Complications of operative treatment of injuries of peripheral arteries

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Category: Cardiovascular, Adolescent, Cardiovascular disease, War, Humans, Female, Male, Amputation, Middle Aged, Adult, CARDİOVASCULAR SURGERY, Brachial artery, Radial Artery, Femoral Artery, Postoperative Complications, Female, Male, Amputation, Middle Aged, Adult, CARDİOVASCULAR SURGERY, Brachial artery, Radial Artery, Femoral Artery, Postoperative Complications

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Cardiovascular Surgery, Vol. 8, No. 4, pp. 256–264, 2000  2000 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd All rights reserved. Printed in Great Britain 0967–2109/00 $20.00

PII: S0967-2109(00)00020-X

www.elsevier.com/locate/cardiosur

Complications of operative treatment of injuries of peripheral arteries M. Milos Velinovic, B. Lazar Davidovic, I. Slobodan Lotina, R. Mile Vranes, L. Petar Djukic, J. Vladislav Arsov, V. Miljko Ristic, J. Mladen Kocica and Lj. Predrag Petrovic Institute for Cardiovascular Diseases — Clinical Centre of Serbia, Belgrade, Yugoslavia In 1991 and 1992, a total of 97 patients with 106 peripherial arterial injuries underwent surgery at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia. Civilian injuries accounted for 53 (54.6%) patients (94.3% males, age range: 16–63 yr, mean: 35.2), and 44 patients had war injuries (93.2% males, age range: 19–61 yr, mean: 34.8). The injuries affected the superfitial femoral artery in 31 (29.24%); the popliteal artery in 28 (26.41%); the brachial artery in 17 (16.04%); the posterior tibial artery in 6 (5.66%); the axillary artery in 5 (4.72%); the anterior tibial artery in 5 (4.72%); the tibioperoneal trunk in 4 (3.77%); the common femoral artery in 4 (3.77%); the external iliac artery in 2 (1.89%); the profound femoral artery in 2 (1.89%); the radial artery in 1 (0.94%); and ulnar artery in 1 (0.94%). A total of 98 reconstructive procedures were used to treat these patients. Graft interposition carried out in 50 (51.02%); by pass in 25 (25.51%); end-to-end anastomosis in 9 (9.18%); suture in 8 (8.16%); ligation in 4 (4.08%); and patch-angioplasty in 2 (2.04%). Primary reconstruction of injured arteries was performed in 72.2% and secondary repair in 27.8% cases. Infection developed in 51 (52.57%) patients, and it was significantly (P ⬍ 0.05) more common in the war injuries (70.45%) and in secondary repairs (88.89%). The presence of associated lesions (69.56%) was also correlated with a greater rate of infection. Amputation was necessary in 21 (21.65%) of our patients, and was significantly (P ⬍ 0.05) more often performed after secondary (44.44%) than primary operations (12.86%) and in the presence of associated injuries (32.61%).  2000 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved Keywords: peripheral arterial injury, civilian injury, war injury, complications

Introduction The civil war in the former Yugoslavia produced many vascular injuries. One of the pioneers in treating vascular traumas was the Serbian surgeon, Vojislav Subotic, who reported the experience of surgeons at the Belgrade Military Hospital during the Serbian–Turkish and Serbian–Bulgarian Wars in a study published in the

Correspondence to: M. Velinovic, Clinical Centre of Serbia, Institute for Cardiovascular Diseases, 8th Koste Todorovica St, 11000 Belgrade, Yugoslavia

256

Lancet, in 1913. Of the 77 patients, who developed pseudoaneurysms and arterio-venous fistulas, ligation of artery was performed in 45 (58.44%), and reconstruction in 32 (41.55%). He performed 19 direct suture arterial repairs, 13 vein repairs, and 15 end-to-end anastomoses (11 arterial) [1]. The value of these results was confirmed when they were compared to the results from World War II. According to De Bakey and Simone’s stastistics from 1946, most of the 2471 arterial injuries were treated by ligation, and in 49% amputations were required [2]. Better results were achieved in the Korean War where Hughes showed that 269 of 304 arterial injuries were successfully reconstructed and only 35 were CARDIOVASCULAR SURGERY

JUNE 2000 VOL 8 NO 4

Complications of operative treatment of injuries of peripheral arteries: M. M. Velinovic et al. Table 1 Factors analysed The The The The The The The The

nature of the injury (civil or war) type of reconstruction (primary or secundary) operative procedure applied mechanism of injury type of injured artery pathoanatomical finding localisation of injury presence of conjoined lesions

treated by ligation. Amputations were required in 13% of cases [3]. The frequency of arterial injuries is greater in war than in peace. In 1968 Vollmar reported that only 197 (0.3%) of 85,000 patients treated at The Heidelberg Clinic between 1953 and 1966 had an arterial injury [4]. In the Vietnam War, Rich found that 1000 (2%) of 200,000 injuries were arterial [5]. In 1972 Geer published a report, showing that 9.4% of 2373 cases from Vietnam War had a vascular injury [6]. The purpose of this study was, to analyze the frequency of infections and amputations, after arterial repairs, in relation to various factors, shown in Table 1.

Seventy patients had a primary operation after the adequate first aid had been provided, whereas 27 were reoperated after an unsuccessful primary operation performed in a different medical institution (Table 8). The most common reasons for secondary reconstruction were hemorrhage and ischaemia (Table 9). The only reason for performing ligature was an injury of one of the lower leg arteries, which could not cause the loss of the extremity. Because of the extent of the injury and associated soft tissue destruction, primary amputation of extremity was required in 3.9% of patients. Statistical analysis of our data was performed by using the statistical software package SPSS for Windows 7.0 (descriptive statistics, crosstabulation, Xsquare/tables of contingency/and Mantel–Haenszel test). Pearson’s coefficient of contingency was used as a measure dependence among the variables. The levels of significance P ⬍ 0.05 with were marked which an asterisk (*) should be carefully interpreted because they represent the result of statistical analysis in the tables with frequency ⬍ 5 in one of their cells. There were a great number of modalities for some variables.

Results

Material and methods From January 1991 to December 1992, a total of 97 patients, with 106 injuries of peripherial arteries, were operated on at the Institute for Cardiovascular Diseases — Clinical Centre of Serbia. There were 53 patients with civilian arterial injuries, of whom 50 (94.3%) were male and 3 (5.7%) female. Of 44 patients with war injuries, 41 (93.2%) were male and 3 (6.8%) female. The mean age of the patients with civilian injuries was 35.23 (13–63) yr, and of those with war injuries 34.87 (19–61) yr. According to Table 2, gunshot and explosive injuries were the most common (Table 3). The most common type of arterial injury was laceration (Tables 4 and 5). The injuries of the superficial femoral artery were the most common ones, at war as well as at peacetime (Tables 6 and 7).

Postoperatively, infection was observed in 20 (37.7%) patients after civil trauma, and in 31 (70.5%) with war injuries. The difference between these two groups of patients was statistically significant (P ⬍ 0.05). Amputation was performed in 10 (18.9%) patients after civil trauma and in 11 (25%) after war injuries. This difference was not statistically significant (P ⬍ 0.05). The incidence of wound infection after primary operations was 38.6% (27 patients), and after the secondary operations (after unsuccessful reconstructive surgery) 88.9% (24 patients). This difference was statistically significant (P ⬍ 0.05). The incidence of amputation after primary operations was 12.9% (9 patients), and after secondary operations 44.4% (12 patients). This difference was statistically significant (P ⬍ 0.05).

Table 2 Mechanisms of arterial injury in peacetime and wartime conditions Injury

Bullet

Explosion

Industrial

Traffic

Cold weapon

Fall

Bite

Civilian

14 (26.4%) 29 (65.9%) 43 (44.3%)

4 (7.5%) 15 (34.1%) 19 (19.6%)

8 (15.1%) –

10 (18.9%) –

11 (20.8%) –

5 (9.4%) –

1 (1.9%) –

8 (8.2%)

10 (10.3%)

11 (11.3%)

5 (5.2%)

1 (1.0%)

War Σ

CARDIOVASCULAR SURGERY

JUNE 2000 VOL 8 NO 4

257

Complications of operative treatment of injuries of peripheral arteries: M. M. Velinovic et al. Table 3 Pathoanatomical finding on the injured arteries Lesion

Lac-Sect*

Contusion

AV fistula

PsAn†

Thrombosis

Civilian War Σ

32 (60.4%) 13 (29.5%) 45 (46.4%)

11 (20.8%) 6 (13.6%) 17 (17.5%)

1 (1.9%) 1 (2.3%) 2 (2.1%)

3 (5.7%) 5 (11.4%) 8 (8.2%)

6 (11.3%) 19 (43.2%) 25 (25.8%)

* Laceration-section† Psuedo aneurysm

Table 4 Localisation of injured arteries Injury/site

Upper limb

Lower limb

Civilian War Σ

16 (30.18%) 8 (18.181%) 24 (24.74%)

37 (69.82%) 36 (81.82%) 73 (75.26%)

Table 5 Type of injured arteries Arterial vessel

Civilian

War

Σ

Axillary Brachial Radial Ulnar Iliac Common femoral Superficial femoral Profound femoris Popliteal Tibio-peroneal trunk Anterior tibial Posterior tibial

4 (6.89%) 10 (17.24%) 1 (1.72%) 1 (1.72%) 2 (3.44%) 3 (5.17%) 13 (22.41%) 1 (1.72%) 15 (25.86%) 2 (3.44%) 2 (3.44%) 4 (6.89%)

1 (2.08%) 7 (14.58%) – – – 1 (2.08%) 18 (37.5%) 1 (2.08%) 13 (27.08%) 2 (4.16%) 2 (6.25%) 2 (4.16%)

5 (4.71%) 17 (16.03%) 1 (0.94%) 1 (0.94%) 2 (1.88%) 4 (3.77%) 31 (29.24%) 2 (1.88%) 28 (26.41%) 4 (3.77%) 5 (4.71%) 6 (5.66%)

Table 6 Isolated-conjoined lesion ratio Arterial injury

Isolated

Conjoined

Civilian War Σ

33 (62.26%) 18 (40.91%) 51 (52.57%)

20 (37.73%) 26 (59.09%) 46 (47.43%)

Table 7 The most commonly affected tissues Conjoined injuries

Bone

Nerv

Bone ⫹ Nerv

Civilian War Σ

8 (40.0%) 10 (38.46%) 18 (39.13%)

6 (30.0%) 7 (26.92%) 13 (28.26%)

6 (30.0%) 9 (34.61%) 15 (32.60%)

258

CARDIOVASCULAR SURGERY

JUNE 2000 VOL 8 NO 4

Complications of operative treatment of injuries of peripheral arteries: M. M. Velinovic et al. Table 8 Primary and secondary reconstruction Operation

Primary

Secondary

Civilian War Σ

47 (88.7%) 23 (52.3%) 70 (72.2%)

6 (11.3%) 21 (47.7%) 27 (27.8%)

Table 9 Types of operative procedures Operative procedure

Civilian

War

Σ

Suture T-T anastomosis Patch plasty Graft interposition By pass procedure Ligature Exploration ⫹ amputation

4 (7.5%) 4 (7.5%) 2 (3...

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