National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma.

Lower extremity injury is common in trauma patients; however, the influence of arterial injury on devastating patient and limb outcomes can be confounded by the presence and physiological derangement of concomitant head or thoracoabdominal injuries. We analyzed isolated lower extremity injuries with an arterial component. Our aim was to elucidate factors associated with mortality and limb loss in this selected population. We reviewed trauma incidents from the National Trauma Data Bank (2002-2006) containing isolated lower extremity injury codes and a specified infrainguinal arterial injury. Demographics, injury patterns, clinical characteristics, and adverse outcomes (death, amputation) during initial hospitalization were collected. Multivariate logistic regression was used to identify risk factors for limb loss. There were 651 isolated infrainguinal arterial injuries. Death (18) and early limb loss (42) were studied by mechanism (penetrating, n = 431; blunt, n = 220). Half of the deaths involved injury to the common femoral artery (CFA), and over 80% had injury to the CFA or superficial femoral artery (SFA). Death was three times as frequent in the CFA/SFA than in the popliteal/tibial injuries (P = .02). Penetrating injuries were present in almost 80% of deaths, and most of these were gunshot wounds. Patients who died had mean initial systolic blood pressure of 59.7 mm Hg, and almost 40% had no blood pressure on arrival. Mean initial Glasgow Coma Score was 4.5, and almost 80% arrived with a Glasgow Coma Score of 3 despite the absence of head injury. Twenty-seven above- and 15 below-the-knee amputations were performed. The popliteal artery was injured in half of the amputations, with injury isolated to the popliteal or tibial arteries in about three-quarters. Amputation was twice as frequent in popliteal/tibial than CFA/SFA injury (P = .03) and twice as frequent in blunt than penetrating injury (P = .05). Multiple arterial injuries (odds ratio, 5.2; 95% confidence interval, 1.7-15.6; P = .003), and fracture (odds ratio, 2.2; 95% confidence interval, 1.1-4.2; P = .02) independently predicted amputation, while the presence of nerve injury and soft tissue disruption did not. Isolated lower extremity trauma with vascular injury has a nearly 10% rate of mortality or limb loss. Mortality is associated with penetrating mechanism and early shock, likely resulting from prehospital proximal arterial hemorrhage. In contrast, early limb loss is more common with blunt distal vascular injury, especially to the popliteal and tibial arteries. Neither nerve nor soft tissue injury predicted limb loss but may result in delayed amputations not captured in this acute outcomes dataset.

Kauvar DS ，Sarfati MR ，Kraiss LW 《-》

Lower extremity vascular injuries caused by firearms have a higher risk of amputation and death compared with non-firearm penetrating trauma.

Firearm injuries have traditionally been associated with worse outcomes compared with other types of penetrating trauma. Lower extremity trauma with vascular injury is a common presentation at many centers. Our goal was to compare firearm and non-firearm lower extremity penetrating injuries requiring vascular repair. We analyzed the National Inpatient Sample from 2010 to 2014 for all penetrating lower extremity injuries requiring vascular repair based on International Classification of Diseases, Ninth Revision codes. Our primary outcomes were in-hospital lower extremity amputation and death. We identified 19,494 patients with lower extremity penetrating injuries requiring vascular repair-15,727 (80.7%) firearm injuries and 3767 (19.3%) non-firearm injuries. The majority of patients were male (91%), and intent was most often assault/legal intervention (64.3%). In all penetrating injuries requiring vascular repair, the majority (72.9%) had an arterial injury and 43.8% had a venous injury. Location of vascular injury included iliac (19.3%), femoral-popliteal (60%), and tibial (13.2%) vascular segments. Interventions included direct vascular repair (52.1%), ligation (22.1%), bypass (19.4%), and endovascular procedures (3.6%). Patients with firearm injuries were more frequently younger, black, male, and on Medicaid, with lower household income, intent of assault or legal action, and two most severe injuries in the same body region (P < .0001 for all). Firearm injuries compared with non-firearm injuries were more often reported to be arterial (75.5% vs 61.9%), to involve iliac (20.6% vs 13.7%) and femoral-popliteal vessels (64.7% vs 39.9%), to undergo endovascular repair (4% vs 2.1%), and to have a bypass (22.5% vs 6.5%; P < .05 for all). Firearm-related in-hospital major amputation (3.3% vs 0.8%; P = .001) and mortality (7.6% vs 4.2%; P = .001) were higher compared with non-firearm penetrating trauma. Multivariable analysis showed that injury by a firearm source was independently associated with postoperative major amputation (odds ratio, 4.78; 95% confidence interval, 2.07-11.01; P < .0001) and mortality (odds ratio, 1.74; 95% confidence interval, 1.14-2.65; P = .01). Firearm injury is associated with a higher rate of amputation and mortality compared with non-firearm injuries of the lower extremity requiring vascular repair. These data can continue to guide public health discussions about morbidity and mortality from firearm injury.

Siracuse JJ ，Farber A ，Cheng TW ，Jones DW ，Kalesan B ... -  《-》

Contemporary outcomes of civilian lower extremity arterial trauma.

Lower extremity arterial injury may result in limb loss after blunt or penetrating trauma. This study examined outcomes of civilian lower extremity arterial trauma and predictors of delayed amputation. The records of patients presenting to a major level I trauma center from 2004 to 2014 with infrainguinal arterial injury were identified from a prospective institutional trauma registry, and outcomes were reviewed. Standard statistical methods were used for data analysis. We identified 149 patients (86% male; mean age, 33 ± 14 years,). Of these, 46% presented with blunt trauma: 19 (13%) had common femoral artery, 26 (17%) superficial femoral artery, 50 (33%) popliteal, and 54 (36%) tibial injury. Seven patients underwent primary amputation; of the remainder, 21 (15%) underwent ligation, 85 (59%) revascularization (80% bypass grafting, 20% primary repair), and the rest were observed. Delayed amputation was eventually required in 24 patients (17%): 20 (83%) were due to irreversible ischemia or extensive musculoskeletal damage, despite having adequate perfusion. Delayed amputation rates were 26% for popliteal, 20% for tibial, and 4.4% for common/superficial femoral artery injury. The delayed amputation group had significantly more (P < .05) blunt trauma (79% vs 30%), popliteal injury (46% vs 27%), compound fracture/dislocation (75% vs 33%), bypass graft (63% vs 43%), and fasciotomy (75% vs 43%), and a higher mangled extremity severity score (6.1 ± 1.8 vs 4.3 ± 1.6). Predictors of delayed amputation included younger age, higher injury severity score, popliteal or multiple tibial injury, blunt trauma, and pulseless examination on presentation. Individualized decision making based on age, mechanism, pulseless presentation, extent of musculoskeletal trauma, and location of injury should guide the intensity of revascularization strategies after extremity arterial trauma. Although patients presenting with vascular trauma in the setting of multiple negative prognostic factors should not be denied revascularization, expectations for limb salvage in the short-term and long-term periods should be carefully outlined.

Liang NL ，Alarcon LH ，Jeyabalan G ，Avgerinos ED ，Makaroun MS ，Chaer RA ... -  《-》

Lower extremity arterial injuries over a six-year period: outcomes, risk factors, and management.

Topal AE ，Eren MN ，Celik Y 《-》

A propensity-matched analysis of contemporary outcomes of blunt popliteal artery injury.

Traumatic popliteal artery injury is associated with an increased propensity for limb loss, morbidity, and mortality above an already elevated baseline risk to life and limb. Previous studies of outcomes in this patient group have been limited by selection bias. This study analyzed outcomes after blunt popliteal artery injury using propensity matching to reduce confounding variables associated with multiple mechanisms of traumatic vascular injury and to identify factors associated with amputation. A retrospective review was conducted of prospectively collected data from the National Trauma Data Bank. Patients were identified using International Classification of Diseases, Ninth Revision codes related to patterns of blunt injury associated with popliteal arterial injury or intervention. Using Trauma Quality Improvement Program variables as a reference, specific characteristics were collected. Variables found significant on univariate analysis were used to generate propensity-matched amputation and nonamputation cohorts. Multivariate logistic regression was used to assess for risk factors associated with amputation and inpatient mortality. In total, 3029 patients with blunt popliteal artery injury were identified; 628 (20.7%) underwent amputation. Patients who underwent amputation presented with more frequent hypotension (systolic blood pressure of 0-99 mm Hg, 22.7% vs 12.8%; P < .001) and tachycardia (heart rate >120 beats/min, 28.5% vs 14.5%; P < .001). Limb loss was also associated with concurrent popliteal vein injury (18.3% vs 8.7%; P < .001) and tibial nerve injury (5.3% vs 1.3%; P < .001) as well as with elevated Injury Severity Score (median, 13 vs 9; P < .001) and lower extremity Abbreviated Injury Scale score (3 vs 2; P < .001). Subsequently, 794 patients were divided into equal number propensity-matched amputation and nonamputation cohorts. Regression analysis revealed that patients with diabetes mellitus (odds ratio [OR], 1.763; P = .049), popliteal vein injury (OR, 1.657; P = .012), or tibial nerve injury (OR, 3.537; P = .007) were more likely to undergo amputation. Further regression analysis with patients matched for Injury Severity Score revealed that age ≥86 years (OR, 38.092; P = .009), patellar fracture (OR, 3.445; P = .036), and elevated Abbreviated Injury Scale score (OR, 1.101; P < .001) were associated with higher risk of inpatient death. Trauma patients who sustain blunt popliteal artery injury are at an increased risk of amputation. Propensity-matched analysis revealed that concurrent popliteal vein and tibial nerve injury but not severity of tissue injury predicted limb loss.

Futchko J ，Parsikia A ，Berezin N ，Shah A ，Stone ME Jr ，McNelis J ，Rivera A ... -  《-》