European Journal of Vascular & Endovascular Surgery
Volume 39, Issue 2 , Pages 160-164, February 2010

Repair of Arterial Injury after Blunt Trauma in the Upper Extremity – Immediate and Long-term Outcome

Department of Vascular Surgery, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria

Received 11 August 2009; accepted 17 November 2009. published online 08 December 2009.

Article Outline

Abstract 

Objective

In contrast to upper extremity stab and gunshot wounds, data on management and outcome in blunt trauma (BT) are limited by small numbers and short follow-up periods.

Methods

This study is a retrospective data analysis. All patients who had undergone arterial repair after upper-limb BT were included. Exclusion criteria were artery ligation and/or primary limb amputation. Endpoints included the following: peri-operative death, limb salvage, primary and secondary patency, vascular re-operation and/or intervention.

Results

Eighty-nine patients (71 male; median age: 34.6 years, range: 2.5–81.7) underwent reconstruction of 96 arteries after BT since 1989: subclavian (n=16), axillary (n=22), brachial (n=48) and forearm (n=10). Concomitant arm vein lesions were present in 15 patients (17%) and accompanying nerve (n=38; 43%) and/or orthopaedic injuries (n=64; 72%) in 77 patients (87%). The 30-day mortality rate was 2% with the limb-salvage rate being 98%. Six reconstructions occluded during the first week (primary/secondary patency rate: 93%/99%). After a median follow-up time of 5.1 years, 67% of the patients were followed: There were no secondary amputations and no arterial re-interventions.

Conclusions

Arterial repair in upper extremity BT has excellent early and long-term outcome. In contrast to a significant risk of early occlusion, limb loss after repair, late vascular re-intervention and late arterial occlusion or stenosis are rare.

Keywords: Upper limb, Artery, Arterial repair, Trauma, Blunt, Outcome

 

Initial and ultimate outcome of vascular injuries are determined in large part by the mechanism of injury.1 Most reports on results of arterial reconstructions deal with cases of upper extremity trauma predominantly resulting from stab or gunshot injuries (see Table 1),2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and outcome analyses in large series of patients frequently combine both types of injury. In contrast to penetrating trauma, which is usually characterised by limited damage within a limited area and few accompanying lesions, blunt trauma is more frequently associated with neurological and orthopaedic injuries and leads to a significantly higher rate of disability.1, 4, 7, 8, 10, 11, 17, 18, 19, 20, 21, 22

Table 1. Incidence of blunt and penetrating upper extremity trauma in previously published civilian series and length of mean follow-up (FU). Only studies published after 1980 with more than 20 patients and series with data available for the upper extremity are shown. PY=publication year; n total=total number of patients; n blunt=number of patients with blunt injury; n penetr=number of patients with penetrating injury; NA=data not available; *=numbers given: number of arteries treated.
AuthorPYn totaln bluntn penetrFU
Bormann2, *198326919 (7%)250 (93%)6 months
Orcutt319861439 (6%)134 (94%)NA
Myers419909527%73%6 months
Creagh519915043 (86%)7 (14%)NA
Andreev61992509 (18%)42 (82%)NA
Fitridge7199411452 (46%)62 (54%)14.5 months
van der Sluis819972519 (76%)6 (24%)2 years
Pillai91997216 (29%)15 (71%)3.1 months
Manord1019984618 (39%)28 (61%)43 months
Brown1120017121 (30%)50 (70%)6.3 months
Shanmugam1220042712 (44%)15 (56%)70 days
Cakir1320057844 (56%)34 (44%)NA
Franz14, *20093012 (40%)18 (60%)NA
Ekim1520094945 (92%)4 (8%)NA
Prichayudh1620095225 (48%)27 (52%)NA
Our series 8989 (100%)05.2 years

The present study is a retrospective outcome analysis of arterial repair in a consecutive series of patients with blunt upper-extremity injuries treated in our institution, a Level I trauma centre.

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Patients and Methods 

Patients who had undergone repair of arterial injuries in upper limb trauma during the past 2 decades in our institution were identified by searching our institutional diagnosis registry. Patients were included for analysis, if they had blunt trauma only. Furthermore, patients were excluded if artery ligation and/or primary limb amputation was performed.

In a retrospective data analysis, the medical records of 89 identified individuals with a total of 96 injured arm arteries that underwent repair during the past 2 decades were reviewed. Data collection included demographic parameters, mechanism of injury, location and type of injury, presence of ischaemia, presence of concomitant vein, nerve and/or bone/joint injuries and details of arterial reconstruction as well as follow-up investigations. To evaluate outcome, perioperative death (30-day mortality), limb-salvage rate, primary and secondary patency of arterial reconstruction and early and late vascular re-interventions were considered study endpoints.

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Results 

Since 1989, a total of 89 consecutive patients (median age: 34.6 years, range: 2.5–81.7; 71 male) underwent reconstruction of 96 injured arteries of the upper limb after blunt trauma. During the same time period, 10 patients were operated for penetrating trauma and another 11 individuals for iatrogenous lesions to upper limb arteries, but were not included for further analysis. Of the 96 blunt injuries, the left extremity was involved in 53 lesions, the right extremity in 43 cases. Sports accidents accounted for most injuries (n=31; 35% of patients), and traffic accidents (n=24; 27%) and injuries at work (n=26; 29%) were also frequent. Forty-two patients (47%) presented with signs of limb ischaemia at the injured arm. Arteries injured included: subclavian (n=16; 17%), axillary (n=22; 23%), brachial (n=48; 50%), radial (n=6; 6%) and ulnar (n=4; 4%). Concomitant arm vein lesions were detected in 15 patients (17%) and involved subclavian (n=2), axillary (n=4), brachial (n=8) and forearm veins (n=1). Accompanying injuries of nerves (n=38; 43%) and/or orthopaedic injuries (n=64; 72%) were present in 77 patients (87%). Numbers and percentages of associated nerve and orthopaedic injuries in different arterial segments are shown in Table 2. Nerve injuries included 21 lesions to the brachial plexus, which were associated with injuries of the subclavian (n=8), axillary (n=12) or brachial (n=1) artery (as shown in Table 2).

Table 2. Location of arterial injuries, number (n) of arterial injuries and number (n)/percentage (%) with associated injuries to the nerves, to the brachial plexus and fractures and/or luxations.
Location (Artery)Overall injuries (n)Nerve lesionInjury to brachial plexusOrthopaedic lesionNerve or orthopaedic lesion
Subclavian168 (50%)8 (50%)10 (63%)13 (81%)
Axillary2216 (73%)12 (55%)21 (95%)22 (100%)
Brachial4813 (27%)1 (2%)29 (60%)37 (77%)
Radial61 (17%)02 (33%)3 (50%)
Ulnar4002 (50%)2 (50%)
Total9638 (43%)21 (22%)64 (6.3%)77 (87%)

Repair of injured arteries was accomplished either by end-to-end anastomosis (n=11; 11.5%), simple stitches for closure of wall defects (n=6; 6.3%), patch angioplasty (n=9; 9.4%) or interposition grafts (n=66; 68.7%), which included 62 autogenous vein grafts and four prosthetic conduits. Four lesions (4.2%), all of them located in the subclavian artery, were treated by stent-graft insertion. The type of repair in the different arterial segments of the upper extremity are summarised in Table 3. Associated arm-vein injuries were either ligated (n=4) or repaired (n=12) by vein interposition grafts (n=7), end-to-end anastomosis (n=1), closure of wall defects (n =2) or patch angioplasty (n=1). In addition to vascular repair, fasciotomy was indicated in 11 individuals after reconstruction of subclavian (n=1), axillary (n=3), brachial (n=4) or forearm arteries (n=3).

Table 3. Location of arterial injuries, number (n) of injuries and type of arterial repair performed (EEA=end-to-end anastomosis; simple stitches; patch angioplasty; interposition graft; Stentgraft).
Location (Artery)Overall injuries (n)EEASimple stitchesPatch angioplastyInterposition graftStentgraft
Subclavian1601 (6.3%)011 (68.8%)4 (25%)
Axillary224 (18.2%)04 (18.2%)14 (63.6%)0
Brachial487 (14.6%)2 (4.2%)4 (8.3%)35 (72.9%)0
Radial602 (23%)04 (67%)0
Ulnar401 (25%)1 (25%)2 (50%)0
Total9611 (11.5%)6 (6.3%)9 (9.4%)66 (68.7%)4 (4.2%)

There was no death intra-operatively; however, two patients died within 1 month after serious traffic accidents and upper extremity arterial repair (30-day mortality rate: 2.2%): A 57-year-old man died from multi-organ failure on the 15th postoperative day after polytrauma and reconstruction of a brachial artery lesion by vein graft interposition. A 16-year-old male died on the 20th postoperative day after polytrauma including craniocerebral injury and subclavian artery repair using a vein graft.

Limb salvage was achieved in all but two patients (98%): In a 39-year-old man with complete traumatic amputation at the elbow joint, an upper-arm amputation was performed on the first postoperative day after reconstruction of both the axillary and the brachial arteries. In addition, a 42-year-old man with subtotal amputation of the upper arm after a motor vehicle accident was amputated on the 10th day after repair of the brachial artery. Both amputations were indicated because of severe life-threatening wound infection.

Six arterial reconstructions occluded postoperatively (primary patency rate: 93%): five brachial arteries were successfully revised; one radial artery occlusion, which was detected on the 2nd day after repair using a vein interposition, was treated conservatively due to the absence of symptoms. Four of the five brachial artery occlusions presented on the 1st postoperative day, and one was diagnosed on the 8th day after repair. Injured vessel, initial procedure, day of revision and type of secondary repair in patients with early occlusions are summarised in Table 4. At the time of patient discharge from the hospital, all but one arterial repairs were patent (secondary patency rate: 99%).

Table 4. Six patients developed arterial reconstruction occlusions within 30 days postoperatively: Location of injured artery, initial procedure (EEA=end-to-end anastomosis; vein interposition, GSV=greater saphenous vein), postoperative day of arterial occlusion and secondary procedure.
Patient (Initials)Localization (Artery)Initial repairDay of occlusionSurgery performed
A.P.BrachialVein interposition (GSV)1Graft replacement
B.L.BrachialEEA1Vein interposition (GSV)
K.F.RadialVein interposition (arm vein)2None
O.J.BrachialVein interposition (GSV)8Graft replacement
W.A.BrachialVein interposition (GSV)1Thrombectomy
W.W.BrachialVein interposition (GSV)1Thrombectomy

After a median follow-up time of 5.1 years (range: 0.5-19.7), clinical follow-up data were available from 57 (67%) of the 85 patients that survived with successful limb salvage initially. Meanwhile, three additional patients were deceased, none of them as a consequence of extremity injury. No secondary amputation was performed; ablation was considered in a 19-year-old patient disabled by an almost non-functional upper extremity after reconstruction of a complete traumatic amputation. Occlusion of arterial repair was detected in two individuals during follow-up: a 52-year-old man after brachial artery repair with vein graft interposition and a 67-year-old woman after the stent graft of a subclavian artery pseudoaneurysm (long-term patency rate: 96%). Another two patients had a high-grade stenosis at the repaired arterial segment. All four patients presented with no or mild clinical symptoms. Therefore, none of them underwent arterial procedures.

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Discussion 

We retrospectively analysed early and late outcome of a consecutive series of patients that underwent arterial reconstructions after civilian trauma in the upper extremity in our institution. Only patients with blunt trauma were included. In contrast, as shown in Table 1, most previously published series predominantly involved patients with penetrating stab or gunshot injuries, and outcome of a mixture between blunt and penetrating injuries was analysed regularly.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 The case mix in other series presumably influenced overall early and late results leading to inconsistent conclusions.

Vascular injuries accompanying upper-extremity trauma are considered to be rare3, 8, 9, 14, 19, 23, 24, 25, 26 and the brachial artery is injured most frequently.3, 4, 5, 6, 7, 8, 13, 14, 18, 22, 27, 28, 29 In our cohort of patients, half of the patients had brachial artery repair, and approximately 20% of the patients had axillary or subclavian artery reconstructions (Table 2). The relatively small number of patients with radial and ulnar artery repair in our institution may be due to the fact that single-vessel forearm injuries were ligated or embolised rather than repaired, which has been demonstrated to be safe.1, 30

Our data are in agreement with previous reports showing that blunt trauma is frequently associated with major musculoskeletal and brachial plexus injury.7, 13 In our cohort, skeletal and nerve injuries were most frequently seen in axillary artery lesions (see Table 2), where all patients had either nerve or orthopaedic lesions.

Our strategy for operative management of upper extremity arterial injuries was published earlier.31 We recommend a commonly used vascular access for exposure of the artery and not to accept a compromise due to other procedures planned. The site of injury is inspected after proximal and distal control of the artery, or an endoluminal balloon occlusion is used. We avoid the use of intraluminal shunts. Systemic anticoagulation using heparin can be initiated if not contraindicated. Alternatively, local instillation of diluted heparin to the artery can be considered. Surgical repair is principally dependent on the severity and extent of damage: Lateral suture patch angioplasty, tension-free end-to-end anastomosis or graft interposition may be considered. In other series with a high incidence of blunt trauma, the majority of arterial injuries were treated with vein graft interposition rather than primary anastomosis7, 8, 11 and this was also the method of arterial repair most frequently used in our cohort (see Table 3) because of extensive vessel damage. As a principle, the use of autologous vein grafts from uninjured limbs is preferred. Whenever possible, we perform a completion arteriography to visualise arterial run-off and to document initial technical success of revascularisation. Primary nerve repair and exploration of the brachial plexus was preferentially performed at the time of arterial repair, as in previously published series.6, 11, 19, 32

When procedure-related death and early limb loss are considered, our data indicate that perioperative death due to upper extremity trauma is rare and limb loss after reconstruction can be avoided in most patients. Similar results were published previously,4, 14, 16, 33, 34, 35, 36 but may be different in series which include patients with irreversible tissue damage and patients with severe co-existing injuries to central nervous system or visceral organs that preclude any complex arterial reconstruction. Primary amputation should be considered if life is threatened. Decisions have to follow the rule ‘life before limb’.

Primary patency of arterial repair was 93%, which is similar to previously published results.6, 10, 27 Manord and co-workers10 had 88% primary patent reconstructions and they concluded that there might be a relatively high technical error rate and broader tissue damage in patients with blunt injuries. In our series, six arterial reconstructions occluded postoperatively, all but one were located in the brachial artery and all but one had undergone vein interposition initially (see Table 4). Five of six graft occlusions occurred on the 1st or 2nd day after repair. After a median follow-up period of more than 5 years, only two patients (out of 57 followed) were diagnosed with late graft occlusions, and both patients were asymptomatic. Our data demonstrate that there is a considerable risk of arterial thrombosis perioperatively, whereas the risk of late occlusion is low. We suppose that main reasons for early graft occlusions are technical errors, poor graft quality and/or insufficient anticoagulation. Our rationale for adjuvant medical treatment has to address the risk of early occlusions: patients should be put on continuous heparin infusion unless anticoagulation is contraindicated.

Previously reported follow-up data after arterial trauma in the upper limb are limited by relatively short follow-up periods,2, 4, 7, 8, 9, 10, 11, 12 and several studies do not include any follow-up data3, 5, 6, 13, 14, 15, 16 (see Table 1). Our study, for the first time, provides results with follow-up longer than 5 years (median follow-up period: 61 months; range 6–236 months) in a large series of patients: Long-term results were obtained for 67% of the patients that had successful limb salvage initially. No late amputation was performed in our cohort. In literature, secondary amputation after upper-extremity trauma was rarely indicated,8, 27 but was considered in patients with total non-functional limbs.1 In our cohort, delayed amputation was offered to one patient without functional recovery after arm replantation; however, the patient preferred to retain his limb. Follow-up investigations detected two patients with occluded arterial repair, and another two with high-grade stenosis at the anastomotic site. None of them underwent arterial re-do procedures, as they had no or mild clinical symptoms.

There are several limitations to our study. First, our data were collected retrospectively from the patients' charts and op notes. Documentation might have been incomplete and therefore, some details in individual patients are missing. This cutback is inherent to most other publications regarding outcome following vascular trauma. Second, we excluded patients that underwent primary amputation, and, retrospectively, we could not calculate injury severity scores to compare patients who had repair with those who underwent primary amputation. Third, we cannot exclude selection bias for follow-up data, as patient follow-up was incomplete. Fourth, as in most other series reporting on outcome after complex upper-extremity reconstructions, the overall number of patients did not allow for calculations of the outcome of specific subgroups, such as patients with and without fasciotomy or patients that underwent venous repair simultaneously, though these may be important factors influencing long-term results.1, 4, 7, 37, 38

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Conflict of Interest/Funding 

None.

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References 

  1. Weaver FA, Papanicolaou G, Yellin AE. Difficult peripheral vascular injuries. Surg Clin North Am. 1996;76:843–859
  2. Bormann KR, Snyder WH, Weigelt JA. Civilian arterial trauma of the upper extremity – an 11 year experience in 267 patients. Am J Surg. 1984;148:796–799
  3. Orcutt MB, Levine BA, Gaskill HV, Sirinek KR. Civilian vascular trauma of the upper extremity. J Trauma. 1986;26:63–67
  4. Myers SI, Harward TR, Maher DP, Melissinos EG, Lowry PA. Complex upper extremity vascular trauma in an urban population. J Vasc Surg. 1990;12:305–309
  5. Creagh TA, Broe PJ, Grace PA, Bouchier-Hayes DJ. Blunt trauma-induced upper extremity vascular injuries. J R Coll Surg Edinb. 1991;36:158–160
  6. Andreev A, Kavrakov T, Karakolev J, Penkov P. Management of acute arterial trauma of the upper extremity. Eur J Vasc Surg. 1992;6:593–598
  7. Fitridge RA, Raptis S, Miller JH, Faris I. Upper extremity arterial injuries: experience at the Royal Adelaide Hospital, 1969 to 1991. J Vasc Surg. 1994;20:941–946
  8. van der Sluis CK, Kucey DS, Brenneman FD, Hunter GA, Maggisano R, ten Duis HJ. Long-term outcomes after upper limb arterial injuries. Can J Surg. 1997;40:265–270
  9. Pillai L, Luchette FA, Romano K, Ricotta JJ. Upper-extremity arterial injury. Am Surg. 1997;63:224–227
  10. Manord JD, Garrard CL, Kline DG, Sternbergh WC, Money SR. Management of severe proximal vascular and neural injury of the upper extremity. J Vasc Surg. 1998;27:43–49
  11. Brown KR, Jean-Claude J, Seabrook GR, Towne JB, Cambria RA. Determinates of functional disability after complex upper extremity trauma. Ann Vasc Surg. 2001;15:43–48
  12. Shanmugam V, Velu RB, Subramaniyan SR, Hussain SA, Sekar N. Management of upper limb arterial injury withour angiography – Chennai experience. Injury. 2004;35:61–64
  13. Cakir O, Subasi M, Erdem K, Eren N. Treatment of vascular injuries associated with limb fractures. Ann R Coll Surg Engl. 2005;87:348–352
  14. Franz RW, Goodwon RB, Hartman JF, Wright ML. Management of upper extremity arterial injuries at an urban level I trauma centre. Ann Vasc Surg. 2009;23:8–16
  15. Ekim H, Tuncer M. Management of traumatic brachial artery injury: a report on 49 patients. Ann Sudi Med. 2009;29:105–109
  16. Prichayudh S, Verananvattna A, Sriussadaporn Suk, Sriussadaporn Suv, Kritayakirana K, Pak-art R, et al. Management of upper extremity vascular injury: outcome related to the mangled extremity severity score. World J Surg. 2009;33:857–863
  17. Hardin WD, O'Connell RC, Adinolfi MF, Kerstein MD. Traumatic arterial injuries of the upper extremity: determinants of disability. Am J Surg. 1985;150:266–270
  18. Thompson PN, Chang BB, Shah DM, Darling RC, Lether RP. Outcome following blunt vascular trauma of the upper extremity. Cardiovasc Surg. 1993;1:248–250
  19. Visser PA, Hermreck AS, Pierce GE, Thomas JH, Hardin CA. Prognosis of nerve injuries incurred during acute trauma to peripheral arteries. Am J Surg. 1980;140:596–599
  20. Van Wijngaarden M, Omert L, Rodriguez A, Smith TR. Management of blunt vascular trauma to the extremities. Surg Gynecol Obstet. 1993;177:41–48
  21. Rozycki GS, Tremblay LN, Feliciano DV, McClelland WB. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma. 2003;55:814–824
  22. Joshi V, Harding GE, Bottoni DA, Lovell MB, Forbes TL. Determination of functional outcome following upper extremity arterial trauma. Vasc Endovascular Surg. 2007;41:111–114
  23. Mattox KL, Feliciano DV, Burch J, Beall AC, Jordan GL, DeBakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958-1987. Ann Surg. 1989;209:698–705
  24. Sparks SR, DeLaRosa J, Bergan JJ, Hoyt DB, Owens EL. Arterial injury in uncomplicated upper extremity dislocations. Ann Vasc Surg. 2000;14:110–113
  25. Peacock JB, Proctor HJ. Factors limiting extremity function following vascular injury. J Trauma. 1977;17:532–535
  26. Oller DW, Rutledge R, Clancy T, Cunningham P, Thomason M, Meredith W, et al. Vascular Injuries in a rural state: a review of 978 patients from a state trauma registry. J Trauma. 1992;32:740–745
  27. Shaw AD, Milne AA, Christie J, Jenkins AM, Murie JA, Ruckley CV. Vascular trauma of the upper limb and associated nerve injuries. Injury. 1995;26:515–518
  28. Fingerhut A, Leppaniemi AK, Androulakis GA, Archodovassilis F, Bouillon B, Cavina E, et al. The European experience with vascular injuries. Surg Clin North Am. 2002;82:175–188
  29. Kohli A, Singh G. Management of extremity vascular trauma: Jammu experience. Asian Cardiovasc Thorac Ann. 2008;16:212–214
  30. Johnson M, Ford M, Johansen K. The combined hand surgery service. Radial or ulnary laceration: repair or ligate?. Arch Surg. 1993;128:971–975
  31. Klocker J, Fraedrich G. Traumatic injury of upper extremity arteries. In:  Liapis CD,  Balzer K,  Benedetti-Valentini F,  Fernandes e Fernandes J editor. European manual of medicine – vascular surgery. Berlin, Heidelberg, New York: Springer; 2007;p. 257–261
  32. Nichols JS, Lillehei KO. Nerve injury associated with acute vascular trauma. Surg Clin North Am. 1988;68:837–852
  33. Hammond DC, Gould JS, Hanel DP. Management of acute and chronic vascular injuries to the arm and forearm. Indications and technique. Hand Clin. 1992;8:453–463
  34. Adinolfi MF, Hardin WD, O'Connell RC, Kerstein MD. Amputations after vascular trauma in civilians. South Med J. 1983;76:1241–1243
  35. Graham JM, Mattox KL, Feliciano DV, DeBakey ME. Vascular injuries of the axilla. Ann Surg. 1982;195:232–238
  36. Simmons JD, Schmieg RE, Porter JM, D'Souza SE, Duchesne JC, Mitchell ME. Brachial artery injuries in a rural catchment trauma centre: are the upper and lower extremity the same?. J Trauma. 2008;65:327–330
  37. Stone WM, Fowl RJ, Money SR. Upper extremity trauma: current trends in management. J Cardiovasc Surg. 2007;48:551–555
  38. Feliciano DV, Cruse PA, Spjut-Patrinely V, Burch JM, Mattox KL. Fasciotomy after trauma to the extremities. Am J Surg. 1988;156:533–537

PII: S1078-5884(09)00588-7

doi:10.1016/j.ejvs.2009.11.019

European Journal of Vascular & Endovascular Surgery
Volume 39, Issue 2 , Pages 160-164, February 2010

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