical management remains controversial.2 Surgical management for popliteal vessel injury includes primary amputation, primary vascular repair, intravascular shunting or bypass, and endovascular stenting.3–5 The management strategy depends on the
extent and mechanism of injury and surgeon preference. The effect of the different surgical procedures on limb salvage outcomes is unclear. This study aims to determine the incidence, management, and limb salvage outcome following popliteal artery injury (PAI), popliteal vein injury (PVI), and concomitant popliteal artery and vein injury (CPAVI). 1 Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA 2 Department of Vascular Surgery, Southern Illinois University, Springfield, IL, USA
Corresponding author: Anahita Dua, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA. Email: [email protected]
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Methods
Results
Database and selection A retrospective analysis was completed using the Nationwide Inpatient Sample (NIS), a part of the Health Care Utilization Project that is maintained by the Agency for Healthcare Research and Quality (AHRQ). The NIS is the largest all-payer inpatient database and includes a stratified random sample of patients from a 20% sampling of participating nonfederal hospitals throughout the USA. Weighting from the original datasets was utilized. Clinical records between 2000 and 2010 were derived using the ninth revision of the International Classification of Diseases (ICD-9) diagnosis and procedure codes to include patients with isolated PAI (904.41), isolated PVI (904.42), and isolated CPAVI (958.92).
Variables Variables included demographics, procedure type (primary amputation (without revascularization attempt), stent, bypass, primary repair, and fasciotomy), compartment syndrome, length of stay, and outcome (secondary amputation (amputation after revascularization attempt)) during the hospital course. This study was exempt from the IRB and no identifiable patient data were utilized.
Statistical analysis Statistical analysis was completed using the Fisher exact test for continuous variables and chi-squared for categorical variables. Data analysis and management were completed using the IBM SPSS software package (SPSS version 22.0, SPSS Inc., Chicago, IL, USA). Statistical significance was set at a probability of P < 0.05. Values are presented as mean standard deviation or absolute percentages.
A total of 2216 patients presented with popliteal vessel trauma between 2000 and 2010. Of these patients, 71% had PAI, 14% with PVI, and 15% with CPAVI. Most patients with PAI underwent some form of revascularization, including primary repair (27.4%), bypass (45.7%), or stent placement (2.4%). Primary amputation was necessary in 5.9% of patients and 3.8% had ligation of the artery. In contradistinction, few patients with PVI underwent any form of revascularization with only two (0.7%) patients undergoing a venous bypass. Patients who required an intervention underwent ligation (8.2%), and only one (0.3%) patient required primary amputation (Table 1). Patients with CPAVI were more likely to undergo a revascularization procedure, including primary artery repair (57.3%), arterial bypass (34.8%), arterial stent placement (0.6%), or venous bypass (1.2%). Primary ligation of the popliteal artery occurred in 4.1% of patients, and primary ligation of the PVI in 17.0% of patients. Vein ligation was significantly more common in the CPAVI patients than PVI (P < 0.05). Primary arterial repair was also more common for CPAVI patients than PAI (P < 0.05); however, arterial bypass was more common in PAI patients (P < 0.001). The primary amputation rate in patients with combined injury was 3.5% (Table 1). Primary amputation was significantly more common in PAI and CPAVI patients compared to PVI (P < 0.001). The overall rate of amputation (primarily and secondary) was greatest for patients with PAI at 9.8%, followed by patients with CPAVI at 8.2% and PVI at 0.7% (P < 0.001 for PAI or CPAVI vs. PVI) (Table 1). The choice of intervention correlated with the rate of amputation. Patients with PAI were most likely to undergo amputation following primarily ligation (10.0%), followed by primary repair (6.3%), peripheral
Table 1. Initial procedure type for popliteal artery injury alone, popliteal vein injury alone, and combined popliteal artery and vein injuries. Initial procedure type
Popliteal artery injury (1568)
Popliteal vein injury (306)
Popliteal artery and vein injury (342)
Primary amputation Artery ligation Vein ligation Primary repair of artery Bypass of artery Bypass of vein Stent of artery Overall amputation rate (primary þ secondary)
92 60 13 429 717 0 38 154
1 0 25 0 0 2 0 2
12 14 58 196 119 4 2 28
(5.9%) (3.8%) (0.8%) (27.4%) (45.7%) (0%) (2.4%) (9.8%)
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(0.3%) (8.2%)
(0.7%) (0.7%)
(3.5%) (4.1%) (17.0%) (57.3%) (34.8%) (1.2%) (0.6%) (8.2%)
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Table 2. Amputation rates based on procedure type. Amputation rates Revascularization procedure type Amputation Amputation Amputation Amputation
after after after after
ligation primary repair bypass stent
Popliteal artery injury (1568)
Popliteal vein injury (306)
Popliteal artery and vein injury (342)
6 27 35 1
0 1 (4.0%) 0 0
5 (36.7%) 8 (4.1%) 10 (8.4%) 0
(10.0%) (6.3%) (4.9%) (2.6%)
Table 3. Rates of prophylactic fasciotomy, compartment syndrome, and therapeutic fasciotomy.
Prophylactic fasciotomy rate Compartment syndrome rate Therapeutic fasciotomy rate post compartment syndrome diagnosis
Popliteal artery injury (1568)
Popliteal vein injury (306)
Popliteal artery and vein injury (342)
480 (30.6%) 161 (10.3%) 105 (65.2%)
34 (11.1%) 11 (3.6%) 7 (63.8%)
145 (42.4%) 41 (12.0%) 27 (65.8%)
bypass (4.9%), and stent placement (2.6%). Only one (4.0%) patient with PVI underwent amputation, which occurred after primary venous repair. The highest rates of amputation were seen in patients who underwent ligation of the popliteal vessels following CPAVI (36.7%), arterial bypass (8.4%), and primary repair (4.1%) (Table 2). Prophylactic fasciotomy was most likely to be completed in patients with CPAVI (42.4%), followed by PAI (30.6%) and PVI (11.1%; P < 0.01 for CPAVI vs. PAI or PVI) (Table 3). The rate of compartment syndrome was highest for CPAVI (12.0%), followed by PAI (10.3%) and PVI (3.6%; P < 0.001 for CPAVI vs. PVI). Therapeutic fasciotomy following the diagnosis of compartment syndrome was required in 63.8%– 65.8% of all patients regardless of type of injury (P ¼ NS).
Discussion Amputation rates in the civilian population following traumatic disruption of popliteal vasculature range from 14.5 to 25%.2 Over a 10-year period in our analysis, 2216 patients presented with isolated injury to the popliteal system consisting of 71% PAI, 14% PVI, and 15% CPAVI. This study was performed to report national management practices and limb salvage outcomes in these civilian patients in relation to their corresponding procedure type. In our study, we found that primary amputation was significantly increased in PAI and CPAVI injury comparing to PVI. This is expected since arterial injuries are
more commonly associated with severe limb ischemia at initial presentation, which would likely lead the surgeons’ decisions against salvage procedures. In addition, primary repair of popliteal artery was more commonly utilized for CPAVI than for PAI while arterial bypass was more commonly performed for PAI compared to CPAVI. We also found in our study that ligation of the popliteal vein was significantly more common in CPAVI injuries than in PVI. Vein ligation was the management of choice for peripheral venous injuries prior to Vietnam era with the thinking that venous repair inevitably led to thrombosis and various sequalae.6 With newer studies, it was shown that while venous ligation of upper extremities associated with no long-term sequela, primary repair by lateral suture or primary end to end reanastomosis is recommended when technically feasible for venous injuries of the legs. However, in unstable patients or when primary repair cannot be repaired, venous ligation was still recommended with aggressive post operative management to prevent edema and thrombosis.6 This would explain the higher rates of popliteal vein ligation in CPAVI than PVI in our study. Interestingly, recent studies have shown that venous repair with meticulous surgical technique increased extremity salvage rate and decreased long-term complications in PVIs especially in concomitant PAI. It was argued that with modern patient monitoring and blood product availability, popliteal vein ligation is only indicated in unstable patients refusing blood transfusions.7
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We found that the overall amputation rate was significantly greater for PAI when compared to PVI, but no different when compared to CPAVI. This indicates that PVI ligation does not necessarily impact amputation rates and the vein can hence be safely ligated without increasing amputation risk at least in the short term. This is important given the fact that lengthy operations attempting to repair an injured vein may result in longer operating times without any significant benefit. Although it is expected that arterial injury would carry a higher rate of amputation, it was interesting that CPAVI led to no significant increase in amputation rate versus PAI injury alone. This raises the question of the significance of venous injury which may require further investigation. However, it was obvious in our study that injuries treated with arterial ligation carried a significantly higher rate of subsequent amputation. Our study showed that the use of stent placement to treat PAI was associated with the least amputation rate. The use of endovascular techniques to treat traumatic peripheral arterial injuries is gaining more popularity across the nation.8 While indications for endovascular repair are not well elucidated, substantial injuries including transections are typically repaired in an open approach.8 Thus, it is hard to tell if the low amputation rate with endovascular repairs is due to the choice of the intervention (open vs. endovascular) or the severity of injury. In addition, the patency of the stent and long-term limb salvage outcomes need to be further studied. Lastly, patients with CPAVI were found to have a significant higher rate of prophylactic fasciotomy compared to PAI or PVI, while compartment syndrome was diagnosed in significantly lower frequency in PVI but in similar rate in CPAVI and PAI. The higher prophylactic fasciotomy rate in CPAVI is likely the result of individual surgeons’ more aggressive mentality in the face of seemingly more severe injuries. However, whether CPAVI results in actual higher rate of compartment syndrome requiring more aggressive prophylactic fasciotomy remains to be determined.
Limitations
Isolated venous injury may be underreported in this study given that a number of these injuries would not have been explored. Another important point is that ICD-9 codes may have resulted in understating of certain procedures. Fasciotomies were performed in only around 70% of the patients who were documented as having compartment syndrome. This is likely due to other codes being utilized to document fasciotomies. Furthermore, we were only able to analyze events occurred during the acute hospitalization setting due to the use of NIS and ICD-9 codes. Possible longterm sequelae of various procedures such as distal limb edema following popliteal vein ligation were not included in our analysis. Lastly, variation in the popliteal vein anatomy can have a significant effect on outcomes after PVI; 44% of patients can have two or more popliteal veins.9 Popliteal vein ligation can obviously be safe in patients with duplicated popliteal veins. The National institutes of health (NIH) does not provide any data on variations of popliteal vein anatomy in patients with PVI. Thus, we cannot determine the effect of popliteal vein ligation on limb salvage outcomes with absolute certainty.
Conclusion Evidence-based management of popliteal vasculature may increase rates of limb salvage. Patients with PVI or CPAVI may be managed with vein ligation safely without increased amputation rates as compared to PAI. In patients with CPAVI, amputation rates are significantly increased when the arterial injury is managed with ligation. If revascularization is performed, rates of amputation between PAI and CPAVI are not different. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Acknowledgement
ICD-9 codes were utilized to select patients and procedures included in this study. Thus, the validity of the data in this study is limited by the coding accuracy of respective institutions. In our study, we made every attempt to include patients with only PAI, PVI, or CPAVI. However, we were unable to determine whether these patients truly sustained isolated vascular injuries. For example, in patients coded with PAI, 0.8% received vein ligation. It remains unclear to us whether this was due to error in coding or iatrogenic injury during arterial repair and subsequent venous ligation.
This study was presented as a poster at the American College of Surgeons, San Francisco, 27 October 2014.
References 1. Mullenix PS, Steele SR, Andersen CA, et al. Limb salvage and outcomes among patients with traumatic popliteal vascular injury: an analysis of the National Trauma Data Bank. J Vasc Surg 2006; 44: 94–100. 2. Dua A, Patel B, Desai SS, et al. Comparison of military and civilian popliteal artery trauma outcomes. J Vasc Surg 2014; 59: 1628–1632.
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3. Trellopoulos G, Georgiadis GS, Aslanidou EA, et al. Endovascular management of peripheral arterial trauma in patients presenting in hemorrhagic shock. J Cardiovasc Surg (Torino) 2012; 53: 495–506. 4. Huynh TT, Pham M, Griffin LW, et al. Management of distal femoral and popliteal arterial injuries: an update. Am J Surg 2006; 192: 773–778. 5. Sultanov DD, Usmanov NU, Baratov AK, et al. Traumatic injuries of the popliteal and tibial arteries: limb ischemia and problems of surgical management. Angiol Sosud Khir 2004; 10: 104–113.
6. Hardin WD Jr, Adinolfi MF, O’Connell RC, et al. Management of traumatic peripheral vein injuries. Am J Surg 1982; 144: 235–238. 7. Ekim H, Basel H and Odabasi D. Management of traumatic popliteal vein injuries. Injury 2012; 43: 1482–1485. 8. Desai SS, DuBose JJ, Parham CS, et al. Outcomes after endovascular repair of arterial trauma. J Vasc Surg 2014; 60: 1309–1314. 9. Quinlan DJ, Alikhan R, Gishen P, et al. Variations in lower limb venous anatomy: implications for US diagnosis of deep vein thrombosis. Radiology 2003; 228: 443–448.
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Vascular OnlineFirst, published on May 25, 2015 as doi:10.1177/1708538115589251
Original Article
Popliteal vein repair may not impact amputation rates in combined popliteal artery and vein injury
Vascular 0(0) 1–5 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538115589251 vas.sagepub.com
Anahita Dua1, Sapan S Desai2, Fadwa Ali1, Kai Yang1 and Cheong Lee1
Abstract Introduction: This study aimed to determine the incidence, management, and outcomes of popliteal artery injury, popliteal vein injury, and concomitant popliteal artery injury and vein injury. Methods: A retrospective analysis was completed using the 2000–2010 Nationwide Inpatient Sample utilizing International Classification of Diseases-9 codes to select patients with isolated popliteal artery injury (904.41), isolated popliteal vein injury (904.42), and isolated concomitant popliteal artery and vein injury (958.92). Variables included demographics, procedure type, and outcome during hospital course. Statistical analysis was with chi-square, Fisher exact test, and multivariate analysis. Results: A total of 2216 patients presented with injury to the popliteal system; 71% (1568) presented with isolated popliteal artery injury, 14% (306) with isolated popliteal vein injury, and 15% (342) with concomitant popliteal artery and vein injury. Amputation was significantly increased in popliteal artery injury and concomitant popliteal artery and vein injury (P < 0.001) as compared to popliteal vein injury. Ligation of the vein was more common in concomitant popliteal artery and vein injury when compared to popliteal vein injury (P < 0.05). The rate of amputation was 9.8% for popliteal artery injury, significantly greater than for popliteal vein injury (0.7%, P < 0.001) but not different than for concomitant popliteal artery and vein injury (8.2%, P ¼ NS). Conclusion: Evidence-based management of popliteal vasculature may increase rates of limb salvage. Within the limitations of the data set used, conclusions appear to be that patients with popliteal vein injury or concomitant popliteal artery and vein injury may be managed with vein ligation without increased amputation rates as compared to popliteal artery injury.
Keywords Popliteal injury, revascularization, popliteal trauma
Introduction Traumatic popliteal injury is an uncommon but potentially devastating problem that carries the highest amputation rates among all peripheral vascular injuries.1 Prior studies consist of retrospective case series of popliteal vessel injury among military and civilian populations.2 Although rates of amputation remain high in both military and civilian groups at 30% and 20%, respectively, exact surgical management remains controversial.2 Surgical management for popliteal vessel injury includes primary amputation, primary vascular repair, intravascular shunting or bypass, and endovascular stenting.3–5 The management strategy depends on the
extent and mechanism of injury and surgeon preference. The effect of the different surgical procedures on limb salvage outcomes is unclear. This study aims to determine the incidence, management, and limb salvage outcome following popliteal artery injury (PAI), popliteal vein injury (PVI), and concomitant popliteal artery and vein injury (CPAVI). 1 Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA 2 Department of Vascular Surgery, Southern Illinois University, Springfield, IL, USA
Corresponding author: Anahita Dua, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA. Email: [email protected]
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Methods
Results
Database and selection A retrospective analysis was completed using the Nationwide Inpatient Sample (NIS), a part of the Health Care Utilization Project that is maintained by the Agency for Healthcare Research and Quality (AHRQ). The NIS is the largest all-payer inpatient database and includes a stratified random sample of patients from a 20% sampling of participating nonfederal hospitals throughout the USA. Weighting from the original datasets was utilized. Clinical records between 2000 and 2010 were derived using the ninth revision of the International Classification of Diseases (ICD-9) diagnosis and procedure codes to include patients with isolated PAI (904.41), isolated PVI (904.42), and isolated CPAVI (958.92).
Variables Variables included demographics, procedure type (primary amputation (without revascularization attempt), stent, bypass, primary repair, and fasciotomy), compartment syndrome, length of stay, and outcome (secondary amputation (amputation after revascularization attempt)) during the hospital course. This study was exempt from the IRB and no identifiable patient data were utilized.
Statistical analysis Statistical analysis was completed using the Fisher exact test for continuous variables and chi-squared for categorical variables. Data analysis and management were completed using the IBM SPSS software package (SPSS version 22.0, SPSS Inc., Chicago, IL, USA). Statistical significance was set at a probability of P < 0.05. Values are presented as mean standard deviation or absolute percentages.
A total of 2216 patients presented with popliteal vessel trauma between 2000 and 2010. Of these patients, 71% had PAI, 14% with PVI, and 15% with CPAVI. Most patients with PAI underwent some form of revascularization, including primary repair (27.4%), bypass (45.7%), or stent placement (2.4%). Primary amputation was necessary in 5.9% of patients and 3.8% had ligation of the artery. In contradistinction, few patients with PVI underwent any form of revascularization with only two (0.7%) patients undergoing a venous bypass. Patients who required an intervention underwent ligation (8.2%), and only one (0.3%) patient required primary amputation (Table 1). Patients with CPAVI were more likely to undergo a revascularization procedure, including primary artery repair (57.3%), arterial bypass (34.8%), arterial stent placement (0.6%), or venous bypass (1.2%). Primary ligation of the popliteal artery occurred in 4.1% of patients, and primary ligation of the PVI in 17.0% of patients. Vein ligation was significantly more common in the CPAVI patients than PVI (P < 0.05). Primary arterial repair was also more common for CPAVI patients than PAI (P < 0.05); however, arterial bypass was more common in PAI patients (P < 0.001). The primary amputation rate in patients with combined injury was 3.5% (Table 1). Primary amputation was significantly more common in PAI and CPAVI patients compared to PVI (P < 0.001). The overall rate of amputation (primarily and secondary) was greatest for patients with PAI at 9.8%, followed by patients with CPAVI at 8.2% and PVI at 0.7% (P < 0.001 for PAI or CPAVI vs. PVI) (Table 1). The choice of intervention correlated with the rate of amputation. Patients with PAI were most likely to undergo amputation following primarily ligation (10.0%), followed by primary repair (6.3%), peripheral
Table 1. Initial procedure type for popliteal artery injury alone, popliteal vein injury alone, and combined popliteal artery and vein injuries. Initial procedure type
Popliteal artery injury (1568)
Popliteal vein injury (306)
Popliteal artery and vein injury (342)
Primary amputation Artery ligation Vein ligation Primary repair of artery Bypass of artery Bypass of vein Stent of artery Overall amputation rate (primary þ secondary)
92 60 13 429 717 0 38 154
1 0 25 0 0 2 0 2
12 14 58 196 119 4 2 28
(5.9%) (3.8%) (0.8%) (27.4%) (45.7%) (0%) (2.4%) (9.8%)
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(0.3%) (8.2%)
(0.7%) (0.7%)
(3.5%) (4.1%) (17.0%) (57.3%) (34.8%) (1.2%) (0.6%) (8.2%)
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Table 2. Amputation rates based on procedure type. Amputation rates Revascularization procedure type Amputation Amputation Amputation Amputation
after after after after
ligation primary repair bypass stent
Popliteal artery injury (1568)
Popliteal vein injury (306)
Popliteal artery and vein injury (342)
6 27 35 1
0 1 (4.0%) 0 0
5 (36.7%) 8 (4.1%) 10 (8.4%) 0
(10.0%) (6.3%) (4.9%) (2.6%)
Table 3. Rates of prophylactic fasciotomy, compartment syndrome, and therapeutic fasciotomy.
Prophylactic fasciotomy rate Compartment syndrome rate Therapeutic fasciotomy rate post compartment syndrome diagnosis
Popliteal artery injury (1568)
Popliteal vein injury (306)
Popliteal artery and vein injury (342)
480 (30.6%) 161 (10.3%) 105 (65.2%)
34 (11.1%) 11 (3.6%) 7 (63.8%)
145 (42.4%) 41 (12.0%) 27 (65.8%)
bypass (4.9%), and stent placement (2.6%). Only one (4.0%) patient with PVI underwent amputation, which occurred after primary venous repair. The highest rates of amputation were seen in patients who underwent ligation of the popliteal vessels following CPAVI (36.7%), arterial bypass (8.4%), and primary repair (4.1%) (Table 2). Prophylactic fasciotomy was most likely to be completed in patients with CPAVI (42.4%), followed by PAI (30.6%) and PVI (11.1%; P < 0.01 for CPAVI vs. PAI or PVI) (Table 3). The rate of compartment syndrome was highest for CPAVI (12.0%), followed by PAI (10.3%) and PVI (3.6%; P < 0.001 for CPAVI vs. PVI). Therapeutic fasciotomy following the diagnosis of compartment syndrome was required in 63.8%– 65.8% of all patients regardless of type of injury (P ¼ NS).
Discussion Amputation rates in the civilian population following traumatic disruption of popliteal vasculature range from 14.5 to 25%.2 Over a 10-year period in our analysis, 2216 patients presented with isolated injury to the popliteal system consisting of 71% PAI, 14% PVI, and 15% CPAVI. This study was performed to report national management practices and limb salvage outcomes in these civilian patients in relation to their corresponding procedure type. In our study, we found that primary amputation was significantly increased in PAI and CPAVI injury comparing to PVI. This is expected since arterial injuries are
more commonly associated with severe limb ischemia at initial presentation, which would likely lead the surgeons’ decisions against salvage procedures. In addition, primary repair of popliteal artery was more commonly utilized for CPAVI than for PAI while arterial bypass was more commonly performed for PAI compared to CPAVI. We also found in our study that ligation of the popliteal vein was significantly more common in CPAVI injuries than in PVI. Vein ligation was the management of choice for peripheral venous injuries prior to Vietnam era with the thinking that venous repair inevitably led to thrombosis and various sequalae.6 With newer studies, it was shown that while venous ligation of upper extremities associated with no long-term sequela, primary repair by lateral suture or primary end to end reanastomosis is recommended when technically feasible for venous injuries of the legs. However, in unstable patients or when primary repair cannot be repaired, venous ligation was still recommended with aggressive post operative management to prevent edema and thrombosis.6 This would explain the higher rates of popliteal vein ligation in CPAVI than PVI in our study. Interestingly, recent studies have shown that venous repair with meticulous surgical technique increased extremity salvage rate and decreased long-term complications in PVIs especially in concomitant PAI. It was argued that with modern patient monitoring and blood product availability, popliteal vein ligation is only indicated in unstable patients refusing blood transfusions.7
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Vascular 0(0)
We found that the overall amputation rate was significantly greater for PAI when compared to PVI, but no different when compared to CPAVI. This indicates that PVI ligation does not necessarily impact amputation rates and the vein can hence be safely ligated without increasing amputation risk at least in the short term. This is important given the fact that lengthy operations attempting to repair an injured vein may result in longer operating times without any significant benefit. Although it is expected that arterial injury would carry a higher rate of amputation, it was interesting that CPAVI led to no significant increase in amputation rate versus PAI injury alone. This raises the question of the significance of venous injury which may require further investigation. However, it was obvious in our study that injuries treated with arterial ligation carried a significantly higher rate of subsequent amputation. Our study showed that the use of stent placement to treat PAI was associated with the least amputation rate. The use of endovascular techniques to treat traumatic peripheral arterial injuries is gaining more popularity across the nation.8 While indications for endovascular repair are not well elucidated, substantial injuries including transections are typically repaired in an open approach.8 Thus, it is hard to tell if the low amputation rate with endovascular repairs is due to the choice of the intervention (open vs. endovascular) or the severity of injury. In addition, the patency of the stent and long-term limb salvage outcomes need to be further studied. Lastly, patients with CPAVI were found to have a significant higher rate of prophylactic fasciotomy compared to PAI or PVI, while compartment syndrome was diagnosed in significantly lower frequency in PVI but in similar rate in CPAVI and PAI. The higher prophylactic fasciotomy rate in CPAVI is likely the result of individual surgeons’ more aggressive mentality in the face of seemingly more severe injuries. However, whether CPAVI results in actual higher rate of compartment syndrome requiring more aggressive prophylactic fasciotomy remains to be determined.
Limitations
Isolated venous injury may be underreported in this study given that a number of these injuries would not have been explored. Another important point is that ICD-9 codes may have resulted in understating of certain procedures. Fasciotomies were performed in only around 70% of the patients who were documented as having compartment syndrome. This is likely due to other codes being utilized to document fasciotomies. Furthermore, we were only able to analyze events occurred during the acute hospitalization setting due to the use of NIS and ICD-9 codes. Possible longterm sequelae of various procedures such as distal limb edema following popliteal vein ligation were not included in our analysis. Lastly, variation in the popliteal vein anatomy can have a significant effect on outcomes after PVI; 44% of patients can have two or more popliteal veins.9 Popliteal vein ligation can obviously be safe in patients with duplicated popliteal veins. The National institutes of health (NIH) does not provide any data on variations of popliteal vein anatomy in patients with PVI. Thus, we cannot determine the effect of popliteal vein ligation on limb salvage outcomes with absolute certainty.
Conclusion Evidence-based management of popliteal vasculature may increase rates of limb salvage. Patients with PVI or CPAVI may be managed with vein ligation safely without increased amputation rates as compared to PAI. In patients with CPAVI, amputation rates are significantly increased when the arterial injury is managed with ligation. If revascularization is performed, rates of amputation between PAI and CPAVI are not different. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Acknowledgement
ICD-9 codes were utilized to select patients and procedures included in this study. Thus, the validity of the data in this study is limited by the coding accuracy of respective institutions. In our study, we made every attempt to include patients with only PAI, PVI, or CPAVI. However, we were unable to determine whether these patients truly sustained isolated vascular injuries. For example, in patients coded with PAI, 0.8% received vein ligation. It remains unclear to us whether this was due to error in coding or iatrogenic injury during arterial repair and subsequent venous ligation.
This study was presented as a poster at the American College of Surgeons, San Francisco, 27 October 2014.
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