Current Outcomes Following Upper and Lower Extremity Arterial Trauma from the National Trauma Data Bank
Sooyeon Kim, Andrew Schneider, Stephen Raulli, Colby Ruiz, William Marston, Katharine L. McGinigle, Jacob Wood, F. Ezequiel Parodi, Mark A. Farber, Luigi Pascarella
University of North Carolina, Chapel Hill, NC
INTRODUCTION: The modern landscape of trauma has changed in recent years with an increasing incidence of firearm injuries. We aim to evaluate the factors associated with limb salvage and mortality in those who sustained upper and lower extremity arterial trauma, especially with respect to the type of conduit utilized in revascularization.
METHODS: The National Trauma Data Bank was queried to identify patients who sustained upper and lower extremity (UE and LE) arterial injuries between 2016 - 2020.
RESULTS: A total of 8,780 patients were found with 5,054 (58%) UE and 3,726 (42%) LE vascular injuries. Eighty-three percent of the patients were men, and the mean age was 34 ± 15 years. Penetrating mechanism was the predominant mode of injury in both UE and LE vascular trauma (73% and 67%, respectively) with a mean injury severity score (ISS) of 14 ± 8. For UE injuries, the majority underwent primary repair (67%, p<0.001), while the remainder received either a bypass (20%) or interposition graft (12%). However, LE vascular injuries were more likely to receive a bypass (52%, p<0.00001) than primary repair or interposition graft (34% and 14%, respectively). Compared to the extremely low rates of amputation and mortality among UE patients (2% for both), LE injuries were more likely to result in both amputation (10%, p<0.001) and death (6%, p<0.001). Notably, use of a prosthetic conduit was associated with a 6.7-fold increased risk of amputation in UE and 2.4-fold increase in LE (p<0.0001 for both). Both interposition grafts and bypasses, when compared to primary repair, were associated with increased unplanned return to the operating room (OR); however, synthetic bypasses fared much worse than vein bypasses. Prosthetic bypasses were associated with a nearly 3-fold increase in return to the OR in UE bypasses (p<0.05) and a 2.4-fold increase in return to the OR in LE bypasses (p<0.0001). Penetrating mechanism, while protective against amputation, was associated with a nearly 2-fold increase in mortality (IRR of 1.9, p<0.05 in UE injuries; IRR of 1.8, p<0.001 in LE injuries).
CONCLUSIONS:In recent years, most extremity vascular trauma was due to penetrating injury with a substantial burden of morbidity and mortality. However, both limb salvage rates and survival rates have remained high. Overall, the patients with LE injuries more often faced amputation and mortality than those with UE injuries. Notably, the risks of unplanned return to the OR and limb loss were far greater with the use of a prosthetic conduit; thus, synthetic grafts should be avoided in extremity arterial trauma.
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