SLR - October 2018 - Christopher Van Damme
Long-Term, Patient-Centered Outcomes of Lower-Extremity Vascular Trauma
Reference: Perkins ZB, Yet B, Glasgow S, Marsh DWR, Tai NRM, Rasmussen TE. Long-Term, Patient-Centered Outcomes of Lower-Extremity Vascular Trauma. J Trauma Acute Care Surg. Jul;85(1S Suppl 2):S104-S111. doi: 10.1097/TA.0000000000001956.
Scientific Literature Review
Reviewed By: Christopher Van Damme, DPM
Residency Program: Maricopa Medical Center, Phoenix AZ
Podiatric Relevance: Lower-extremity vascular injuries are common in modern warfare leading to disability, amputation and often death. Similar injuries are becoming increasingly more common in civilian life with acts of terrorism and mass shootings. Little information regarding lower-extremity vascular trauma is available to guide physicians to realistic and expected results of salvage procedures, timing of decision making, surgical outcomes and quality of life. Notably, the tibial arteries are affected in 43.7 percent of U.S. military service members who sustain extremity vascular injury while serving in war. Injury to these vessels are associated with the highest rates of primary and delayed amputation of part or all of the lower extremity. Evaluation of the decision-making process will guide physicians who treat lower-extremity vascular injuries.
Methods: A level II cohort study of U.S. military service members who sustained lower-extremity vascular injury while serving in Iraq or Afghanistan from March 2003 to February 2012 was performed. A total of 554 soldiers (579 limbs) who suffered lower-extremity vascular injury were evaluated for 1) which arteries were affected 2) physician decision-making on limb salvage vs. amputation 3) timing of treatment decision 4) rationale of decisions 5) surgical outcome and 6) quality of life. Primary amputations included cases in which amputation occurred within 24 hours of injury; secondary amputation included cases in which the limb(s) was nonsalvageable greater than 24 hours. Quality of life was measured with the Short-Form Health Survey (version 2) at least 12 months from the date of injury. Outcome data, including the timing of, and rationale for amputation, were collected from operative records, clinic records and records of multidiscipline meetings.
Results: The most common mechanism of injury was explosion (68.2 percent). Of the 579 limbs, 530 (91.5 percent) underwent limb revascularization and salvage, 49 (8.5 percent) underwent primary amputation and 90 (17.0 percent) had secondary amputation. Tibial arteries were involved in 253 (43.7 percent) of all injuries with the highest association of primary and secondary amputations at 19 (38.8 percent) and 47 (52.2 percent), respectively. Overall, 139 (24.0 percent) limbs were amputated. Of the 90 secondary amputations, 60 (66.6 percent) were performed within 30 days. The leading reason for amputation was nonviable tissue (41.7 percent) with fracture, uncompensated shock, ischemia lasting longer than six hours, multiple arterial injury and arterial ligation also proving statistical significance (p < .01). There were no significant differences in reported physical or mental health scores between those who underwent limb reconstruction or those who underwent amputation.
Conclusions: Vascular trauma to tibial arteries greatly increases morbidity. More than one-third of primary and half of secondary amputations are associated with tibial arterial trauma. Other factors increasing amputation risk include poor soft-tissue coverage, fractures, ischemia greater than six hours, uncompensated shock, multiple arterial injuries and arterial ligations. Interestingly, there was no difference in physical or mental health in the amputation vs. nonamputation group. Podiatric physicians, especially those in the armed services, should use this information to establish realistic expectations when treating patients with lower-extremity vascular trauma. Further studies to include traumatic vascular injury to named arteries of the lower leg, ankle and foot are encouraged.