Optimizing Limb Salvage In Shotgun Injuries To The Extremities In Civilian Trauma
Joel B. Durinka, M.D.1, Brandon Kuehlewind, MD2, James K. Lukan1.
1University of Buffalo, Buffalo, NY, USA, 2Brandon Kuehlewind, Buffalo, NY, USA.
OBJECTIVES:Vascular trauma in civilian settings has often resulted in high rates of amputation or mortality. Although treatment was individualized, patients were managed according to the following protocol: Clinical evaluation and identification of patients that require immediate exploration. Determination of ankle-ankle indices, with a threshold of 0.9 mandating further evaluation. Liberal use of computed tomography angiography (CTA) evaluation of injuries. Selected use of digital subtraction angiography with an attempt to treat via endovascular means if there is thought to be a reasonable likelihood of success. Liberal use of fasciotomy. Reconstruction of arterial injury with contralateral reversed saphenous when available. Postoperative follow-up with non-invasive arterial studies. Hypothesis: Protocol driven early assessment and intervention can lead to excellent limb salvage in patients with civilian GSW to the extremities. Methods:We retrospectively reviewed our database from 2012 to 2017, for patients with non-iatrogenic penetrating vascular extremity injuries. Data was analyzed demographics, mode of injury, vessels injured, physical examination, arteriography findings, ischemic time, type of arterial and venous repair, morbidity, mortality, graft patency and functional outcome. Post-operative Follow-up was done with noninvasive arterial studies. Results: Sixteen patients sustained extremity injuries inflicted by shotguns. 15 (94%) underwent preoperative arteriography or CT angiography, revealing occult arterial injury in 9 patients. One patient had soft tissue only and the other 5 who underwent CTA had no evidence of vascular injury. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. (how were they repaired) .Eighty one percent underwent fasciotomy at time of surgery.Fasciotomy occurred in 100% of patients with combined arterial and venous injuries (100%) vs 25% with isolated arterial injury. Arterial continuity was restored by interposition grafting with reversed saphenous vein (100%). There were no deaths or amputations at in office follow up which ranged from 6 months to 7 years. Two patients had saphenous nerve injures one of which fully recovered and the other patient ambulated with a cane due to nerve injury.Conclusion:A protocol of preoperative imaging with either arteriography or CTA for extremity shotgun injuries, use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates of 100% after shotgun vascular trauma to the extremities.
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