Abstract
Introduction
Motor vehicle collisions account for the majority of blunt vascular trauma. Much of the literature describes the management of these injuries in isolation, and there is little information concerning the incidence and outcome in patients suffering multiple trauma. This study was undertaken to describe the spectrum of blunt vascular injuries in polytrauma patients.
Patients and methods
All patients who had sustained blunt vascular trauma over a 6-year period (April 2007–March 2013) were identified from a prospectively gathered database at the Level I Trauma Unit, Inkosi Albert Luthuli Central Hospital, Durban, South Africa. The retrieved data consisted of age, sex, mechanism of injury, referral source, Injury Severity Score (ISS), New Injury Severity Score (NISS), time from injury to admission, surgical intervention and outcome. The initial investigation of choice for patients sustaining multiple injuries was computed tomography (CT) angiography if they were physiologically stable, followed by directed angiography if there was doubt concerning any vascular lesion. If technically feasible, endovascular stenting was the preferred option for both aortic and peripheral vascular injuries.
Results
Of 1,033 patients who suffered blunt polytrauma, 61 (5.9 %) sustained a total of 67 blunt vascular injuries. Motor vehicle collisions accounted for 92 % of the injuries. The median ISS was 34 [interquartile range (IQR) 24–43]. The distribution of blunt vascular injuries was extremity (21), thorax (20), abdomen and pelvis (19), and head and neck (7). Endovascular repair was employed in 12 patients (ten blunt aortic injury, one carotid-cavernous sinus fistula, one external iliac artery). Of the extremity injuries, primary amputation was undertaken in 8 (38.1 %) and secondary amputation in 2 (9.5 %). The total amputation rate was 48 %. There were 17 (28.3 %) deaths, of which 11 (64.7 %) were directly attributable to the vascular injury and 6 (35.3 %) of these occurred on the operating table from exsanguination, the majority from injuries to the abdominal vena cava.
Conclusions
Blunt vascular injury is uncommon in the patient with multiple trauma but confers substantial morbidity and mortality. In those cases with peripheral injuries, delays in referral to definitive care frequently exceed the ischaemic time, resulting in a high rate of amputations. Central injuries, especially those of the vena cava, account for the majority of directly attributable deaths.
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References
Bolandparvaz S, Ghaffari B, Mousavi SM, Paydar S, Abbasi HR. Predictive value of biochemical markers for extremity vascular trauma outcome. Bull Emerg Trauma. 2013;1:34–7.
Frykberg ER. Popliteal vascular injuries. Surg Clin North Am. 2002;82:67–89.
Leholha P. Road traffic accident deaths in South Africa 2001–2006. Evidence from death notification. Statistics South Africa, Pretoria. 2009. Report no. 03-09-07.
O’Connor JV, Byrne C, Scalea TM, Griffith BP, Neschis DG. Vascular injuries after blunt chest trauma: diagnosis and management. Scand J Trauma Resusc Emerg Med. 2009;17:42. doi:10.1186/1757-7241-17-42.
Bromberg WJ, Collier BC, Diebel LN, Dwyer KM, Holevar MR, Jacobs DG, Kurek SJ, Schreiber MA, Shapiro ML, Vogel TR. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of trauma. J Trauma. 2010;68:471–7.
Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT. Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg. 1985;62:248–56.
Tjoumakaris SI, Jabbour PM, Rosenwasser RH. Neuroendovascular management of carotid cavernous fistulae. Neurosurg Clin N Am. 2009;20:447–52.
Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg. 2012;72:330–7.
Mueller C-A, Peters I, Podlogar M, Kovacs A, Urbach H, Schaller K, Schramm J, Kral T. Vertebral artery injuries following cervical spine trauma: a prospective observational study. Eur Spine J. 2011;20:2202–9.
Chokshi FH, Munera F, Rivas LA, Henry RP, Quencer RM. 64-MDCT angiography of blunt vascular injuries of the neck. AJR Am J Roentgenol. 2011;196:W309–15.
Mwipatayi BOP, Jeffery P, Beningfield SJ, Motale P, Tunnicliffe J, Navsaria PH. Management of extra-cranial vertebral artery injuries. Eur J Vasc Endovasc Surg. 2004;27:157–62.
Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology. 2008;248:748–62.
Cook CC, Gleason TG. Great vessel and cardiac trauma. Surg Clin North Am. 2009;89:797–820.
Azizzadeh A, Charlton-Ouw KM, Chen Z, Rahbar MH, Estrera AL, Amer H, Coogan SM, Safi HJ. An outcome analysis of endovascular versus open repair of blunt traumatic aortic injuries. J Vasc Surg. 2013;57:108–14.
Asensio JA, Forno W, Roldán G, Petrone P, Rojo E, Ceballos J, Wang C, Costaglioli B, Romero J, Tillou A, Carmody I, Shoemaker WC, Berne TV. Visceral vascular injuries. Surg Clin North Am. 2002;82:1–20.
Buckman RF, Pathak AS, Badellino MM, Bradley KM. Injuries of the inferior vena cava. Surg Clin North Am. 2001;81:1431–7.
Holly BP, Steenburg SD. Multidetector CT of blunt traumatic venous injuries in the chest, abdomen, and pelvis. Radiographics. 2011;31:1415–24.
Sangthong B, Demetriades D, Martin M, Salim A, Brown C, Inaba K, Rhee P, Chan L. Management and hospital outcomes of blunt renal artery injuries: analysis of 517 patients from the National Trauma Data Bank. J Am Coll Surg. 2006;203:612–7.
Cestero RF, Plurad D, Green D, Inaba K, Putty B, Benfield R, Lam L, Talving P, Demetriades D. Iliac artery injuries and pelvic fractures: a national trauma database analysis of associated injuries and outcomes. J Trauma. 2009;67:715–8.
Kertesz JL, Anderson SW, Murakami AM, Pieroni S, Rhea JT, Soto JA. Detection of vascular injuries in patients with blunt pelvic trauma by using 64-channel multidetector CT. Radiographics. 2009;29:151–64.
Banderker MA, Navsaria PH, Edu S, Bekker W, Nicol AJ, Naidoo N. Civilian popliteal artery injuries. S Afr J Surg. 2012;50:119–23.
Gable DR, Allen JW, Richardson JD. Blunt popliteal artery injury: is physical examination alone enough for evaluation? J Trauma. 1997;43:541–4.
Ganie FA, Lone H, Wani ML, Wani N, Ahangar AG, Ganie SA. The increasing rate of secondary amputation in popliteal arterial injury associated with multi-organ injuries and hypotension. Int Cardiovasc Res J. 2012;6:124–7.
Oliver JC, Gill H, Nicol AJ, Edu S, Navsaria PH. Temporary vascular shunting in vascular trauma: a 10-year review from a civilian trauma centre. S Afr J Surg. 2013;51:6–10.
Aucar JA, Hirshberg A. Damage control for vascular injuries. Surg Clin North Am. 1997;77:853–62.
Klocker J, Falkensammer J, Pellegrini L, Biebl M, Tauscher T, Fraedrich G. Repair of arterial injury after blunt trauma in the upper extremity—immediate and long-term outcome. Eur J Vasc Endovasc Surg. 2010;39:160–4.
Demetriades D, Asensio JA. Subclavian and axillary vascular injuries. Surg Clin North Am. 2001;81:1357–73.
DuBose JJ, Rajani R, Gilani R, Arthurs ZA, Morrison JJ, Clouse WD, Rasmussen TE; Endovascular Skills for Trauma and Resuscitative Surgery Working Group. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury. 2012;43:1785–92.
Hardcastle TC, Johnson W. Brachial artery injuries: a seven-year experience with a prospective database. Eur J Trauma Emerg Surg. 2008;34:493–7.
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Muckart, D.J.J., Pillay, B., Hardcastle, T.C. et al. Vascular injuries following blunt polytrauma. Eur J Trauma Emerg Surg 40, 315–322 (2014). https://doi.org/10.1007/s00068-014-0382-y
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DOI: https://doi.org/10.1007/s00068-014-0382-y