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Contemporary outcomes of lower extremity vascular repairs extending below the knee: A multicenter retrospective study

Fortuna, Gerald MD; DuBose, Joseph J. MD; Mendelsberg, Ranan MD; Inaba, Kenji MD; Haider, Ansab MD; Joseph, Bellal MD; Skarupa, David MD; Selleck, Matthew J. DO; O'Callaghan, Thomas A. MD; Charlton-Ouw, Kristofer MDThe Lower Extremity Vascular Repairs Outcome Group

Journal of Trauma and Acute Care Surgery: July 2016 - Volume 81 - Issue 1 - p 63–70
doi: 10.1097/TA.0000000000000996
EAST 2016 Plenary Papers
Editor's Choice

OBJECTIVES To determine the outcomes of vascular injury interventions extending below the knee.

METHODS Vascular injury repairs extending below the knee from January 2008 to December 2014 were collected from six American College of Surgeons Level I trauma centers. Demographics, management, and outcomes were collected and analyzed.

RESULTS A total of 194 vascular injuries were identified. The mean age was 33.7 years, with 88.1% male, and 71.1% had blunt injury. Admission systolic blood pressure was less than 90 mm Hg in 10.8%; prehospital tourniquets were used in 5.6%. Median mangled extremity severity score (MESS) was 6.0 [interquartile range, 6]. Imaging used included computed tomography angiography (58.2%) and angiography (7.2%); with 66 (34.0%) proceeding directly to OR based on examination alone. Vascular interventions were conducted primarily by vascular (66.0%) and trauma (25.3%) surgeons at a median time from injury of 8 hours (interquartile range, 7 hours). Initial interventions included graft interposition (57.7%) with saphenous vein (111) or synthetic graft (1), primary repair (14.9%), endovascular stent-graft (1.5%), and patch angioplasty (2.1%). Fasciotomy was performed at initial operation in 41.8%, and for delayed compartment syndrome in 2.1%. Vascular reintervention was required in 20 patients (6.7%) for bleeding (seven patients) or thrombosis (13 patients). There was a higher reintervention rates for thrombosis among interposition grafts with distal anastomotic sites at the below-knee popliteal compared to those extending to the tibioperoneal trunk or distal trifurcation vessels, but this was not significant. (4/60, 6.7% vs. 6/49, 12.2%; p = 0.34). Postintervention amputation rates were significantly higher among interposition grafts extending distal to the popliteal (4/60 [6.7%] vs. 15/49 [30.6%]; p = 0.006).

CONCLUSIONS The management of vascular injuries extending below the knee remains a complex issue of extremity trauma care. The need for delayed amputation is significantly more common when revascularization below the distal popliteal artery is required.

LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic/care management study, level IV.

From the University of Texas Health Sciences Center (G.F., K.C-O.), Houston, Texas; David Grant Medical Center (J.J.D.), University of California–Davis, Sacramento, California; Los Angeles County and University of Southern California Hospital (R.M., K.I.), Los Angeles, California; University of Arizona (A.H., B.J.), Tucson, Arizona; University of Florida-Jacksonville (D.S.), Jacksonville, Florida; Loma Linda University Medical Center (M.J.S., T.A.O.), Loma Linda, California.

Submitted: December 3, 2015, Revised: January 22, 2016, Accepted: January 25, 2016, Published online: February 18, 2016.

This study was presented at the 29th annual meeting of the Eastern Association for the Surgery of Trauma, January 12–16, 2016, in San Antonio, Texas.

Address for reprints: Joseph J. DuBose, MD, FACS, FCCM, 101 Bodin Circle, David Grant Medical Center, Travis AFB, CA, 94535; email:

© 2016 Lippincott Williams & Wilkins, Inc.