Management of traumatic upper limb arterial injuries: three years study

Upper limb vascular injury conditions requiring surgical intervention are multivarious and so are the surgical techniques employed. In the developing countries traumatic events predominate and the mechanism by which varies from society to another. Upper limb vascular injury must be approached promptly to avoid debilitating morbidity and mortality. is to assess the current management approach and to evaluate the outcome of patients with upper limb vascular trauma in Assiut University hospital. Forty two patients requiring operative intervention for upper limb vascular trauma from October 2009 - October 2012 were included. Patients were underwent full physical examination and resuscitation. The diagnosis of vascular injury is initially made by clinical examination as part of the full trauma assessment, plain x-ray, Doppler, Duplex and CT-angiography when indicated. Types of vascular repairs, orthopedic fixation, nerve repair, fasciotomy procedure and state of limb function after management were recorded. Forty two patients [37 males and 5 females] with mean age of 27H2.6 years [range 1.5 -70 ys] were included. The right upper limb was affected in 22 patients and the left was affected in 20 patients. Brachial artery was the most frequently affected 57.1%, followed by the axillary artery 31%, subclavian artery 9.5% and the ulnar artery 2.4%. The patients were presented 1-10 hours after injury [mean 6 +/- 2.1 hrs] with bleeding in 42.9%, ischemia 30.9%, ischemia 4 bleeding 9.5%, ischemia + hematoma 7.2% and expansile hematoma 9.5%. Penetrating trauma was in 90.4% and blunt trauma was in 9.6%. Injury by fire arm was in 40.4%, sharp objects 26%, motor car and train accidents 21%, iatrogenic 2.1% and fall from height 9.5%. Concomitant vein and/or nerve injuries were in 73%. Isolated nerve injury [brachial plexus or median nerve] was in 9.5%, isolated vein injury in 7.2% and both were injured in 57%. Orthopedic injuries occurred in 33% [open fracture 19%, closed fracture 12% and dislocation 2.4%]. Orthopaedic repair was done firstly before vascular repair except in delayed cases. Arterial repair in the form of end to end anastmosis in 42.8%, interposition vein graft 33.4%, simple repair 12%, ligation 4.7%, or thromboembolectomy in 4.7% were done. Heparin was applied both intralesional and systemic. Prophylactic fasciotomy with other vascular repair was also done in 30%. Primary nerve repair in non thermal [firearm] injuries was obtained while delayed repair was decided in thermal injuries. Small veins are ligated and large veins are managed by simple repair. The success rate of vascular repair was 39/42 [92.8%] assessed by the return of distal pulses at the end of the operation and limb salvage in follow up period. Three patients [7.2%], one of them [2.4%] died because of major head injury and above elbow amputation was done for the other two [4.8%]. All surviving patients were followed for one year for hand function and distal pulse. Clinical examination of the injured upper limb is a reliable diagnostic approach for evaluation of the vascular injury. Factors could help promoting good prognosis are; not wasting time with preoperative diagnostic tests, early intervention within 10 hours after trauma, performing orthopaedic repair firstly before vascular repair except in delayed cases, assessment and management of nerve injuries, use of intralesional and systemic anticoagulants, and prophylactic fasciotomy performance

Efficacy of preoperative duplex scanning in planning for infrainguinal revascularization procedures

To evaluate safety and efficacy of preoperative duplex scanning in planning for infrainguinal revascularization procedures. Thirty patients [mean age 70 years] underwent elective DSA of lower extremity arteries at the Vascular and Endovascular Surgery unit of Perugia, Italy and were included in the study. Duplex evaluation of arterial lesions was performed for the site and degree of severity. Results were compared with DSA serving as the standard reference. Our study showed that duplex was able to determine significant lesions [either critical stenosis or occluded segments] in the femoral region with an overall sensitivity and specificity of 96.5% and 93.3% respectively and 77.7% and 99.1% as the positive predictive and negative predictive values respectively. At the popliteal region, we estimated the sensitivity and specificity as 84% and 89.2% respectively and 75% and 93.5% as the positive and negative predictive values. The overall accuracy measurements of duplex scanning at the region of leg vessels were 82.9%, and 89.4% for combined anterior and posterior tibial arteries. It seems feasible to perform infrainguinal arterial reconstructions, without preoperative angiography. Technical limitations of duplex scanning leading to inaccurate assessment of the inflow and outflow arteries, or non-visualized distal runoff arteries, should prompt angiographic evaluation