No abstract

Introduction and Objectives Lower Extremity (LE) arterial trauma and its treatment may lead to extremity compartment syndrome (ECS). In that setting, the decision to perform fasciotomies is multifactoral and is not well delineated. We evaluated the outcomes of patients with surgically treated LE arterial injury who underwent early or delayed fasciotomies. Methods The National Trauma Data Bank (NTDB) was retrospectively reviewed for patients who had LE arterial trauma and underwent both open vascular repair and fasciotomies. Exclusion criteria were additional non-LE vascular trauma, head or spinal cord injuries, crush injuries, burn injuries, and declaration of death on arrival. Patients were divided into those who had fasciotomies performed within 8 hours (Early Group) or > 8 hours after open vascular repair (Late Group). Comparative analyses of demographics, injury characteristics, complications, and outcomes were performed. Results Of the 1,469 patient admissions with lower extremity arterial trauma that met inclusion criteria there were 612 patients (41.7%) who underwent fasciotomies. There were 543 and 69 patients in the Early and Late Fasciotomy Groups, respectively. There was no significant difference in age, injury severity, mechanism of injury, associated injuries, and type of vascular repair between the groups. A higher rate of iliac artery injury was observed in the Late Fasciotomy Group (23.2% vs. 5.9%, P<.001). Patients in the Early Fasciotomy Group had lower amputation rate (8.5% vs. 24.6%, P<.001), lower infection rate (6.6% vs. 14.5%, P=.028) and shorted total hospital stay (18.5±20.7 days vs. 24.2±14.7 days, P=.007) than those in the Late Fasciotomy Group. On multivariable analysis, early fasciotomy was associated with a 4-fold lower risk of amputation (Odds Ratio 0.26, 95% CI 0.14–0.50, p<.0001) and 23% shorter hospital LOS (Means Ratio 0.77, 95% CI 0.64–0.94, P=.01). Conclusion Early fasciotomy is associated with improved outcomes in patients with lower extremity vascular trauma treated with surgical intervention. Our findings suggest that appropriate implementation of early fasciotomy may reduce amputation rates in extremity arterial injury.

Objective-Optimal patient selection for lower extremity revascularization remains a clinical challenge among the hemodialysis-dependent (HD). The purpose of this study was to examine contemporary real world open and endovascular outcomes of HD patients to better facilitate patient selection for intervention.Methods-A regional multicenter registry was queried between 2003 and 2013 for HD patients (N = 689) undergoing open surgical bypass (n = 295) or endovascular intervention (n = 394) for lower extremity revascularization. Patient demographics and comorbidities were recorded. The primary outcome was overall survival. Secondary outcomes included graft patency, freedom from major adverse limb events, and amputation-free survival (AFS). Multivariate analysis was performed to identify independent risk factors for death and amputation.Results-Among the 689 HD patients undergoing lower extremity revascularization, 66% were male, and 83% were white. Ninety percent of revascularizations were performed for critical limb

In the VQI, PVI was more frequently offered to patients who were older and had more comorbidities, and LEB patients were more likely to have a history of previous interventions. Patients treated with PVI had lower perioperative mortality overall, although this benefit was not seen when treating patients with fewer comorbidities or less advanced disease. However, PVI patients had higher adjusted 3-year mortality in the overall sample and in lower-risk patients. Limitations to this study, especially the follow-up, hamper meaningful interpretation of reinterventions and further reinforce the need for large, randomized, clinical studies with better long-term follow-up.

Endovascular interventions of the CFA/DFA have a low rate of periprocedural morbidity and mortality. One-year patency is lower than historically observed for CFA endarterectomy. Stent use is associated with reinterventions and amputation. Longer-term analysis is needed to better assess durability.

The VSGNE risk prediction model is best at forecasting mortality among this patient population. The Medicare and VGNW models showed good discrimination.

The data presented in this review article allow vascular clinicians to optimize patient care and achieve effective limb salvage for this growing segment of the population.

Routine UG may potentially protect against the complication of hematoma for both modifiable and nonmodifiable patient and procedural characteristics. Encouraging routine UG is a feasible quality improvement opportunity to decrease patient morbidity after PVI.