Ganapathy Anand, Khouqeer Ahmed F, Todd S Robb, Mills Joseph L, Gilani Ramyar
Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
Injury. 2017 May;48(5):1025-1030. doi: 10.1016/j.injury.2017.02.002. Epub 2017 Feb 4.
Endovascular therapy is well studied in atraumatic conditions; and there appears to be a growing interest in its application to traumatic injuries. The objective of this study is to compare open and endovascular techniques in the management of peripheral arterial trauma.
This is a retrospective review of patients admitted to a Level I Trauma Center sustaining injuries to the subclavian, axillary, superficial femoral, and popliteal arteries. Demographics, surgical interventions, complications, and clinical outcomes were evaluated in patients requiring open or endovascular repair between 2009 and 2015.
Sixty-eight patients with 70 total arterial injuries were identified. There were 10 subclavian, 14 axillary, 15 superficial femoral, and 31 popliteal artery injuries. Endovascular (n=20) compared to open repairs (n=50) were more commonly performed: by vascular surgeons (90% vs. 54%, p=0.01); in older patients (median age: 38 years vs. 25, p=0.01); primarily involving upper extremity injuries (60% vs. 24%, p=0.01). Furthermore, endovascular repairs less commonly required fasciotomy (15% vs. 46%, p=0.03) and trended towards lower transfusion requirements (50% vs. 77%, p=0.06). Patients undergoing open repair had lower pre-hospital systolic blood pressures (110 vs. 120, p=0.03) and lower initial hematocrit (31.5 vs. 36.2, p=0.02). However, outcomes between groups were trending higher in the endovascular group with respect to limb salvage rates at discharge (94% vs. 89%), median length of stay (14days vs. 9), and median follow-up (288days vs. 92) compared to the open group, but the data were not statistically significant. There was increasing utilization of endovascular repair over time (7% of total procedures in 2009; 50% in 2014).
Overall, endovascular and open techniques were not statistically different in early outcomes. Endovascular therapy appears to provide some advantage when it comes to: challenging anatomy, decreasing blood product utilization, and minimizing physiologic derangement. However, patients with injuries resulting in free hemorrhage or significant external blood loss may still be best served with open repair. Despite this, given the increasing use of endovascular techniques, close collaboration is needed between trauma and endovascular specialists to properly select the optimal management for patients with peripheral arterial trauma.
血管内治疗在非创伤性疾病中已得到充分研究；并且其在创伤性损伤中的应用似乎也越来越受到关注。本研究的目的是比较开放手术和血管内技术在处理外周动脉创伤方面的效果。
这是一项对一级创伤中心收治的锁骨下动脉、腋动脉、股浅动脉和腘动脉损伤患者的回顾性研究。对2009年至2015年间需要进行开放手术或血管内修复的患者的人口统计学资料、手术干预措施、并发症及临床结果进行评估。
共确定68例患者，总计70处动脉损伤。其中锁骨下动脉损伤10处，腋动脉损伤14处，股浅动脉损伤15处，腘动脉损伤31处。与开放修复组（n = 50）相比，血管内修复组（n = 20）的手术更多由血管外科医生完成（90%对54%，p = 0.01）；患者年龄更大（中位年龄：38岁对25岁，p = 0.01）；主要涉及上肢损伤（60%对24%，p = 0.01）。此外，血管内修复较少需要进行筋膜切开术（15%对46%，p = 0.03），且输血需求有降低趋势（50%对77%，p = 0.06）。接受开放修复的患者院前收缩压较低（110对120，p = 0.03），初始血细胞比容也较低（31.5对36.2，p = 0.02）。然而，血管内修复组在出院时的肢体挽救率（94%对89%）、中位住院时间（14天对9天）和中位随访时间（288天对92天）方面与开放手术组相比有升高趋势，但数据无统计学意义。随着时间推移，血管内修复的应用越来越多（2009年占总手术量的7%；2014年占50%）。
总体而言，血管内技术和开放手术技术在早期结果上无统计学差异。在处理解剖结构复杂的情况、减少血制品使用以及使生理紊乱最小化方面，血管内治疗似乎具有一定优势。然而，对于导致自由出血或大量外出血的损伤患者，开放修复可能仍是最佳选择。尽管如此，鉴于血管内技术的使用日益增加，创伤外科医生和血管内专家之间需要密切合作，以便为外周动脉创伤患者正确选择最佳治疗方案。
