Frank Brian, Maher Zoё, Hazelton Joshua P, Resnick Shelby, Dauer Elizabeth, Goldenberg Anna, Lubitz Andrea L, Smith Brian P, Saillant Noelle N, Reilly Patrick M, Seamon Mark J
From the Department of Surgery, Geisinger Health System (B.F.), Danville; Division of Trauma and Surgical Critical Care, Department of Surgery (Z.M.) and Department of Surgery (E.D., A.L.L.), Temple University School of Medicine, Philadelphia, Pennsylvania; Division of Trauma and Surgical Critical Care, Department of Surgery, Cooper Medical School of Rowan University (J.P.H., A.G.), Camden, New Jersey; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania (S.R., B.P.S., P.M.R., M.J.S.), Philadelphia, Pennsylvania; and Massachusetts General Hospital (N.N.S.), Boston, Massachusetts.
J Trauma Acute Care Surg. 2017 Dec;83(6):1095-1101. doi: 10.1097/TA.0000000000001655.
Venous thromboembolism (VTE) after major vascular injury (MVI) is particularly challenging because the competing risk of thrombosis and embolization after direct vessel injury must be balanced with risk of bleeding after surgical repair. We hypothesized that venous injuries, repair type, and intraoperative anticoagulation would influence VTE formation after MVI.
A multi-institution, retrospective cohort study of consecutive MVI patients was conducted at three urban, Level I centers (2005-2013). Patients with MVI of the neck, torso, or proximal extremities (to elbows/knees) were included. Our primary study endpoint was the development of VTE (DVT or pulmonary embolism [PE]).
The 435 major vascular injury patients were primarily young (27 years) men (89%) with penetrating (84%) injuries. When patients with (n = 108) and without (n = 327) VTE were compared, we observed no difference in age, mechanism, extremity injury, tourniquet use, orthopedic and spine injuries, damage control, local heparinized saline, or vascular surgery consultation (all p > 0.05). VTE patients had greater Injury Severity Score (ISS) (17 vs. 12), shock indices (1 vs. 0.9), and more torso (58% vs. 35%) and venous (73% vs. 48%) injuries, but less often received systemic intraoperative anticoagulation (39% vs. 53%) or postoperative enoxaparin (47% vs. 61%) prophylaxis (all p < 0.05). After controlling for ISS, hemodynamics, injured vessel, intraoperative anticoagulation, and postoperative prophylaxis, multivariable analysis revealed venous injury was independently predictive of VTE (odds ratio, 2.7; p = 0.002). Multivariable analysis of the venous injuries subset (n = 237) then determined that only delay in starting VTE chemoprophylaxis (odds ratio, 1.3/day; p = 0.013) independently predicted VTE after controlling for ISS, hemodynamics, injured vessel, surgical subspecialty, intraoperative anticoagulation, and postoperative prophylaxis. Overall, 3.4% of venous injury patients developed PE, but PE rates were not related to their operative management (p = 0.72).
Patients with major venous injuries are at high risk for VTE, regardless of intraoperative management. Our results support the immediate initiation of postoperative chemoprophylaxis in patients with major venous injuries.
Therapeutic/care management, level IV.
重大血管损伤（MVI）后的静脉血栓栓塞症（VTE）极具挑战性，因为直接血管损伤后血栓形成和栓塞的竞争风险必须与手术修复后的出血风险相平衡。我们推测静脉损伤、修复类型和术中抗凝会影响MVI后VTE的形成。
在三个城市的一级中心（2005 - 2013年）对连续的MVI患者进行了一项多机构回顾性队列研究。纳入颈部、躯干或近端肢体（至肘部/膝部）发生MVI的患者。我们的主要研究终点是VTE（深静脉血栓形成或肺栓塞[PE]）的发生。
435例重大血管损伤患者主要为年轻（27岁）男性（89%），有穿透伤（84%）。比较有VTE（n = 108）和无VTE（n = 327）的患者，我们发现年龄、损伤机制、肢体损伤、止血带使用、骨科和脊柱损伤、损伤控制、局部肝素盐水或血管外科会诊方面均无差异（所有p > 0.05）。VTE患者的损伤严重程度评分（ISS）更高（17 vs. 12）、休克指数更高（1 vs. 0.9），且躯干损伤（58% vs. 35%）和静脉损伤（73% vs. 48%）更多，但接受全身术中抗凝（39% vs. 53%）或术后依诺肝素预防（47% vs. 61%）的频率更低（所有p < 0.05）。在控制了ISS、血流动力学、损伤血管、术中抗凝和术后预防因素后，多变量分析显示静脉损伤是VTE的独立预测因素（比值比，2.7；p = 0.002）。对静脉损伤亚组（n = 237）进行多变量分析，在控制了ISS、血流动力学、损伤血管、手术亚专业、术中抗凝和术后预防因素后，确定只有开始VTE化学预防的延迟（比值比，1.3/天；p = 0.013）是VTE的独立预测因素。总体而言，3.4%的静脉损伤患者发生了PE，但PE发生率与手术管理无关（p = 0.72）。
无论术中管理如何，有重大静脉损伤的患者发生VTE的风险都很高。我们的结果支持对有重大静脉损伤的患者立即启动术后化学预防。
治疗/护理管理，四级。
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