eMedicine Specialties > Vascular Surgery > Medical Topics

Extremity Vascular Trauma: Follow-up

Author: H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
Coauthor(s): David FE Stuhlmiller, MD, FACEP, EMS Medical Director, Emergency Medical Associates of Westchester Medical Center; Medical Director, LifeNet of New York, An Air Methods Company; Medical Advisor, International Association of Flight Paramedics
Contributor Information and Disclosures

Updated: Jun 18, 2009

Outcome and Prognosis

In 1986, Floyd and Kerstein34 documented 10 patients with successful vascular reconstructions; however, in every case, the patients' outcome included a permanent disability that was moderately severe to severe. In most cases, the disability was due to concurrent partial or complete nerve injury. In addition, while no early amputations were necessary, there was a 40% amputation rate.

In 1994, Humphrey et al14 noted a reduction in the amputation rate from 18% to 7%, with a stable 4.8% patient mortality rate with institution of a helicopter transport system in rural Missouri.

In 1996, Magee et al13 reported a 6% amputation rate and a 19% complication rate at 6-month follow-up in the United Kingdom. However, no information was noted regarding disability.

In 1999, Razmadze11 reported a 16% early and late amputation rate, with a 7.6% patient mortality rate in the former Soviet republic of Georgia.

These data clearly show that extremity vascular injury, especially those with concomitant nerve, bone, and significant soft tissue injury, can be disastrous to patients. Early and aggressive vascular repair improves patient outcome but cannot reverse the effects of some injuries. Amputation and disability rates remain high, even with optimal transport, trauma care, and successful operative intervention.

Future and Controversies

Improved Emergency Medical Services (EMS) systems, faster transport times, availability of interventional radiological techniques, improved surgical technique, and new vascular conduits may further reduce the morbidity and mortality of extremity vascular injury. The future of limiting the morbidity and mortality of these injuries probably lies with advancements in other areas, eg, motor vehicle safety, worldwide control and cleanup of antipersonnel mines, and injury prevention programs.

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Edward J Jakubs, MD, to the development and writing of this article.



More on Extremity Vascular Trauma

Overview: Extremity Vascular Trauma
Workup: Extremity Vascular Trauma
Treatment: Extremity Vascular Trauma
Follow-up: Extremity Vascular Trauma
Multimedia: Extremity Vascular Trauma
References
Further Reading
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References

  1. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War II: An analysis of 2,471 cases. Ann Surg. 1946;123:534.

  2. Rich NM, Baugh JH, Hughes CW. Acute arterial injuries in Vietnam: 1,000 cases. J Trauma. May 1970;10(5):359-69. [Medline].

  3. Rich NM, Leppaniemi A. Vascular trauma: a 40-year experience with extremity vascular emphasis. Scand J Surg. 2002;91(1):109-26.

  4. Venermo M, Kantonen I, Suominen V, Salenius J, Roth WD, Lepäntalo M. [Emergency problems in vascular surgery]. Duodecim. 2009;125(4):439-47. [Medline].

  5. Husum H, Ang SC, Fosse E. War Surgery Field Manual. Penang, Malaysia:. Third World Network;1995.

  6. Mattox KL, Feliciano DV, Burch J, et al. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Ann Surg. Jun 1989;209(6):698-705; discussion 706-7. [Medline].

  7. Feliciano DV, Herskowitz K, O'Gorman RB, Cruse PA, Brandt ML, Burch JM, et al. Management of vascular injuries in the lower extremities. J Trauma. Mar 1988;28(3):319-28. [Medline].

  8. Sherif AA. Vascular injuries: experience during the Afghanistan War. Int Surg. Apr-Jun 1992;77(2):114-7. [Medline].

  9. Fasol R, Irvine S, Zilla P. Vascular injuries caused by anti-personnel mines. J Cardiovasc Surg (Torino). May-Jun 1989;30(3):467-72. [Medline].

  10. Tobin SA, Gurry JF, Doyle JC, et al. Vascular trauma at a university teaching hospital. Aust N Z J Surg. Nov 1988;58(11):873-7. [Medline].

  11. Razmadze A. Vascular injuries of the limbs: a fifteen-year Georgian experience. Eur J Vasc Endovasc Surg. Sep 1999;18(3):235-9. [Medline].

  12. Kjellstrom T, Risberg B. Vascular trauma. Review of 10 years' experience. Acta Chir Scand. 1980;146(4):261-5. [Medline].

  13. Magee TR, Collin J, Hands LJ, et al. A ten year audit of surgery for vascular trauma in a British teaching hospital. Eur J Vasc Endovasc Surg. Nov 1996;12(4):424-7. [Medline].

  14. Humphrey PW, Nichols WK, Silver D. Rural vascular trauma: a twenty-year review. Ann Vasc Surg. Mar 1994;8(2):179-85. [Medline].

  15. Caps MT. The epidemiology of vascular trauma. Semin Vasc Surg. Dec 1998;11(4):227-31. [Medline].

  16. Dougherty PJ, Najibi S, Silverton C, Vaidya R. Gunshot wounds: epidemiology, wound ballistics, and soft-tissue treatment. Instr Course Lect. 2009;58:131-9. [Medline].

  17. Johansen K, Lynch K, Paun M, Copass M. Non-invasive vascular tests reliably exclude occult arterial trauma in injured extremities. J Trauma. Apr 1991;31(4):515-9; discussion 519-22. [Medline].

  18. Lynch K, Johansen K. Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma?. Ann Surg. Dec 1991;214(6):737-41. [Medline].

  19. Nassoura ZE, Ivatury RR, Simon RJ, et al. A reassessment of Doppler pressure indices in the detection of arterial lesions in proximity penetrating injuries of extremities: a prospective study. Am J Emerg Med. Mar 1996;14(2):151-6. [Medline].

  20. Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling VII: cervical vascular, peripheral vascular, adrenal, penis, testis, and scrotum. J Trauma. Sep 1996;41(3):523-4. [Medline].

  21. [Best Evidence] Prichayudh S, Verananvattna A, Sriussadaporn S, Sriussadaporn S, Kritayakirana K, Pak-art R, et al. Management of upper extremity vascular injury: outcome related to the mangled extremity severity score. World J Surg. Apr 2009;33(4):857-63. [Medline].

  22. Bush RL, Fairman RM, Flaherty SF, Gillespie DL. The role of SVS volunteer vascular surgeons in the care of combat casualties: results from Landstuhl, Germany. J Vasc Surg. Jan 2009;49(1):226-9. [Medline].

  23. Shah DM, Leather RP, Corson JD, Karmody AM. Polytetrafluoroethylene grafts in the rapid reconstruction of acute contaminated peripheral vascular injuries. Am J Surg. Aug 1984;148(2):229-33. [Medline].

  24. Stevens WS, Kron IL. Vascular trauma of the extremities: factors causing failure of arterial repair. South Med J. Mar 1987;80(3):305-8.

  25. Nypaver TJ, Schuler JJ, McDonnell P, et al. Long-term results of venous reconstruction after vascular trauma in civilian practice. J Vasc Surg. Nov 1992;16(5):762-8.

  26. Gonzalez RP, Scott W, Wright A, Phelan HA, Rodning CB. Anatomic location of penetrating lower-extremity trauma predicts compartment syndrome development. Am J Surg. Mar 2009;197(3):371-5. [Medline].

  27. Vertrees A, Fox CJ, Quan RW, Cox MW, Adams ED, Gillespie DL. The use of prosthetic grafts in complex military vascular trauma: a limb salvage strategy for patients with severely limited autologous conduit. J Trauma. Apr 2009;66(4):980-3. [Medline].

  28. Prichayudh S, Verananvattna A, Sriussadaporn S, Sriussadaporn S, Kritayakirana K, Pak-Art R, et al. Management of upper extremity vascular injury: outcome related to the mangled extremity severity score. World J Surg. Apr 2009;33(4):857-63. [Medline].

  29. Durham RM, Mistry BM, Mazuski JE, et al. Outcome and utility of scoring systems in the management of the mangled extremity. Am J Surg. Nov 1996;172(5):569-73; discussion 573-4. [Medline].

  30. Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score. Clin Orthop. Jul 1990;(256):80-6. [Medline].

  31. Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. J Trauma. Jan 1993;34(1):99-104. [Medline].

  32. Veith FJ, Marin ML. The present status of endoluminal stented grafts for the treatment of aneurysms, traumatic injuries and arterial occlusions. Cardiovasc Surg. Feb 1996;4(1):3-7. [Medline].

  33. Weiss VJ, Chaikof EL. Endovascular treatment of vascular injuries. Surg Clin North Am. Jun 1999;79(3):653-65. [Medline].

  34. Floyd HD, Kerstein MD. Successful vascular reconstruction. Determinants of disability. Am Surg. Feb 1986;52(2):91-2. [Medline].

  35. Diamond S, Gaspard D, Katz S. Vascular injuries to the extremities in a suburban trauma center. Am Surg. Oct 2003;69(10):848-51.

  36. Langworthy MJ, Smith JM, Gould M. Treatment of the mangled lower extremity after a terrorist blast injury. Clin Orthop Relat Res. May 2004;88-96.

  37. Modrall JG, Weaver FA, Yellin AE. Diagnosis and management of penetrating vascular trauma and the injured extremity. Emerg Med Clin North Am. Feb 1998;16(1):129-44. [Medline].

  38. Schwartz MR, Weaver FA, Bauer M, et al. Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis. J Vasc Surg. Jan 1993;17(1):116-22; discussion 122-4. [Medline].

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Further Reading

Clinical guidelines

Guideline for management of wounds in patients with lower-extremity neuropathic disease.
Wound, Ostomy, and Continence Nurses Society - Professional Association.  2004.  57 pages.  NGC:003898

VA/DoD clinical practice guideline for rehabilitation of lower limb amputation.
Department of Defense - Federal Government Agency [U.S.]
Department of Veterans Affairs - Federal Government Agency [U.S.]
Veterans Health Administration - Federal Government Agency [U.S.].  2007 Aug.  163 pages.  NGC:006060

Guideline for management of wounds in patients with lower-extremity arterial disease.
Wound, Ostomy, and Continence Nurses Society - Professional Association.  2002 Jun (revised 2008).  63 pages.  NGC:006521

Clinical trials

 A Study to Evaluate the Efficacy and Safety of Fondaparinux for the Prevention of Venous Blood Clots in Patients With a Plaster Cast or Other Type of Immobilization for a Below-Knee Injury Not Needing Surgery

Hand Transplantation for the Reconstruction of Below the Elbow Amputations

The Role of Total Body Imaging in Asymptomatic Pediatric Trauma Patients


Related eMedicine topics

Hand, Upper Extremity Vascular Injury 

Peripheral Vascular Injuries

Compartment Syndrome, Extremity

Compartment Syndrome, Upper Extremity

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Keywords

extremity vascular trauma, extremity trauma, vascular trauma, trauma, land mines, land mine injuries, land mine trauma, motor vehicle accidents, amputation, soft tissue injury, penetrating trauma, blunt trauma

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Contributor Information and Disclosures

Author

H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

David FE Stuhlmiller, MD, FACEP, EMS Medical Director, Emergency Medical Associates of Westchester Medical Center; Medical Director, LifeNet of New York, An Air Methods Company; Medical Advisor, International Association of Flight Paramedics
David FE Stuhlmiller, MD, FACEP is a member of the following medical societies: Air Medical Physician Association, Alpha Omega Alpha, American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Ernest Dunn, MD, Program Director of General Surgery, Director of Trauma and Critical Care, Clinical Associate Professor, Department of Surgery, Methodist Hospitals of Dallas, University of Texas Southwestern
Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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