European Journal of Cardiovascular Medicine

Vascular trauma, encompassing injuries to arteries, veins, and lymphatic vessels, constitutes a critical and potentially life-threatening entity that demands immediate medical attention.[1] The severity and complexity of vascular trauma can vary widely, ranging from minor lacerations to devastating damage requiring extensive reconstruction.[2] Despite advances in medical care, vascular trauma remains a significant source of morbidity, mortality, and long-term disability.[3]

The consequences of untreated or improperly managed vascular trauma can be catastrophic, leading to limb loss, organ dysfunction, and even mortality. Various scoring systems like Mangled Extremity Severity Score and Predicted Salvageability Index exist, however no scoring system till date has a 100% accuracy in predicting limb salvageability after vascular trauma.[4] Prompt recognition, accurate diagnosis, and timely intervention are crucial to preventing complications, minimizing tissue damage, and optimizing functional outcomes. Vascular injuries can occur in various anatomical locations, with upper and lower limb vascular trauma being among the most common and complex presentations.[5] Upper limb vascular trauma, often resulting from penetrating or blunt injuries, can compromise blood flow to the arm, hand, or fingers, potentially leading to ischemia, nerve damage, and disability. Lower limb vascular trauma, frequently associated with high-energy trauma or complex fractures, can jeopardize circulation to the leg, foot, or toes, increasing the risk of limb loss and chronic impairment.[6] Popliteal artery injury is associated with highest rates of limb-loss.[7]

It has been seen and studied that Upper extremity injuries are associated with a lower rate of amputation and limb-loss, however they are associated more frequently with neurological deficit as compared to lower limb vascular trauma.[8] Lower limb vascular trauma routinely involves the femoropopliteal system with the superficial femoral artery being most commonly injured, and requires prompt revascularisation whenever possible due to high rates of limb-loss.[9] Effective management of upper and lower limb vascular trauma requires a multidisciplinary approach, incorporating expertise from vascular surgery, orthopaedic surgery, emergency medicine, and rehabilitation. Surgical interventions, including repair, bypass, thrombectomy, flap cover of the defect, and amputation, aim to restore blood flow, prevent complications, and optimize functional outcomes.[10][11]

Recent advances in endovascular techniques, imaging modalities, and perioperative care have significantly improved outcomes for vascular trauma patients. However, challenges persist, particularly in the context of complex injuries, polytrauma, and resource-limited settings.[12][13]

This article aims to provide an examination of upper and lower limb vascular trauma, focusing on epidemiology and mechanisms of injury, surgical options and techniques, as well as outcomes and complications viz. gangrene and amputation rates.

Study design: The study was a single-centre retrospective observational study. Patients who presented with extremity traumatic (civilian) vascular injury to the Emergency Department of Safdarjung Hospital, New Delhi and underwent intervention by Department of Cardiothoracic and Vascular Surgery between January 2023 and July 2024 were studied.

Patient selection: Patients above the age of 18 years who presented with extremity vascular trauma, with or without Orthopaedic intervention, who underwent intervention by the Department of CTVS were included. Patients with solid organ injury viz. liver, lung, brain were excluded. Iatrogenic vascular injuries were excluded. Patients in clinical shock (Systolic Blood Pressure <90 mm Hg) were also excluded.

Data collection: A total of 60 patients were studied, 30 patients with upper limb vascular trauma and 30 patients with lower limb vascular trauma. In all patients, some form of surgical intervention by Department of CTVS was carried out. Data regarding gender, age, etiology, associated bony injury, mode of intervention (viz. thrombectomy, ligation of vessel, primary end-to-end anastomosis or interposition venous graft repair), outcomes (viz. palpable distal pulses postoperatively, neurological deficit, development of gangrene and progress to amputation) were studied in each group and results compared.

Outcome measures: Outcomes that were studied included the presence of a postoperative palpable distal pulse in the operated limb and a postoperative neurological deficit in the same hospital admission as the intervention. Development of gangrene and progress to amputation was also studied. Only those amputations that were carried out in the same hospital admission were included due to loss to follow-up of a majority of cases after discharge.

Analysis: Data was analysed using SPSS version 20. Statistical significance was defined as a p value of <0.05.

Mean age of presentation in upper limb vascular trauma was 32 years and lower limb vascular trauma was 24 years

Majority of patients in both groups were males. (66.6% in upper limb and 86.6% in lower limb vascular injuries).

Most commonly involved artery in upper limb vascular injury was brachial artery (93%)  and Superficial Femoral artery (56%) followed by Popliteal artery (36%) in lower limb vascular trauma. 53% cases of upper extremity vascular trauma were not associated with any bony injury, as compared with 23% cases of lower extremity vascular trauma (p = <0.001)

A similar proportion of patients with upper and lower limb vascular injuries were managed with primary end-to-end anastomosis of injured vessel. (53% in upper limb, 50% in lower limb) as shown in Figure 3. Ligation of injured vessel was carried out in 16.6% cases of upper limb trauma and 23% of cases of lower limb trauma as shown in Figure 4. Repair of injured vessel using interposition great saphenous vein graft was carried out in 20% of upper limb trauma cases and 30% of lower limb trauma cases as shown in Figure 5.Postoperatively, distal pulses in the operated limb were palpable in 63% of cases of upper limb vascular trauma and 36.6% cases of lower limb vascular trauma. (p = 0.039) as shown in Figure 6.3% of upper limb vascular trauma cases progressed to amputation  while 36.6% cases of lower limb vascular trauma required amputation despite vascular surgical intervention (p = 0.001) as shown in Figure 7.

Neurological deficit was seen in 10% of cases of upper limb vascular trauma as against 3.3% cases of lower limb vascular trauma (p = 0.37) as shown in Figure 8.

The only case of upper limb vascular trauma which progressed to amputation was associated with duration since injury > 12 hours. Out of eleven cases of lower limb vascular trauma which progressed to gangrene, seven (63.6%) cases progressed to gangrene. (p = 0.16) as shown in Figure 9.

TABLE 1: Comparison of demographic data and injury details of upper and lower limb.

While approach to and management of extremity vascular trauma differs depending on site of injury, nature of injury, duration since injury etc, the mainstay and principle of treatment is early recognition and prompt management. Hard signs of vascular trauma viz. compartment syndrome, pulseless extremities warrant immediate intervention whereas stable patients without hard signs can be worked up and evaluated with imaging modalities like Doppler and CT Angiography. [14] A significant number of extremity vascular traumatic injuries are associated with long bone fractures, highlighting the need for multidisciplinary approach to management, as well as postoperative rehabilitation and physiotherapy.[15]

Upper extremity vascular trauma has been found to be more frequently associated with neurological deficit as compared to lower limb vascular trauma, as this study also showed, due to the close proximity of the median nerve to the brachial artery in the cubital fossa. As in previously conducted studies, a tendency towards neurological deficit was observed more frequently in upper limb vascular trauma (3 cases out of 30) as compared to lower limb vascular trauma (1 case) with p = 0.37, hence this requires more detailed evaluation with a larger study group.[16]

However, upper extremity vascular trauma is generally associated with a more favourable outcome following vascular surgical intervention with lower rates of gangrene and limb-loss, and a higher proportion of patients with palpable postoperative distal pulses in the operated limb. As seen in this study as well, 36.6% of lower limb vascular trauma cases progressed to gangrene / amputation as against 3.3% of upper limb vascular trauma cases (p = 0.001). Distal pulses were palpable in 63.3% of upper limb vascular trauma cases vis-à-vis 36.6% of lower limb vascular trauma cases, confirming similar findings of other researches in this field.[9]

This study also showed that there is a correlation between duration since injury and limb-loss in lower limb vascular trauma, with 63.6% cases  with duration more than 12 hours progressing to gangrene (p = 0.16), however this requires a larger study population to arrive at a definitive statistically significant correlation. More extensive data for upper limb vascular trauma is required. [18]

The most preferred conduit in both groups (viz. upper and lower limb vascular trauma) remains autologous great saphenous vein graft. However, many patients have long-term limb dysfunction associated with concomitant nerve injury and immediate intraoperative bypass revision.[16]

The most definitive and predictive outcomes of vascular trauma are based on the severity of injury, nature of injury, presence / absence of contamination, duration since injury as well as vessel involved. In general, mangled extremity vascular trauma and crush injuries are associated with an unfavourable outcome and amputation is usually considered the principal approach. However, limb salvageability is the norm, and attempt at repair of arterial injury must always be considered unless absolute contraindications exist. [17][19]

This single-centre retrospective study showed that the mainstay in management of extremity vascular trauma is early recognition and prompt intervention. Intervention can be in the form of vessel ligation, primary end-to-end anastomosis and interposition great saphenous vein graft repair, with the latter being most commonly performed. The most frequently injured artery in upper limb is brachial artery whereas in lower extremity vascular trauma, the Superficial Femoral Artery followed by the Popliteal artery are most frequently injured. Lower limb vascular injuries are more frequently associated with bony injury, while upper extremity vascular trauma is more frequently associated with neurological deficit postoperatively but with more favourable functional outcomes and lower rates of limb loss, possibly due to the extensive collateral formation in upper limb.

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2.       Mirdamadi N, Bakhtiari M, Baratloo A, Fattahi MR, Farshidmehr P. An Epidemiologic Overview of Traumatic Vascular Injuries in Emergency Department; a Retrospective Cross-Sectional Study. Arch Acad Emerg Med 2022;10(1):e59.

3.       Perkins ZB, De'Ath HD, Aylwin C, Brohi K, Walsh M, Tai NR. Epidemiology and outcome of vascular trauma at a British Major Trauma Centre. Eur J Vasc Endovasc Surg 2012;44(2):203-209.

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12.    Liu JL, Li JY, Jiang P, Jia W, Tian X, Cheng ZY, et al. Literature review of peripheral vascular trauma: Is the era of intervention coming? Chin J Traumatol 2020;23(1):5-9.

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15.    Hussain SA, Walters S, Ahluwalia A, Trompeter A. Diagnosis and management of arterial injuries associated with limb fracture or dislocation. Br J Hosp Med (Lond) 2022;83(3):1-8. doi: 10.12968/hmed.2021.0454. PMID: 35377208.

16.    Forsyth A, Haqqani MH, Alfson DB, Shaikh SP, Brea F, Richman A, Siracuse JJ, Rybin D, Farber A, Brahmbhatt TS. Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma. J Vasc Surg 2024;79(6):1339-1346. doi: 10.1016/j.jvs.2024.01.204. PMID: 38301809.

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