Risk factors associated with amputation in civilian popliteal artery trauma

Popliteal artery trauma is uncommon but is associated with a high risk of limb loss depending on the scenario involving blunt or penetrating trauma as well as the severity and extent of injury that has occurred. In our setting there is a significant amount of gang and civilian warfare resulting in Vascular Trauma. There were 32 patients over a decade who sustained traumatic injury to the popliteal artery consisting of 30 males (94%) and 2 females with an age range 16–59 years with a mean of 32. There were 20 cases of penetrating trauma (63%) and 12 cases of blunt trauma (37%). Of the penetrating trauma, 18 were due to gunshot wounds (GSWs) (90%) and 2 stabs. The majority (7/12; 58%) of blunt trauma was due to falls, and 42% (5/12) secondary to motor vehicular accidents (MVAs). In terms of extent of injury, 21 of 32 patients (65%) sustained an isolated popliteal artery injury, whilst 6 (19%) had injury to both the popliteal artery and vein and another 5 (16%) had combined popliteal artery, vein and nerve injuries. There were 14 cases with associated orthopaedic injuries: 7 posterior knee dislocations, 1 fracture/dislocation of the knee, 2 femoral fractures, 2 tibial plateau fractures and 2 tibia/fibula fracture. Methods of repair included 14 reversed vein grafts, 16 polytetrafluoroethylene (PTFE) grafts and 2 primary. The overall amputation rate was 28% (9 patients). Of the penetrating trauma patients 25% required amputations composed of 5 GSWs, 33% of the blunt trauma patients required amputations. It was noted that factors associated with (but not statistically significant) poor outcomes included combined artery/vein injury, artery/vein/nerve injury, concomitant fracture/dislocation and delayed transfer to a Vascular Surgery Unit. The type of graft or repair did not affect outcome. The incidence of popliteal artery trauma was calculated at 2.46 per 100,000 population per year.     

Successful vascular reconstruction. Determinants of disability

Improvements in limb salvage during the last decade are a reflection of advances in angiography, antibiotics and technique. We report a 100 per cent success rate with vascular repair and a 100 per cent disability outcome in extremity injuries. Ten male patients, with a mean age of 27.3 (range 18 to 41) years, sustained trauma to the extremity with vascular injury. The etiology of injury was gunshot wounds (5), blunt trauma (4), and stab wounds (1). Time from injury to vascular repair was a mean of 186 (range 60 to 360) min. Vessels injured included popliteal artery and vein (4), tibial artery and vein (2), subclavian artery and vein (2), and axillary artery (1). Six of the injuries were associated with fracture of the adjacent bone and treated with external skeletal fixation. All patients had an associated nerve injury. Five patients underwent fasciotomy; nine were treated with 500 ml Dextran-40 for 48 hr (each day for 2 days). All patients received cephalosporin antibiotics pre-, intra-, and post-operatively. All patients had successful vascular repair, as identified by Doppler ultrasound (10 patients) and intra-/post-operative arteriography (5 patients). The median follow-up period was 22 (range 18 to 30) months. There were no primary amputations (within 30 days); there were four late amputations (2, no function and foot ulcer; 2, causalgia). The five popliteal/tibial injuries had no dorsiflexion and foot drop, two had no function and leg ulcers; two patients had femoral and sciatic nerve injury at the thigh; and three patients had injuries to the brachial plexus.(ABSTRACT TRUNCATED AT 250 WORDS)     

Venous injuries of the lower extremities and pelvis: repair versus ligation.

Many surgeons advocate repair of venous injuries to prevent the sequelae of venous ligation. Since 1986, we have treated 74 patients with 79 venous injuries of the lower extremity or pelvis. There were 68 men and six women with a mean age of 29.2 years (range, 16-62 years). The mechanisms of injury were gunshot wounds in 61 patients, stab wounds in 11 patients, and shotgun wounds and blunt trauma in one patient each. Forty-eight injuries were treated by ligation; 31 injuries were treated by repair. Repairs included two interposition grafts, eight end-to-end repairs, 16 venorrhaphies, and five vein patches. In addition, we developed a venous injury staging system (VIS), which ranged from grade I (less than 50% laceration) to grade IV (complete interruption with soft-tissue injury). Patient age, mechanism, location of injury, associated injuries, and incidence of arterial injury were not different between the patients treated by ligation and those treated by repair. Patients treated with venous ligation had a greater VIS (mean, 3.45 vs. 2.0), a greater incidence of shock (71% vs. 39%), and higher transfusion requirements (9.23 vs. 4.82 units). Postoperative morbidity rates were identical, however. There was no increase in the need for fasciotomy in patients treated with venous ligation. Eighty-six percent of the patients treated by ligation were totally free of edema at discharge. The others had only mild edema that did not interfere with daily activities at discharge and follow-up. Ligation is a safe alternative to repair in patients with injuries to the lower extremities or pelvis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complex upper extremity vascular trauma in an urban population

Eighty patients with upper extremity vascular trauma were treated during a 4-year period. Of 123 vascular injuries, 95 were arterial, 1 was primary venous, and 27 were associated venous injuries. Causes included penetrating (64%), blunt (27%), and iatrogenic injuries (9%). Arteries injured were ulnar (34), radial (28), brachial (22), subclavian (6), and axillary (5). Numbers of patients with associated injuries were nerve (53), vein (27), bone (23), and soft tissue injuries (60). The most common techniques of arterial repair were end-to-end anastomosis (50), followed by interposition saphenous vein grafting (40). Fasciotomy was used in 36 patients. Two arterial repairs failed during surgery and required revision (1) or thrombectomy (1). One radial artery repair thrombosed during late follow-up, with maintenance of normal extremity perfusion via the ulnar artery. No amputations were required, and 83% of all patients treated for nerve injuries resolved or improved their neurologic deficits. Two or more operations for surgical debridement and subsequent wound closure were required in 35 patients. This study supports an aggressive approach to diagnosis and treatment of complex upper extremity vascular trauma emphasizing meticulous surgical technique, liberal use of fasciotomy, and aggressive intraoperative debridement and repair of associated injuries.     

Long-term results with autogenous tissue repair of traumatic extremity vascular injuries.

With extensive vascular injuries in which a vascular conduit is required, there is controversy as to whether an autogenous or prosthetic graft is preferable. The authors reviewed their experience with 91 extremity arterial injuries in which autogenous tissue was used to repair vascular injuries of the extremities. Twenty-two patients also had concomitant repair of associated venous injuries with autogenous vein grafts. Ten patients required amputations, despite patent grafts in five patients, because of severe muscle necrosis. Two patients had thrombosis of their vein grafts develop in the early postoperative period but did not require amputation. The authors identified only one late vein graft failure in a patient in whom an infected pseudoaneurysm developed. Three patients with extensive soft tissue injuries had infection develop in vein grafts, with subsequent massive bleeding that ultimately required arterial ligation. Among the 22 patients with repair of their venous injuries, occlusion of popliteal vein repairs was documented in two patients and suspected in three others. The remainder of patients had satisfactory results. The excellent results obtained in the vast majority of the authors' patients with extremity vascular injuries reinforces their preference for using autogenous tissue whenever a vascular conduit is required. Exceptions include patients with extensive soft tissue loss precluding adequate graft coverage, the repair of large vessels, and life-threatening emergencies when there is insufficient time to harvest and prepare a vein.     

Surgical strategy in traumatic lesions of the popliteal artery

An examination and treatment of 32 patients with injured popliteal arteries are analyzed. Among the etiological factors there were gunshot wounds (16), crushed (4), punctured-incised (7) and blunt (7) traumas. Combined injuries of the popliteal vein were diagnosed in 12 patients, and injuries of the bones--in 16 patients. Errors were made in 19 cases at the prehospital stage: late diagnosis of the injury (11), transporting the patient in the state of shock (5), ligation of the popliteal artery (3). The term of extremity ischemia more than 8 hours was noted in 13 admitted patients. Decompensation of circulation was diagnosed in 22 patients. The primary amputation was performed on 6 patients with moist gangrene. Vascular reconstructions were made in 26 cases including the autovenous prosthesis and circular suture. Secondary amputations were fulfilled to 6 patients. Three patients died. Good results were obtained in 20 cases.     

Outcomes of popliteal vascular injuries at Sri Lankan war-front military hospital: Case series of 44 cases

Background and aims

Traumatic injury to the popliteal vascular zone remains a challenging problem on the modern battlefield and is frequently associated with more complications than other vascular injuries. Limb salvage and morbidity (graft infection, thrombosis and delayed haemorrhage) were studied.

Materials and methods

All popliteal vascular injuries over an 8 month period admitted to the Military Base Hospital were analyzed. Local limb evaluation included confirmation of the presence of ischaemia, extent of soft tissue damage, muscle viability after calf fasciotomy, and neurological injury. Ischaemic time was recorded from the time of injury to definitive revascularization. If there was a prior attempt at reconstruction, the amputation was considered delayed.

Results

For a series of 44 patients with popliteal vascular injury average time to presentation was 390 min, 46% were completely ischaemic. Of those 39 (89%) had popliteal artery injuries. There were 24 (62%) complete popliteal artery transections and associated venous (69%) and osseous (46%) injuries. The preferred technique of repair was inter-position venous graft (IPVG) (54%). Eleven immediate amputations were performed (28%). There were 13 wound infections (33%), 5 early graft thromboses (5 of 21 IPVG, 238%), 2 anastomotic disruptions (2 of 21 IPVG, 9%), which resulted in 4 delayed amputations. Mortality was 5% (2 patients).

Conclusions

In this case series of popliteal artery injury early identification of limbs at risk, early four compartment fasciotomy, temporary intra-luminal shunting, definitive repair of concomitant venous injuries and aggressive treatment of haemodynamic instability were shown to be beneficial in achieving reasonable outcome in an austere environment with limited recourses.     

Popliteal artery trauma. Systemic anticoagulation and intraoperative thrombolysis improves limb salvage.

OBJECTIVE: This study was conducted to evaluate those factors associated with popliteal artery injury that influence amputation, with emphasis placed on those that the surgeon can control. SUMMARY BACKGROUND DATA: Generally accepted factors impacting amputation after popliteal artery injury include blunt trauma, prolonged ischemic times, musculoskeletal injuries, and venous disruption. Amputation ultimately results from microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. METHODS: Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic times) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studied. Severity of extremity injury was quantitated by the Mangled Extremity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). After univariate analysis, logistic regression analysis was performed to identify the independent risk factors for limb loss. RESULTS: One hundred two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating trauma. There were 25 amputations (25%; 11 primary and 14 secondary). Patients with totally ischemic extremities (no palpable or Doppler pulse) more likely were to be amputated (31% vs. 13%; p < 0.04). All requiring primary amputations had severe soft tissue injury and three had posterior tibial nerve transection; the average MESS was 7.6. Logistic regression analysis identified independent factors associated with secondary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MESS (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no complications with either heparin or urokinase. CONCLUSIONS: Minimizing ischemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputation. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvage. The authors recommend the use of these agents to maximize limb salvage in association with repair of popliteal artery injuries.     

Amputation risk factors in concomitant superficial femoral artery and vein injuries

Only a small subset of patients with combined superficial femoral artery and vein injuries results in amputation. The importance of the venous component as a risk factor for amputation is uncertain. Ligation vs. reconstruction of venous injuries is controversial. For clarification of these issues, we analyzed retrospectively multiple risk factors for amputation in combined superficial femoral artery and vein injuries in a civilian population. There were 25 patients treated in a 20-year period. Sixteen injuries were caused by small caliber missiles, six by shotgun blasts, and three by knife wounds. Three patients (12%) ultimately underwent amputation. The major risk factor for amputation was method of vascular reconstruction. All three amputations underwent ligation of the superficial femoral vein with arterial reconstruction by placement of a reversed interposition saphenous vein graft (p = 0.0009). None of the remaining 22 patients with salvaged limbs underwent reconstruction by this combination of techniques. Consequently, the authors emphasize the importance of venous reconstruction, particularly in combined injuries with major arterial involvement requiring interposed grafts.     

Diagnosis and management of major vascular injuries: a review of 200 operative cases.

In a series of 250 civilian vascular injuries, 85 per cent were due to firearms and 50 per cent involved the torso, both of which represent an increased frequency of occurrence over other reports. There were 40 deaths, 31 of which occurred during operation or in the recovery room and were due to irreversible shock or coagulopathy. Of the nine late deaths, failure of the vascular repair was responsible for only three. In 124 extremity artery injuries, there were 12 leg amputations (10%) with shotgun wounds responsible for nine and popliteal artery injuries involved in seven. In gunshot wounds of the aorta and iliac arteries, there were five suture line disruptions in nine primary repairs and no disruptions in 11 patients repaired by grafts. The evidence indicates that an antibiotic soaked dacron graft is the method of choice to repair gunshot wounds of the aorta and iliac arteries at this time.     

Isolated iliac vascular injuries and outcome of repair versus ligation of isolated iliac vein injury

Objective

The incidence of morbidity and mortality for iliac vascular injuries in the literature are likely overestimated owing to associated injuries. Data for isolated iliac vascular injuries are very limited. No large studies have reported the incidence of morbidity for repair versus ligation of isolated iliac vein injuries.

Venous injury: to repair or ligate, the dilemma

Surgical management of major venous injuries remains controversial. The medical records of 184 patients with major venous injury were reviewed. Forty-three patients had isolated venous injury; 31 of 43 patients (72%) underwent ligation to treat their vein injury. Another 141 patients had combined arterial and venous injury; 117 of these patients (83%) had ligation. Injured were the inferior vena cava, iliac, femoral, popliteal, distal leg, and arm veins; all patients underwent surgical exploration. Arterial injuries were repaired by standard techniques and venous injuries were either ligated or repaired by end-to-end or lateral phleborrhaphy. Adjunctive fasciotomy was used when clinically indicated. The patients were followed up for 1 month to 9 years. No permanent sequelae of venous ligation were identified. Transient extremity edema developed in up to 32% of patients, regardless of whether vein ligation or repair was performed. This edema resolved completely within 12 weeks of the injury. No extremity was lost after ligation of a venous injury. Although it may be ideal to repair all venous vascular injuries, selective management reflecting mechanism of injury, blood loss, anesthesia requirements, associated organ injury, and other concerns may mitigate against extensive venous repair.     

Vascular injuries in everyday practice

BACKGROUND: It was the objective of this retrospective study to analyse the causes of injury, surgical approaches, outcome, and complications in patients with vascular trauma and to report our experience with vein homografts for arterial reconstruction in the upper and lower limbs and cervicothoracic region in patients operated on over a period between 1981-2001. PATIENTS: In 128 patients with peripheral arterial injuries the mechanism was direct penetration in 90 cases and blunt injury in 20 cases. In 4 cases a chronic damage (false aneurysm, AV fistula) was observed. Isolated vascular trauma was present in 97 patients (75.8%), 31 cases (24.2%) were aggravated by concomitant bone fractures, and nerve or soft tissue damage. Most frequently injured vessels were the superficial femoral (22.6%), crural (22.6%), and ulnar and radial (13.2%) arteries. 16 patients with penetrating cervicothoracic arterial injuries were registered during this period. 8 patients underwent emergency exploration and 8 patients angiography prior urgent exploration. RESULTS: Saphenous vein interposition grafting was applied with good results in 34 patients, polytetrafluoroethylene and Dacron grafts were used in eight cases, end to end anastomosis in 12 cases, venous bypasses in 5 cases, venous patches in 7 cases. 17 patients underwent arterial repair and 9 venous repair. Vein homografts as an arterial substitute were implanted in 8 patients. Five secondary amputations were performed and five patients died. The limb salvage rate was 95% and the primary patency rate of vein homografts was 75% (excluded primary amputations). The penetrating cervicothoracic injuries were all repaired with improvement in level of consciousness and neurological deficit when present. CONCLUSIONS: Most vascular injuries of the extremities can be managed successfully unless associated with severe concomitant damage of the bones, nerves and soft tissues. In the absence of suitable autologous vein grafts, homografts appear to be an interesting alternative for arterial repair. In penetrating cervicothoracic vascular injuries immediate operative repair offers the best chance of recovery.     

Management of traumatic popliteal vein injuries

PurposeThe aim of this study was to evaluate different repair methods of popliteal vein injuries, and to assess the relationship between early patency and surgical outcome.MethodsThirty patients with popliteal vein injuries underwent surgical repair procedure at our hospital from March 2000 to April 2010. Patients who were haemodynamically unstable and those with massive bleeding from limb wounds were taken directly to the operating room. Stable patients underwent preoperative colour-flow duplex ultrasonography (CFDU).ResultsOur study group consisted of 26 males and 4 females, ranging in age from 17 to 60 years with a mean age of 25.3 ± 5.9 years. The mechanism of trauma was penetrating in 27 patients and blunt in the remaining 3 patients. Treatment included primary venous repair in 11 cases, end-to-end anastomosis in 8, interposition vein graft in 10, and interposition polytetrafluoroethylene (PTFE) graft in 1. There were 26 patients with associated arterial injury, of which 4 cases had primary repair, 9 had end-to-end anastomosis, 11 had saphenous vein graft interposition, and 2 had PTFE graft interposition. Associated bone fracture was seen in 6 patients. There were no deaths. One patient required a below-knee amputation. Postoperative CFDU revealed thrombosed venous repair in 7 cases without any sequelae.ConclusionPopliteal venous injuries can be repaired with minimal downside and a good early patency rate. Additionally, transient venous patency allows for establishment of venous and lymphatic collateralisation. Alternatively, venous ligation should be considered only in unstable patients who refuse blood transfusion (Jehovah's witnesses). In these victims, adjuvant management may be required such as the use of fasciotomy and anticoagulation treatment.     

Acute popliteal arterial injury: The role of angioscopy

Accurate identification of arterial injury in the emergency setting constitutes one of the essential prognostic factors in patients presenting with acute popliteal arterial injury (APAI). The modalities of angioscopy performed intraoperatively by the vascular surgeon, including the details of how angioscopy can contribute to therapeutic decisions in this setting, are presented. Between June 1987 and August 1993, 26 patients presenting with 27 APAIs (one patient had a bilateral APAI) were treated at our institution. Eighteen (67%) lesions were due to closed trauma, three (11%) to shotgun pellets, three (11%) to knife wounds, two (7%) to iatrogenic wounds, and one (4%) to a bullet wound. Between June 1987 and January 1992 (group I, n=20), treatment consisted of 15 (75%) saphenous vein bypasses and five (25%) local repairs. Pre- or intraoperative arteriograms were obtained in 14 (70%) cases. Three (15%) major amputations were required after popliteal reconstruction. Between February 1992 and August 1993 (group II, n=7), two (29%) saphenous vein grafts and five (71%) local repairs were performed after routine intraoperative angioscopy. Arteriograms were obtained in six (86%) instances. No amputations were necessary in this group. As a complement to arteriography, intraoperative angioscopy can determine the extent and number of injuries, provides direct visualization of the intima of the entire femoropopliteal artery, even when the latter is obscured by thrombus, and ensures a final control of popliteal artery repair at completion. After angioscopy, local repair was possible more often (71% vs. 25%,p = 0.03) and treatment was associated with a better functional result (0% vs. 15% amputation rate,p = 0.04) in group II.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Paris, France, June 25–26, 1993.     

Atherosclerotic popliteal aneurysms with particular regard to the contralateral side

A retrospective analysis of 75 patients with 103 atherosclerotic popliteal aneurysms, seen at Princess Alexandra Hospital, Brisbane, was undertaken to assess the results of management and the most appropriate approach to the contralateral popliteal aneurysm. These patients were seen between January 1968 and December 1985. There were no females, the mean age was 66.3 years and 36% of the patients had bilateral popliteal aneurysms. There was a high incidence of other associated aneurysms, abdominal aortic (21), femoral (12) and isolated iliac (3). Thrombosis in a popliteal aneurysm was the most common reason for presentation initially (48%), followed by detection of a lump in the popliteal fossa (22.6%), embolic phenomena (10.6%) and ruptured popliteal aneurysm (four cases). The most common presentation for contralateral aneurysms was detection of a lump in the popliteal fossa. Management of the contralateral popliteal aneurysm was classified as early, elective repair (n = 14) and no surgery or surgery delayed until the development of symptoms (n = 14). Outcome was classified as successful, retained and fully functional limb at follow-up; or failure, amputation or debilitating ischaemia. There was one failure among those undergoing early elective repair and seven failures among those undergoing no or delayed surgery (P = 0.033, Fisher's Exact Test). There were 79 reconstructions. Bypass and ligation (n = 54) resulted in two amputations and two long-term occlusions, interposition augmented vein graft (n = 15) in two amputations and no long-term occlusions and interposition Dacron grafts (n = 10) with no amputations and three long-term occlusions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Orthopedic trauma of limbs associated with vascular injuries

Objective： To evaluate the treatment for patients with major vascular injuries associated with traumatic orthopedic injuries. Methods： A total of 196 patients, aged from 4-67 years with the mean age of 29.88 years, had major vascular injuries associated with traumatic orthopedic injuries and were treated in our hospital in a period of 44 years. The most common mechanism of trauma was blunt trauma （67.3 % ）, open injuries accounted for 32.4 % and 54.5 % of the injuries were located in the lower extremities. The vascular injury frequently happened in the femoral artery （26. 7 % ） and popliteal artery （ 20. 3 % ）. The treatment principle consisted of aggressive resuscitation, Doppler imaging and stable bone internal fixation with subsequent vascular repair and debridement. The vascular repair for injuries included end-to-end anastomosis （80 cases, 39.6 % ）, interpositional vein graft （94, 46.5 % ）, vascular decompression through fracture distraction （ 18, 8.9% ）,arterial ligation （6, 3.0% ）, vein patch （2, 1. 0%）, bypass graft （ 2, 1.0% ）, venous repair including autogenous vein graft （9, 24. 3%） and ligation （28, 75.7% ） and prophylactical fasciotomy （15. 7. 4%）. Postoperative amputation was performed in 16 cases （16.3%）. Results： No intraoperative death was observed and all fractures united within 6 months. Limbs were salvaged in 180 patients （91. 8% ）. Among these patients, early complications were found in 19 patients （9. 7 % ） and late complications were observed in 8 patients （4.1% ）. Conclusions： A well-organized approach, based on a specific treatment principle, not only improves clinical outcome but also does good to excellent functional recovery for patients with severe orthopedic injuries and concomitant vascular lesion.     

Vascular trauma of the lower limbs

BACKGROUND: This study was conducted to evaluate the results of treatment of vascular trauma of the lower extremities and those factors associated with limb loss. Design: a retrospective evaluation of a series with lower extremities vascular trauma. Setting: University Hospital. METHODS: Thirty-one patients accounting for 45 vascular lesions of the lower extremities (27 arterial and 18 venous injuries), over a 15 years period ending December 1998. Age, sex, modality of the trauma, site of the lesion and associated skeletal injuries, diagnostic procedures, ischemic time, arterial and venous repair performed were analyzed. RESULTS: Perioperative mortality was 7.4%. For arterial injuries, limb salvage was obtained in 22 patients (81.5%). Five amputations (18.5%), 1 primary and 4 secondary have been performed. Amputation rate was 26.7% for popliteal lesions versus 8.3% for other locations, 40% when a skeletal lesion was associated versus 5.9% for those without such injuries, 37.5% for reverse saphenous vein interpositions versus 5.6% for arterial repair without interposition. CONCLUSIONS: In this study, the factors influencing limb loss in vascular trauma of the lower extremities are popliteal location, the association with skeletal injuries, the need of saphenous vein interposition for arterial repair.     

Subclavian and innominate artery trauma: a recent experience with nine patients

This report summarizes a recent 24-month experience with 9 patients who were treated for injuries to the innominate or subclavian arteries at a large urban hospital. All patients were male, age range was 17 to 47 years, and mean age was 29 years. The mechanism of injury included major arterial avulsions sustained during cancer operations at the base of the neck (2), blunt injuries secondary to motor vehicle accidents (2), stab wounds (1), and gunshot wounds (4). The vessels injured included the right subclavian artery (2), the innominate artery (1), and the left subclavian artery (6). Associated major venous injuries were seen in 4 cases (44%) and major non-vascular injuries in 5 cases (55%). Arterial exposure involved a variety of incisions, including left thoracotomy, median sternotomy, clavicular resection, or a combination of these. Arterial continuity was restored in all cases using primary repair (2), autogenous saphenous vein graft (6), or prosthetic graft (1). Venous injuries were treated by ligation (2) or lateral venorraphy (2). One patient died unexpectedly on the tenth postoperative day for an overall mortality of 11 percent. Three of the 8 survivors sustained nonfatal complications (38%). All 8 survivors had patent arterial repairs at the time of hospital discharge, and 5 of 8 survivors were available for follow-up with intravenous digital subtraction angiography (DSA), revealing arterial repair patency in all.(ABSTRACT TRUNCATED AT 250 WORDS)     

Civilian trauma in the 1980s. A 1-year experience with 456 vascular and cardiac injuries.

During 1982, 312 patients with 408 vascular injuries and 48 cardiac injuries were seen. Two or more vascular or cardiac injuries were present in 34% of patients. Over 87% of injuries were secondary to gunshot wounds, stab wounds, or shotgun wounds. Vascular injuries were most commonly seen in the extremities (39.9%) or abdomen (31.9%). The most common arterial injuries occurred in the brachial artery (39 patients), while the most common venous injuries occurred in the internal jugular vein (26 patients). Arterial injuries were treated by the insertion of substitute vascular conduits (33.9%), ligation (22.6%), lateral arteriorrhaphy (18.6%), or end-to-end anastomosis (15.4%). Venous injuries were treated by lateral venorrhaphy (63.7%) or ligation (25.1%). In the 272 patients admitted with only vascular injuries, survival was 84.2%. Cardiac injuries in 38 patients most commonly occurred in the right ventricle (50%) and right atrium (25%). In the 34 patients who had only cardiac injuries and less than 4 minutes of prehospital cardiopulmonary arrest prior to arrival in the emergency center, survival was 64.7%.