Objective

The current Society for Vascular Surgery (SVS) classification scheme for blunt aortic injury (BAI) is descriptive but does not guide therapy. We propose a simplified classification scheme based on our robust experience with BAI that is descriptive and guides therapy.

Methods

Patients presenting with BAI between January 1999 and September 2014 were identified from our institution's trauma registry. We divided patients into eras by time. Era 1: before the first United States Food and Drug Administration (FDA)-approved thoracic endovascular aortic repair (TEVAR) device (1999-2005); era 2: FDA-approved TEVAR devices (2005-2010); and era 3: FDA-approved BAI-specific devices (2010-present). Baseline demographic information, Injury Severity Score, hospital details, and survival were collected and compared. Our classification scheme was minimal aortic injury, SVS grade 1 and 2; moderate aortic injury, SVS grade 3; and severe aortic injury, SVS grade 4.

Results

We identified 226 patients with a diagnosis of BAI: 75 patients in era 1, 84 in era 2, and 67 in era 3. Mean Injury Severity Score was 39.5 (range, 16-75). The BAI-related in-hospital mortality was significantly higher before endovascular introduction in era 1 (14.6% vs 4.8%; P = .03), but was not significantly different between eras 2 and 3 or before and after BAI-specific devices were introduced (P = .43). Of 146 patients (64.6%) who underwent aortic intervention, 91 underwent endovascular repair, and 55 underwent open repair. All but nine patients (94%) had a moderate or severe injury. Survival across all three eras of patients undergoing operative intervention was 80.2%. Survival in eras 2 and 3 was higher than in era 1 (86.4% vs 73.8%) but was not significant (P = .38). Of 47 patients in eras 2 and 3 with minimal aortic injury, 45 (96%) were managed nonoperatively, with no BAI-related deaths. After 2007, follow-up imaging was obtained in 38 patients (80%) with minimal aortic injury, and progression was not observed. Computed tomography scans showed the injury in 13 patients appeared stable, 19 had complete resolution (50%), and 6 had a decreasing size of injury.

Conclusions

Our experience confirms that BAI-related mortality for patients who survive to presentation is now 5%. From our findings during the past 15 years, we propose simplification of the SVS grading criteria of BAI into minimal, moderate, and severe based on treatment differences among the three groups. Minimal aortic injury can be successfully managed nonoperatively without mandatory follow-up imaging. Moderate aortic injury can be managed semielectively with TEVAR, and severe aortic injury, requires emergency TEVAR.

Objective

The primary objective was to evaluate the safety of transfer, type of procedure, and factors associated with limb salvage in patients with acute limb ischemia (ALI) treated at a quaternary referral center.

Methods

A retrospective review of all patients with ALI secondary to thrombotic or embolic occlusion at a quaternary referral hospital from 2013 to 2016 was conducted. Patients were transferred from throughout Washington and Alaska by ambulance, helicopter, or fixed-wing modes of transportation. Demographics, transport and operative timing, Rutherford classification, level of occlusion, procedural information, and fasciotomy characteristics were reviewed. Outcomes measured included limb salvage rates, discharge disposition, and mortality.

Results

One hundred twelve patients with ALI were identified, with 82% due to thrombosis and 18% due to arterial embolization. Fifty-seven percent of patients were transferred from a referring hospital with low mean transfer times (1.9 hours for embolic, 2.7 hours for thrombotic). Although the initial operative strategy varied according to the etiology, with 50% of thrombotic occlusions treated with endovascular therapies and 80% of embolic occlusions treated with open thrombectomy, the rates of limb salvage did not vary based on operative approach (92% endovascular first, 90% open first). Further, limb salvage rates were identical between transferred and nontransferred patients (77%). Limb salvage was successful in 91% of patients with Rutherford class 1 and 2 disease, but only 8% in patients with Rutherford class 3 disease. In-hospital and 30-day mortality rates were not different based on ischemic etiology (5%), although patients with Rutherford class 3 disease had significantly higher mortality rates (15%) compared with patients with class 1 (6%), class 2a (6%), and class 2b (2%) disease. Fasciotomy was performed in 29% of patients, with 59% of fasciotomy wounds closed primarily. Predictors of amputation include multiple attempts at limb salvage, higher Rutherford class, multilevel occlusion, more proximal levels of occlusion, and nonviable muscle seen after fasciotomy, with ischemic times trending toward higher amputation rates without statistical significance. There was no difference in discharge disposition based on ischemic etiology.

Conclusions

The modern treatment of patients with ALI is effective, with high rates of limb salvage and low mortality regardless of transfer status, etiology, or initial operation performed. In situations where compartment syndrome is unclear, fasciotomy should not be withheld because it provides valuable predictive information regarding limb salvage.

Background

Traumatic vascular injury leading to acute limb ischemia (ALI) is an uncommon problem with a potential for high morbidity. We describe a contemporary series of patients with traumatic ALI managed primarily by vascular surgeons at a tertiary referral center and review factors associated with limb salvage and functional limb outcomes.

Methods

We conducted a single institution, retrospective review of all patients requiring revascularization for upper extremity (UE) and lower extremity (LE) ALI secondary to trauma from 2013 to 2016. Demographic data, transfer timing, injury severity score (ISS), Rutherford classification (RC), preoperative imaging, level of occlusion, procedural information, fasciotomy characteristics, and discharge disposition were reviewed. Outcome measures included limb salvage and functional limb outcomes.

Results

We identified 68 patients with traumatic ALI requiring revascularization. The majority of patients had moderate ISS scores, were RC 2a or 2b on presentation (65%), were transferred from another institution (53%), and underwent preoperative imaging (62%) with expeditious time to operation (median 4.5 hr). The most common location of vascular injury for UE was axillary-brachial (88%) and for LE was femoral-popliteal (69%). Open vascular procedures dominated the treatment strategy, and the median number of operations was 3. Fasciotomy was performed in 25% of UE and 58% of LE injuries. Shunts were utilized in only 2 patients. Overall LS was 94% for UE and 78% for LE. The median length of stay (LOS) was 11 days, with 25% of patients discharged to a skilled nursing facility. Follow-up was obtained for 59% of patients. For UE injuries, 57% of patients had no or minimal functional deficits, while 33% had major functional deficits and 10% underwent amputation. For LE injuries, 68% of patients had no or minimal functional deficits, while 6% had major functional deficits, and 26% had undergone amputation. Rutherford class and the number of operations performed were independent predictors of amputation and functional limb at follow-up in our logistic regression model (P < 0.05).

Conclusions

Revascularization for traumatic ALI yields high limb salvage rates in patients with RC 1 and 2 ischemia and patients with UE injuries. However, limb salvage does not necessarily equate to good functional outcomes. This signifies the complex nature of injuries in this patient population, especially when multiple operations are required.