Division of Vascular Surgery, Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
J Trauma Acute Care Surg. 2012 Oct;73(4):818-24. doi: 10.1097/TA.0b013e3182587f32.
Secondary hemorrhage after a dehisced vascular reconstruction is a dreaded complication, yet few reports describe the initial management and outcome of casualties with ruptured grafts from military wounds. We aimed to report a single-center experience of graft ruptures after evacuation of casualties to a tertiary hospital in the continental United States.
Trauma records of US combat casualties were retrospectively reviewed from April 2005 to August 2007. Casualties who underwent an extremity vascular reconstruction in Iraq or Afghanistan and experienced a ruptured graft were included.
Ten graft ruptures (mean time, 14 days) occurred during the study period. All casualties were males with penetrating injuries by secondary blast effects (5, 50%) or gunshot wounds (5, 50%). Mean age and Injury Severity Score were 28.2 years (range, 20-41 years) and 21.1 (range 10-32), respectively. Repairs were performed on the superficial femoral (4, 40%), popliteal (2, 20%), brachial (1, 10%), axillary (1, 10%), iliac (1, 10%), and common femoral (1, 10%) arteries using reversed saphenous vein grafts (10, 100%). Initial management included control of hemorrhage and extra-anatomic reconstruction with a vein graft (4), prosthetic graft (4), end-to-end anatomosis (1), or primary amputation (1). Secondary complications in those 10 limbs requiring reintervention included 4 thrombotic graft failures (40%), and 1 transfemoral amputation from a graft infection. Ruptures were frequently associated with long-bone fractures (6, 60%), large soft tissue open wounds (5, 50%) and infection (7, 70%). At a mean follow-up of 37 months, the amputation rate in this series was 30%, with an amputation-free survival of 70%.
Contaminated military wounds with bony fractures may predispose a graft of any type (vein or prosthetic) to anastomotic dehiscence. Wounds must be carefully debrided, and when grafts cannot be covered with viable muscle, they should be routed around the zone of injury.
Therapeutic study, level V.
血管重建术后愈合不良导致的再次出血是一种可怕的并发症，但鲜有报道描述美军伤员破裂移植物的初始处理和结果。我们旨在报告在大陆美国的一家三级医院接受伤员后，破裂移植物的单一中心经验。
回顾性审查 2005 年 4 月至 2007 年 8 月期间的美国战伤伤员的创伤记录。在伊拉克或阿富汗进行四肢血管重建并发生移植物破裂的伤员纳入研究。
研究期间共发生 10 例移植物破裂（平均时间 14 天）。所有伤员均为男性，均为二次爆炸效应（5 例，50%）或枪伤（5 例，50%）导致穿透伤。平均年龄和损伤严重度评分分别为 28.2 岁（范围 20-41 岁）和 21.1（范围 10-32）。使用大隐静脉移植修复股浅动脉（4 例，40%）、腘动脉（2 例，20%）、肱动脉（1 例，10%）、腋动脉（1 例，10%）、髂动脉（1 例，10%）和股总动脉（1 例，10%）。初次治疗包括控制出血和采用静脉移植物（4 例）、人工移植物（4 例）、端端吻合（1 例）或一期截肢（1 例）进行解剖外重建。10 例肢体需要再次干预的次要并发症包括 4 例血栓性移植物失败（40%）和 1 例因移植物感染行股部截肢。破裂常与长骨骨折（6 例，60%）、大的软组织开放性伤口（5 例，50%）和感染（7 例，70%）有关。平均随访 37 个月时，本系列截肢率为 30%，无截肢生存率为 70%。
合并骨折的污染性军用伤口可能使任何类型的移植物（静脉或人工）发生吻合口裂开。必须仔细清创，当移植物不能被有活力的肌肉覆盖时，应将其绕过损伤区。
治疗研究，5 级。
