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Popliteal Artery injuries: A Meta-Analysis and Literature Review of a Complex Injury

Tejas R Shah, Ans Fakiha, Diego Ayo, Frank Veith, Mark A Adelman, Thomas S Maldonado, Caron B Rockman, Firas F Mussa
NYU Medical Center, New York, NY

INTRODUCTION:
Popliteal artery injuries are rare but potentially morbid injuries associated with significant amputation rates. Previous studies identifying risk factors associated with high amputation rates have been limited to mostly small cohort studies, which are often conflicting. Our goal was to conduct a meta-analysis to better identify predictors of limb loss associated with popliteal artery injuries.
METHODS:
A systematic literature review was conducted on studies reporting amputation rate associated with popliteal artery injuries using PubMed, Embase and Medline databases. Eligible studies included those that reported on civilian population, mechanism of arterial injury, and amputation rates. Data on military population, popliteal pseudoaneurysm, or other associated arterial injuries were excluded.
RESULTS:
705 articles were identified between1954-2014. A total of 145 full text articles were reviewed of which 22 articles were found to fit the study inclusion criteria. 2370 patients with 2394 popliteal artery injuries were identified. 82% were male with a mean age of 32 years. Overall amputation rate was 16.3% (95% CI=[13.8%, 19.2%]). Mortality rate was 3.8% (95% CI=[2.7%, 5.1%]). Injury distribution included blunt trauma (61%), penetrating injury (38%), and iatrogenic (1%). Patients presenting with a blunt injury were 2.03x more likely to have amputation than those with penetrating injury (pooled odds ratio = 2.03, 95% CI = [1.78, 2.32], p<0.0001). Patients that presented with orthopedic fractures were 5.93x more likely to have an amputation (OR = 5.93, 95% CI = [1.51, 23.39], p=0.011). Among those patients with venous injuries, 19.4 % had amputation (OR = 1.57, 95% CI = [0.77, 3.21], p=0.213). Mangled extremity severity score (MESS) was stratified in 3 studies. The amputation rate were higher in patient with high MESS score (50%) than patient with low MESS score (9%) (OR = 9.38, 95% CI = [8.34, 10.56], p<0.001). From 1979 to 2014, the most commonly performed popliteal artery repair technique was saphenous vein grafts (36%) followed by end-end anastomosis (24%).
CONCLUSIONS:
Popliteal artery injuries associated with blunt trauma, concurrent orthopedic injuries, and high MESS score are at higher risk of lower extremity amputation. Of these three predictors, high MESS scores were most strongly associated with amputation. Associated venous injury or fasciotomy failed to show any significant association to limb loss. Popliteal vascular injury remains a challenging clinical entity associated with a significant risk of amputation. Identifying risk factors associated with higher amputation rates may help guide clinical management of these complex injuries.


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