识别动脉修复失败的风险因素和经验教训：斯里兰卡战争中处理 129 例战伤四肢血管的经验。
Identification of risk factors for arterial repair failures and lessons learned: Experiences from managing 129 combat vascular extremity wounds in the Sri Lankan War.
机构信息
From the Army Hospital Colombo 00800 (A.S.R., K.R.), Sri Lanka; General Surgery Trauma Unit, Hadassah Hebrew University Medical Center (M.B.), Jerusalem, Israel; The Department of Surgery at Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center (R.H., T.J.W.); and Department of Surgery (B.S.), University of Peradeniya, Peradeniya, Sri Lanka.
出版信息
J Trauma Acute Care Surg. 2019 Jul;87(1S Suppl 1):S178-S183. doi: 10.1097/TA.0000000000002260.
BACKGROUND
In extremity vascular trauma, early complications occur at a rate of 13% to 44%. The most common of which are infection, dehiscence, thrombosis, and stenosis. Failure of the arterial repair, also called arterial blowout, has the potential for exsanguinating hemorrhage and poses a considerable challenge for the surgeon to save limb and life.
METHOD
All adults with extremity vascular injuries admitted in 8-month period were prospectively recorded and retrospectively analyzed. Extremity vascular injuries in this group include those in which limb salvage attempted. 5 arterial blowouts in a recorded 87 arterial repairs were analyzed for demographics, presentation, management and outcome in the context of identifying most probable causative factors.
RESULT
5 arterial blowouts occurred out of 87 arterial repairs for a rate of 5.75%. These occurred at a mean of 14 days post-operatively. All patients were male with the majority of the injuries, 80%, resulting from gunshot wounds. All injuries were associated with severe soft tissue injury and clinical evidence of bacterial infection. Technical error, inadequate debridement, prolonged exposed vessel and unstable skeletal injury were noted as causative factors in addition to the commonly reported causes of repair failure. At a mean follow-up of 17 days, the arterial blowout cohort had 80% limb survival rate.
CONCLUSION
Ischemic, damaged and contaminated military wounds lead to infections of varied degree. Delay in closure due to tight distal muscle compartments or severe persistent soft tissue infections, necessitating serial irrigation and debridement (I&D) of wounds, is the common chain noted leading to arterial blowout. To break this chain of events the authors suggest early identification of at risk limbs and aggressive soft tissue cover of the newly constructed repair.
LEVEL OF EVIDENCE
Case series, level IV.
背景
在四肢血管创伤中，早期并发症的发生率为 13%至 44%。其中最常见的是感染、裂开、血栓形成和狭窄。动脉修复的失败，也称为动脉破裂，有出血性休克的风险，对外科医生来说，挽救肢体和生命是一个相当大的挑战。
方法
所有在 8 个月期间入院的四肢血管损伤的成年人都被前瞻性记录并回顾性分析。该组中的四肢血管损伤包括试图保留肢体的损伤。对记录的 87 例动脉修复中的 5 例动脉破裂进行了分析，以确定最可能的致病因素，并分析其人口统计学、表现、处理和结果。
结果
在 87 例动脉修复中发生了 5 例动脉破裂，发生率为 5.75%。这些发生在术后平均 14 天。所有患者均为男性，其中 80%的损伤是由枪伤引起的。所有损伤均伴有严重的软组织损伤和细菌感染的临床证据。技术错误、清创不充分、暴露血管时间延长和不稳定的骨骼损伤被认为是除了常见的修复失败原因之外的致病因素。在平均 17 天的随访中，动脉破裂组的肢体存活率为 80%。
结论
缺血、受损和污染的军事伤口导致不同程度的感染。由于远端肌肉间隙紧张或严重持续的软组织感染而导致的延迟闭合，需要对伤口进行反复冲洗和清创（I&D），这是导致动脉破裂的常见链条。为了打破这一连串的事件，作者建议早期识别高危肢体，并积极覆盖新构建的修复体的软组织。
证据水平
病例系列，IV 级。
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