Prevalence and Outcome of Abdominal Vascular Injury in Severe Trauma Patients – An International Registry Analysis

BackgroundThis study details the etiology, frequency and effect of abdominal vascular injuries in patients after polytrauma.Patients and methodsAll patients of TraumaRegister DGU® with following criteria were included: online documentation of European trauma centers, age 16-85 years, presence of abdominal vascular injury, and AIS ≥ 3. Patients were divided in three groups of: arterial injury only, venous injury only, mixed arterial and venous injuries.ResultsA total of 2949 patients were included. All types of vessel injuries were more prevalent in patients with abdominal trauma followed by thoracic trauma. Rate of patients with shock upon admission were the same in patients with arterial injury alone (n= 606, 33%) and venous injury alone (n=95, 32%). Venous trauma showed higher odds ratio for in-hospital mortality (OR: 1.48; 95% CI 1.10-1.98, p=0.010).ConclusionAbdominal arterial injury and venous injury were equally responsible for the rate of hemodynamic instability at the time of admission. However, the proportion of adverse outcome during hospital stay was significantly higher in patients with venous injury. Stable patients suspected of abdominal vascular injuries should be further investigated to exclude or localize the possible retroperitoneal hematoma caused by subtle venous injury.

Factors Contributing to Morbidity after Combined Arterial and Venous Lower Extremity Trauma

The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.

Serious Lower Extremity Venous Injury Management with Ligation: Prospective Overview of 63 Patients

Management of lower extremity venous trauma using repair or ligation has been an area of controversy during the past decades. However, in unstable patients or if primary repair is technically impossible as a result of extensive disruption of the vein, ligation is recommended. This study investigated the effects of venous ligation on major veins in the lower extremities when primary repair is impossible as a result of extensive laceration of the vein. Between January 2001 and April 2004, 63 patients with Grade III and IV venous injuries were observed prospectively. Compression ultrasonography was performed postoperatively on the fifth day, once before discharge, and at the 3-month visit to assess deep vein thrombosis (DVT) and the patency of arterial repair. If DVT was present, the patient was given an oral anticoagulant (warfarin Na) for 3 months (international normalized ratio, 2.0–3.0), and Class II compression stockings (Sigvaris-212, Ganzoni, Switzerland) were used for 1 year. Follow-up visits occurred at 1, 3, 6, and 12 months and at 6-month intervals thereafter. Combined arterial and venous injuries were present in 50 (79.4%) patients and pure venous injuries were present in 13 (20.6%) patients. DVT developed in 49 patients (77.7%; postoperative n = 37 [58.7%], late n = 12 [19%]). Three arterial restenoses (4.7%) and one pseudoaneurysm (1.6%) of the superficial femoral artery developed. Five early (prophylactic) and two late (compartment syndrome) fasciotomies were performed. Postoperative edema was seen in 56 (88.8%) patients and wound infection was seen in 19 patients (30.1%; n = 18 superficial, n = 1 deep). Two amputations (3.2%) were performed. One patient (1.7%) died as a result of irreversible shock. After a median of 18 months, 25 patients were classified with Clinical Etiology, Anatomy, Pathology classification: 10 legs C-0, seven legs C-2, and eight legs C-3. No severe postthrombophlebitic syndrome was observed. Early leg swelling after venous ligation was the most common morbidity. We observed no significant sequelae of chronic venous insufficiency, and venous ligation had no detrimental effect on associated arterial repair. In cases of DVT, anticoagulation with low-molecular-weight heparin and oral anticoagulants should begin immediately and continue for 3 months along with compression stocking support for 1 year.