Upper extremity trauma: current trends in management.

Upper extremity trauma can be penetrating or blunt in etiology. The close proximity of vein, artery and nerve makes for a complicated presentation and potentially complicated reconstruction. Orthopedic and neurologic injuries can cause the more long term disability of these patients, but vascular injuries are initially more life threatening. Control of vascular injuries can be particularly difficult due to anatomic issues in the upper extremities. The intervention carried significant morbidity until evolution to endovascular approaches occurred. By reconstructing the injury from a more ''remote'' access site, less concomitant injury to the extremity can be encountered. However, although control of vascular injuries may result in greater survival rates with less morbidity from the procedure, long term outcome remains dependent upon concomitant injuries. This review will encompass both vascular and neurologic injuries secondary to trauma to the upper extremity and outline some of the trends in management.

Management of true aneurysms distal to the axillary artery.

OBJECTIVE: To delineate management strategies and outcomes for true aneurysms involving arteries of the upper extremity distal to the axillary artery. The management of these rare lesions has not been well established in the literature. METHODS: Retrospective chart review was performed at tertiary referral centers. All patients who received the diagnosis of true upper extremity aneurysms distal to the axillary artery between 1975 and 1995 were included in the review. Nineteen patients were found; seven were excluded because no confirmatory diagnostic imaging study or operative exploration was performed. This represents the largest reported series of true upper extremity arterial aneurysms. RESULTS: Twelve patients (9 men or boys) had 12 confirmed true aneurysms of the brachial or more distal arteries. The average diameters were as follows: brachial artery 4.6 cm, radial artery 2.0 cm, ulnar artery 1.4 cm, and digital artery 0.8 cm. The mean age was 51 years (range, 10 to 86 years). The most common presentation was the presence of a mass. This occurred among eight patients (67%). Four patients (33%) reported pain or paresthesia. One patient (8%) had cold intolerance only. Three patients (25%) had thromboembolic complications. Complications did not consistently correlate with size or presence of intramural thrombus. Three aneurysms (25%) were initially managed nonoperatively and followed for a mean period of 71 months. One of these required operative repair after 5 months because of progressive pain. Ten patients (83%) were treated surgically as follows: five underwent ligation and excision only, and five underwent excision and revascularization. Morbidity was minimal, and there were no perioperative deaths. CONCLUSION: True arterial aneurysms of the upper extremity distal to the axillary artery are rare and most commonly caused by blunt trauma. Fifty-eight percent of these lesions present with symptoms or complications. Thirty-three percent of asymptomatic lesions later become symptomatic. These factors combined with the minimal morbidity associated with repair suggest that operative repair should be routinely performed for these aneurysms. Revascularization can be performed selectively.

Inappropriate use of venous duplex scans: an analysis of indications and results.

PURPOSE: The increasing demand for venous duplex scans despite the relative rarity of detecting acute deep venous thrombosis (DVT) prompted us to review our experience with this diagnostic method. METHODS: We retrospectively analyzed the results and indications of 2993 lower extremity venous duplex scans performed between July 1, 1992, and June 30, 1994, at our institution. The indication for the study and the results were prospectively recorded in a computerized data bank. The indications for these studies were leg pain (34%), leg swelling (24%), surveillance for DVT in a patient at high risk (23%), searching for a source of pulmonary embolism (14%), follow-up of previously diagnosed DVT (3%), and other indications (i.e., varicose veins, venous ulcer, 2%). RESULTS: Overall, 74.1% of all scans were completely normal, and only 13.1% detected acute proximal (popliteal vein or higher) DVT. Scans performed for surveillance (87.3% normal) or source of pulmonary embolism (79.6% normal) were significantly more likely to be normal than when performed for any other indication (p < 0.01). When leg edema or calf tenderness was present, the incidence of acute DVT was significantly greater for all indications (p < 0.0001). CONCLUSIONS: The high percentage of normal venous scans implies that this diagnostic method is being inappropriately used. In the current climate of cost containment our data suggest that indications for venous duplex scans must be better defined and that improved education for referring physicians is needed.

Contralateral duplex scanning for deep venous thrombosis is unnecessary in patients with symptoms.

PURPOSE: Bilateral lower extremity venous duplex scanning for acute deep venous thrombosis (DVT) has been advocated because of the high incidence of occult contralateral leg involvement. We investigated the clinical necessity of such a policy. METHODS: The results from 2996 venous duplex studies performed during the past 2 years were retrospectively reviewed. A total of 1694 of these scans were performed on patients with symptoms, of whom 248 (15%) were found to have an acute DVT. Symptoms were limited to one side in 198 patients, whereas bilateral complaints were noted in 50 patients. RESULTS: Among the patients with symptoms of acute DVT, 72 (29%) had bilateral involvement. Bilaterality was more likely in patients with bilateral symptoms than in those with only unilateral symptoms (56% vs 22%; p < 0.005). Of the patients with unilateral symptoms and bilateral DVT, all of them had either acute (80%) or acute and chronic (20%) thrombosis in the symptomatic leg. The contralateral asymptomatic limb had fewer acute and more chronic DVT (41% and 55%, respectively). No patient from the entire group admitted with symptoms had an acute DVT in the asymptomatic limb without a concomitant acute DVT in the symptomatic leg. Unilateral scanning would decrease the examination time by 21% and potentially increase total reimbursement for symptomatic venous scans by 9% compared with routine bilateral duplex scanning. CONCLUSIONS: Although bilateral involvement is frequent in patients with symptoms of acute DVT, treatment in these patients is not altered by this finding. We conclude that contralateral venous scanning in patients with unilateral symptoms is not clinically indicated and that unilateral scanning would result in improved cost-efficiency for vascular laboratories.

Surveillance venous scans for deep venous thrombosis in multiple trauma patients.

The high reported incidence of deep venous thrombosis (DVT) in trauma patients has prompted surveillance venous duplex scanning of the lower extremities. We report our retrospective experience with 183 multiple trauma patients who were admitted to the surgical intensive care unit and underwent 261 surveillance venous scans. There were 122 men and 61 women whose average age was 38 years. All patients were treated prophylactically with either extremity pneumatic compression or subcutaneous heparin to prevent DVT. Most (87%) patients suffered blunt trauma and had either head (3%), spinal (3%), intra-abdominal (9%), or lower extremity (17%) injuries or a combination of injuries (68%). Almost two thirds of the patients had no symptoms suggestive of possible DVT. Of the 261 venous scans performed, 239 (92%) were normal, 16 (6%) were positive for proximal lower extremity DVT, and six (2%) showed thrombus limited to the calf veins. Patients with symptoms of lower extremity DVT were significantly more likely to have proximal DVT compared to those without symptoms (15% vs. 5%, p < 0.05). Patients with spinal injuries also had a higher incidence of proximal DVT (18% vs. 6%, p < 0.05). At current hospital charges, the cost to identify each proximal DVT was $6688. If surveillance duplex scans were performed on all trauma patients in the surgical intensive care unit, the national annual expense would be $300,000,000. Routine DVT surveillance is expensive and should be reserved for symptomatic patients or those with spinal injuries.

Preoperative duplex venous mapping: a comparison of positional techniques in patients with and without atherosclerosis.

PURPOSE: Preoperative duplex venous mapping is the preferred modality to measure the diameter of the greater saphenous vein and its suitability as an arterial conduit for infrainguinal bypass. We wanted to determine the optimal mapping technique and maximal venous diameter in patients with and without atherosclerosis. METHODS: Three groups of patients were prospectively studied: younger control subjects (n = 20), preoperative atherosclerotic patients (n = 10), and older control subjects (n = 10). All patients underwent greater saphenous vein duplex mapping in a standardized manner. Maximal internal vein diameters were measured with the subjects in the supine position in bed, in the 20 degree reversed Trendelenburg position, sitting on the edge of the bed, standing, and in the supine position with a high-thigh, low-pressure tourniquet. Measurements were taken just beyond the saphenofemoral junction, in the distal thigh, below the knee, at midcalf, and superior to the medial malleolus. RESULTS: In younger control subjects an increasingly more erect position resulted in progressively larger measured vein diameters at all levels along the length of the leg. Both patients with atherosclerosis and older control subjects had no such increase in venous diameter with any positional change from the supine position to standing. Patients with atherosclerosis also had significantly smaller measured veins than either younger or older control subjects. A high-thigh tourniquet significantly increased vein diameters in the atherosclerotic group to the size of vein diameters in the older control group, although the absolute size differences were not large. CONCLUSIONS: The optimal position for venous mapping is with the patient in a supine position. If the internal vein diameter is below an acceptable minimum size, a high-thigh tourniquet will maximally distend the vein in patients with atherosclerosis. Vein diameter decreases with age and is less distended in patients with atherosclerosis compared with older patients without atherosclerosis.

Spontaneous thrombolysis of native artery occlusions.

Acute arterial ischemia of the lower extremities is a major cause of mortality and limb loss in patients with peripheral vascular disease. Patients with acute limb ischemia secondary to embolus or in situ thrombosis usually require emergency revascularization, either surgically or with the use of thrombolytic agents. It is commonly assumed that heparin therapy alone, without disobliterative intervention, can produce clinical improvement through continued patency and enlargement of the collateral circulation. The occurrence of spontaneous thrombolysis of major limb vessels is not generally accepted. We describe three patients, all with confirmed occlusion of either the iliac or superficial femoral arteries, who had spontaneous thrombolysis of occluded vessels. These experiences document that spontaneous resolution of arterial occlusion does occur, although it may be infrequent.

Prevalence of unsuspected abdominal aortic aneurysms in male veterans.

Abdominal aortic aneurysms (AAA) are potentially lethal arterial lesions that are best managed by elective surgical repair. However, asymptomatic AAAs may go undetected on routine physical examination or patients with such lesions may not consult a physician. To determine the prevalence of asymptomatic AAAs in a high-risk population, we retrospectively reviewed all abdominal CT scans on veterans > 50 years of age that had been ordered for indications other than aneurysmal disease during a recent 10-month period. Of the 111 patients studied, 15 (13.5%) had suprarenal and/or infrarenal AAAs (one patient had both). Patients with AAAs were significantly older (p = 0.0001) and were heavier tobacco users (p = 0.003). For patients > 60 years of age with peripheral vascular occlusive disease and a history of tobacco use, there was a 29.2% prevalence for AAA compared with 0% in those without any of these risk factors (p = 0.04). There was a very definite trend suggesting that patients with peripheral vascular disease (p = 0.06) were more likely to have an AAA. Because of the high prevalence of AAAs found in this population we then conducted a prospective study over a 24-month period during which patients > 60 years of age with known peripheral vascular disease and a history of smoking who presented to the vascular laboratory for evaluation of problems not related to AAA were asked to undergo an abdominal CT scan. Fifty-six volunteers agreed to participate in the study. Seven patients had AAAs and one patient had an isolated iliac aneurysm, for a 14.3% overall prevalence of aneurysms.2+ d

Neurovascular lower extremity complications of the lithotomy position.

The lithotomy position is commonly used during the performance of a variety of abdominal and pelvic operations. Previous publications reporting complications with these operations have been largely anecdotal. We report our experience with eight patients over the past four years who have suffered serious lower extremity complications following operations in which the lithotomy position was used. The average time in the lithotomy position for our patients was 7.4 hours (range: 3.7-12 hours). The mean interval between the original operation and the secondary operation to treat the lower extremity complication was 18.9 hours (range: 2-51 hours). The average hospital length of stay for these patients, 38.4 days (range: 11-119 days), was often prolonged as a direct result of their limb complication. Serious lower extremity complications may result from operations in which the lithotomy position is used. To prevent such complications, strict attention should be paid to the positioning of the limbs in the operating room and the time in the lithotomy position should be minimized. Perioperative monitoring of the lower extremity circulation and compartment pressures are essential in these patients since early detection and treatment of these complications is the only way to prevent permanent limb injury.

Mycotic aneurysm of the tibioperoneal trunk: case report and review of the literature.

Peripheral mycotic aneurysms can occur when septic emboli lodge in either the lumen or the vasa vasorum of a peripheral vessel. Such aneurysms have become rare after the widespread use of aggressive antibiotic treatment for bacterial endocarditis. We report the case of a large mycotic aneurysm of the tibioperoneal trunk 18 months after an episode of Streptococcus viridans bacterial endocarditis. Treatment included complete resection of the aneurysmal sac with restoration of circulation to the posterior tibial artery with a reversed saphenous vein graft. To our knowledge, this is the first case of a mycotic aneurysm of the tibioperoneal trunk reported in the English literature. It also represents the first case in which a mycotic aneurysm of an infrapopliteal vessel was managed successfully with restoration of circulation.

Natural history of claudicants with critical hemodynamic indices.

We reviewed the records of approximately 1,500 patients seen in the Vascular Laboratory of the Cincinnati Veterans Affairs Medical Center from 1980 to 1987 and identified 23 patients (25 limbs) who met all of the following criteria: 1) an ankle/brachial index less than or equal to 0.35; 2) an ankle or transmetatarsal pulse volume recording less than or equal to 3 mm in amplitude; and 3) no history of ischemic rest pain or gangrene. These patients were followed in the Vascular Laboratory for periods ranging from 11 to 127 months (mean 45.2 months). The study was terminated in March 1991 or when revascularization or amputation was required for limb-threatening symptoms or if the patient expired. Thirteen extremities (52%) showed no progression to limb-threatening symptoms. Claudication actually improved in three, remained unchanged in eight, and progressed in two. Twelve (48%) extremities developed limb-threatening conditions, with rest pain occurring in three, ischemic ulceration in six and gangrene in three. Eight of these limbs underwent revascularization and only one ultimately required major amputation. Another extremity presented with extensive gangrene and underwent a primary above-knee amputation. Three other patients did not undergo revascularization because of death in one and refusal in two others. Patients with intermittent claudication who have critical hemodynamic indices are at much greater risk for developing symptomatic limb-threatening ischemia. Close follow-up is mandatory since nearly half of these patients will eventually require operation for limb salvage. Patients who are unlikely to comply with a regular follow-up program may be considered for early revascularization to prevent complications of limb-threatening ischemia.

Entrapment of the popliteal artery.

Although entrapment of the popliteal artery is uncommon, it is an important cause of arterial insufficiency in younger patients. Accurate diagnosis depends on a high index of suspicion combined with dynamic noninvasive testing and "stress angiography." Although angiographic demonstration of medial deviation of the artery is diagnostic, absence of this finding does not exclude the diagnosis of entrapment of the popliteal artery. Positional angiography may be necessary in these instances. Surgical exploration should be performed by a posterior approach, since this facilitates identification of the precise anatomic variant while allowing easy arterial repair, if necessary. The condition of the popliteal popliteal artery must dictate the extent of the surgical procedure. If the popliteal artery is normal, then relief of the constricting lesion alone will suffice. If the artery appears diseased or is thrombosed, then myotomy and arterial reconstruction must be performed. This is best accomplished by bypass grafting using autogenous vein or artery. If thromboendarterectomy is used, the clinician can expect a higher percentage of acute postoperative thromboses.

Complications of anomalous origin of the right subclavian artery: case report and review of the literature.

A 35-year-old black woman presented with thrombosis of an anomalous right subclavian artery and distal arterial embolization. Initially, her right subclavian artery was reimplanted onto the common carotid artery, and a brachial artery embolectomy plus intraoperative thrombolytic therapy were used to reopen her distal arterial circulation. When her brachial artery repair thrombosed the following day, a distal ulnar artery bypass and repeat thrombolytic therapy were required to restore arterial patency. Six months later, she returned with severe, progressive, neointimal hyperplasia of her brachial artery and a second attempt at arterial reconstruction was unsuccessful. She eventually required a right below-elbow amputation. This patient demonstrated an anomalous right subclavian artery that presented with distal embolization without an antecedent history of severe atherosclerotic disease or the development of a right subclavian artery aneurysm. A review of the medical literature relating to complications of this anomaly is provided.

Temporary closure of the abdominal wall by use of silicone rubber sheets after operative repair of ruptured abdominal aortic aneurysms.

Management of patients after operative repair of abdominal aortic aneurysms can be further complicated if primary closure of the abdominal wall cannot be technically accomplished or is associated with profound increases in intraabdominal and peak inspiratory pressures. We recently treated five patients with ruptured abdominal aortic aneurysms and one patient with a ruptured thoracoabdominal aneurysm whose abdominal incisions had to be closed with a Dacron reinforced, silicone sheet. All patients were hemodynamically unstable either at admission to the hospital or became so during operation. Four patients required the insertion of a silicone rubber sheet at the primary operation because of massive retroperitoneal hematoma or edema of the bowel wall or both. Incisions in two patients were closed primarily, but the patients required reexploration and secondary closure with silicone rubber sheets because of the development of marked increases in peak inspiratory pressures, intraabdominal pressures, and decreased urinary output. Four of the six patients subsequently underwent successful removal of the silicone rubber sheets with delayed primary closure of the abdominal wall, and two others died before removal. The patient with the ruptured thoracoabdominal aneurysm died on postoperative day 20 because of pulmonary sepsis but had a healed abdominal incision. The three surviving patients have been discharged. A silicone rubber sheet may be necessary for closure of the abdominal wall after repair of ruptured abdominal aortic aneurysm in patients where primary abdominal wall closure is impossible or where it results in compromise in respiratory or renal function.

Prevalence of hemodynamically significant stenosis of the carotid artery in an asymptomatic veteran population.

The results of previous studies have suggested that significant stenosis of the carotid artery occurs in less than 6 per cent of asymptomatic patients. However, some populations studied were not representative of those seen by most vascular surgeons. Accordingly, we examined two cohorts of patients at the Veterans Administration Medical Center using Duplex scanning. There were 153 volunteers in group 1, all more than 50 years of age, who were being treated at our outpatient department for nonvascular problems. There were 116 patients of similar age in group 2 but who were known to have significant arterial occlusive disease of the lower extremity. The majority of patients were men with a mean age of 64.4 years. Risk factors in the total population included hypertension, diabetes mellitus, coronary arterial disease, peripheral vascular disease and smoking. Over-all, significant (greater than 50 per cent diameter) stenosis of the carotid artery was discovered in 25 of 269 patients. The prevalence for those in group 1 was 6.5 per cent versus 12.9 per cent for those in group 2 (p = 0.058). The prevalence in patients with cardiac disease was 15.2 per cent compared with 6.8 per cent in those without cardiac disease (p = 0.032). Smoking was associated with a 10.6 per cent rate of significant disease compared with a 2.3 per cent rate in nonsmokers (p = 0.065). Hypertension and diabetes were not significant risk factors. Significant stenosis of the carotid artery was found in seven of 40 patients in whom coronary arterial disease, peripheral vascular disease and smoking were all present.(ABSTRACT TRUNCATED AT 250 WORDS)

Femur fracture with limb shortening causing occlusion of a polytetrafluoroethylene femoral popliteal graft.

Traumatic occlusion of lower extremity polytetrafluoroethylene arterial grafts is exceedingly rare. We report a patient who suffered a supracondylar femur fracture resulting in shortening of her right lower extremity with kinking and thrombosis of her above-knee polytetrafluoroethylene arterial graft. This is the first report in the English language of prosthetic graft occlusion as a result of traumatic limb shortening. The graft thrombus was successfully lysed by use of intraarterial urokinase, and the kink was repaired by graft resection and reanastomosis. The mechanism of injury and treatment are discussed.

Repositioning of partially dislodged Greenfield filters from the right atrium by use of a tip deflection wire.

Dislodgement of a Greenfield filter in the right atrium is one of the most serious complications of this procedure. Retrieval of such a misplaced filter may require surgical intervention by means of cardiopulmonary bypass surgery, which is very hazardous in these often severely ill patients. We describe two cases in which the filter became partially dislodged from its carrier in the right atrium. We were able to successfully reposition the filter by using a tip deflection wire, thereby obviating the need for an open cardiac procedure.

Preferential use of EPTFE for above-knee femoropopliteal bypass grafts.

We have used polytetrafluoroethylene preferentially for bypasses to the above-knee popliteal artery since 1979. Since this approach has recently been challenged, we reviewed our experience with 138 grafts in 128 patients. The majority (74%) of patients were male with a mean age of 63.2 years. Risk factors included: smoking (85%), hypertension (55%), diabetes mellitus (45%), and coronary artery disease (41%). The indications for operation were disabling claudication (18%), rest pain (42%), gangrene/tissue loss (33%), and miscellaneous (7%). Perioperative (30 day) mortality was 3% and morbidity (excluding amputation or graft failure) was 5%. Patients were followed for up to eight years with a mean follow-up of 22.1 months. Grafts which remained patent, but did not prevent major amputation, were classified as "failed". Primary patency was 75% at one year and 54% at five years. Limb salvage was 88% at one year and 70% at five years. Risk factors, indication for operation and arteriographic runoff had no statistically significant impact on short- or long-term patency. However, bypass grafts to isolated popliteal segments had a significantly (p = 0.025) increased perioperative failure rate compared to all other grafts. Our data support the continued use of polytetrafluoroethylene for above-knee femoropopliteal bypass except perhaps in patients who require grafting to an isolated popliteal segment where higher early failure rates were seen.