Emergency vascular repairs in trauma: Predictors of poor prognosis and a novel scoring system

Abstract

BACKGROUND Vascular injuries comprise 1-4% of all trauma patients and there are no widely used risk-stratification tools. We sought to establish predictors of revascularization failures and compare outcomes of trauma and vascular surgeons. METHODS We performed a single-institution, case-control study of consecutive patients with traumatic arterial injuries who underwent open repair between 2016 and 2021. Multivariable logistic regression was used to investigate covariates impacting the primary composite outcome of repair failure/revision, amputation, or in-hospital mortality. RESULTS Among 165 patients, median age was 34 years, 149 (90%) were male, and 99 (60%) suffered penetrating injury. Popliteal (46%) and superficial femoral (44%) arterial injuries were most common. Interposition graft/bypass was the most frequent repair (n = 107, 65%). Revascularization failure was observed in 24 (15%) patients. Compared to trauma surgeons, vascular surgeons more frequently repaired blunt injuries (66% vs. 20%, p < 0.001), anterior tibial (18% vs. 5%, p = 0.012) or tibioperoneal (28% vs. 4%, p < 0.001) injuries, with a below-knee bypass (38% vs. 20%, p = 0.019). Revascularization failure occurred in 10% (9/93) of repairs by trauma surgeons and 21% (13/61) of repairs by vascular surgeons. Mangled Extremity Severity Score (MESS) > 8 (OR: 15.6, 95% CI: 4.4 – 55.9, p < 0.001) and concomitant laparotomy or orthopedic procedure (OR: 6.7, 95% CI: 1.6 - 28.6, p = 0.010) were independently associated with revascularization failure. A novel composite scoring system (UT Houston Score) was developed by combining MESS score, concomitant procedure, mechanism of injury, and injury location. This score demonstrated a sensitivity of 100% with a score of 0 and a specificity of 95% with a score > 3. CONCLUSIONS After traumatic arterial injury, trauma surgeons repaired less-complex injuries, but with fewer revascularization failures than vascular surgeons. The UT Houston Score may be used to risk-stratify patients to determine who may benefit from vascular surgery consultation. LEVEL OF EVIDENCE Level III, Therapeutic/Care Management