The Utility of Therapeutic Anticoagulation in the Perioperative Period in Patients Presenting in Emergency Surgical Department With Extremity Vascular Injuries

Abstract

Extremity vascular trauma is a challenging surgical emergency in both civilian population and combat environment. It requires vigilant diagnosis and prompt treatment to minimize limb loss and mortality. A multidisciplinary team approach is required to deal with shock states, concomitant abdominal injuries, head injuries, and fractures with significant tissue loss and psychological stress. Anticoagulation is frequently used during traumatic vascular repair to avoid repair site thrombosis, postoperative deep venous thrombosis, and pulmonary embolism (PE). In this review article, we are going to search about how frequent is the use of anticoagulation in terms of limb salvage rates, and mortality rates or side effects of anticoagulation in terms of risk of bleeding episodes, and the need for future prospective studies. Extremity vascular trauma is managed by a variety of methods including open repairs, endovascular repairs, and nonoperative management. Most of the literature demonstrates the use of systemic or regional anticoagulation in the management of vascular injuries with the improvement in limb salvage rates and reduced morbidities but confounding factors lead to variable results. Some studies show an increased risk of bleeding in trauma patients with the use of anticoagulants in trauma settings without any significant effect on repair site thrombosis. More comprehensive studies and randomized controlled trials are needed to confirm the importance of perioperative anticoagulation while avoiding the confounding factors in terms of injury severity scores, ischemia time, demographics of patients, modes of injury, comorbidities, grades of shock, concomitant injuries that need anticoagulation like venous injuries or intracranial injuries that are contraindications to the use of anticoagulation, type of anticoagulation and expertise available as well as the experience level of the operating surgeon. Literature also reveals the use of new oral anticoagulants (e.g., dabigatran) to be associated with lesser bleeding episodes when compared to warfarin, so in future, we can check the feasibility of these agents to reduce the bleeding episodes and at the same time improve the limb salvage rates.

Vascular Surgery of Limbs in Antananarivo: Indications and Outcomes

“…Preoperative medication of statins and platelet antiaggregants could reduced mortality rate in 30-days and improved an absolute 18% 5-year survival after vascular surgery [18]. Perioperative anticoagulation treatment has been associated with 72.41% successfuls of limb salvage [19]. However, dual anticoagulant therapy expose patients to high risk of bleeding after arterial procedures of limbs.…”

Postoperative antiplatelet and/or anticoagulation use does not impact complication or reintervention rates after vein repair of arterial injury: A PROOVIT study

“…The optimal use of postoperative antithrombotic (AT) therapy in trauma patients presenting with arterial injury is not well-established, specifically in patients requiring reconstruction with an autologous vein graft. [1][2][3][4] While there is concern for postoperative hemorrhage in the setting of traumatic injury (at the site of vascular injury or at alternative site(s) of injury], there is also a risk of thrombosis of the vascular reconstruction. In the elective setting, patients undergoing vascular reconstruction with a vein graft are routinely treated with AT therapy; however, there is no consensus to utilize AT therapy in the trauma patient.…”