Long-term follow-up of prophylactic greenfield filters in multisystem trauma patients.

PURPOSE: The efficacy of prophylactic Greenfield filter (PGF) placement in multisystem trauma patients at high risk for venous thromboembolism has been established. The objective of this study is to demonstrate the long-term safety and durability of PGFs placed in young, active trauma patients. METHODS: Starting January 1992, all trauma patients at high risk for development of venous thromboembolism were identified for placement of PGFs. These included patients with ISS > 9 and severe closed head injury, spinal injury, pelvic fracture, multiple long bone fracture, or direct iliofemoral venous injury. Four patients with PGFs placed before the study protocol in 1992 were also included. Follow-up was attempted in all patients with at least 5 years' duration since placement of PGF using physical examination, duplex ultrasound (US), and plain abdominal radiograph. RESULTS: There were 108 patients who had a PGF placement during the period of January 1992 to June 1994 that were eligible for the study. Eighteen of these 108 (17%) patients died. Twelve of them (67%) had autopsies and medical records available to determine the cause of death, none from a pulmonary embolism. The average time of death was 2.7 months after injury. The remaining 90 patients and the 4 patients with PGFs placed before 1992 were sought for follow-up, but only 36 patients could be contacted, 33 of which returned for evaluation (35%). The mean time of follow-up from the time of injury to the time of examination was 67.7 months, and the mean age at follow-up was 38.1 years. Although six patients had mild to moderate lower extremity edema on physical examination, none of them had a deep venous thrombosis by US. Radiographs obtained in 19 of the 33 patients showed no migration or breakdown of the Greenfield filters in place. CONCLUSION: Prophylactic Greenfield filters in high-risk trauma patients are safe and durable. There appears to be no significant consequence in over 5 years of follow-up.

Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: results of 145 cases.

PURPOSE: Our preliminary experience with physical examination alone in the evaluation of penetrating zone 2 neck injuries for vascular trauma was previously reported in 28 patients over a 2-year period (1991-1993). The purpose of the current study was to examine the results of this approach in a much larger group of patients over an 8-year period. METHODS: The medical records for all patients admitted to our level I trauma center (all of them entered into our prospective protocol) between December 1991 and April 1999 with penetrating zone 2 neck trauma were reviewed for their initial presentation and any documented vascular injury. RESULTS: A total of 145 patients made up the study group; in 30 of these patients, the penetrating trajectory also traversed zone 1 or 3. Thirty-one patients (21%) had hard signs of vascular injury (active bleeding, expanding hematoma, bruit/thrill, pulse deficit, central neurologic deficit) and were taken immediately to the operating room; 28 (90%) of these 30 patients had either major arterial or venous injuries requiring operative repair (the false-positive rate for physical examination thus being 10%). Of the 114 patients with no hard signs, 23 underwent arteriography because of proximity of the injury to the vertebral arteries or because the trajectory included another zone. Of these 23 arteriograms, three showed abnormalities, but only one required operative repair. This case had no complications relating to the initial delay. The remaining 91 patients with no hard signs were observed without imaging or surgery for a minimum of 23 hours, and none had any evidence of vascular injury during hospitalization or during the initial 2-week follow-up period (1/114; false-negative rate for physical examination, 0.9%). CONCLUSIONS: This series confirms the earlier report indicating that patients with zone 2 penetrating neck wounds can be safely and accurately evaluated by physical examination alone to confirm or exclude vascular injury. The missed-injury rate is 0.7% (1/145) with this approach, which is comparable to arteriography in accuracy but less costly and noninvasive. Long-term follow-up is needed to confirm this management option.