Kauvar David S, Propper Brandon W, Arthurs Zachary M, Causey M Wayne, Walters Thomas J
Vascular Surgery Service, San Antonio Military Medical Center, Fort Sam Houston, TX; Department of Surgery, Uniformed Services University of the Health Sciences, Fort Sam Houston, TX.
Vascular Surgery Service, San Antonio Military Medical Center, Fort Sam Houston, TX; Department of Surgery, Uniformed Services University of the Health Sciences, Fort Sam Houston, TX.
Ann Vasc Surg. 2020 Jan;62:119-127. doi: 10.1016/j.avsg.2019.08.072. Epub 2019 Aug 30.
By necessity, wartime arterial injuries undergo staged management. Initial procedures may occur at a forward surgical team (role 2), where temporary shunts can be placed before transfer to a larger field hospital (role 3) for definitive reconstruction. Our objective was to evaluate the impact of staging femoropopliteal injury care on limb outcomes.
A military vascular injury database was queried for Iraq/Afghanistan casualties with femoropopliteal arterial injuries undergoing attempted reconstruction (2004-2012). Cases were grouped by initial arterial management: shunt placed at role 2 (R2SHUNT), reconstruction at role 2 (R2RECON), and initial management at role 3 (R3MGT). The primary outcome was limb salvage; secondary outcomes were limb-specific complications. Descriptive and intergroup comparative statistics were performed with significance defined at P ≤ 0.05.
Of 257 cases, all but 4 had definitive reconstruction before evacuation to Germany (median, 2 days): 46 R2SHUNT, 84 R2RECON, and 127 R3MGT; median Mangled Extremity Severity Score was 6 for all groups. R2SHUNT had median extremity Abbreviated Injury Scale--vascular of 4 (other groups, 3; P < 0.05) and was more likely to have concomitant venous injury and to undergo fasciotomy. Shunts were used for 5 ± 3 hr. About 24% of R2RECON repairs were revised at role 3. Limb salvage rate of 80% was similar between groups, and 62% of amputations performed within 48 hr of injury. Rates of limb and composite graft complications were similar between groups. Thrombosis was more common in R2SHUNT (22%) than R2RECONST (6%) or R3MGT (12%) (P = 0.03). Late (>48 hr) thrombosis rates were similar, whereas 60% of R2SHUNT thromboses occurred on day of injury (P = 0.003 vs. 25% and 0%).
Staged femoropopliteal injury care is associated with similar limb salvage to initial role 3 management. Early thrombosis is likely because of shunt failure but does not lead to limb loss. Current military practice guidelines are appropriate and may inform civilian vascular injury management protocols.
战时动脉损伤必然需要分阶段处理。初始手术可能在前方手术团队（2级）进行，在此可放置临时分流管，之后再转至更大的野战医院（3级）进行确定性重建。我们的目的是评估分阶段处理股腘动脉损伤对肢体预后的影响。
查询军事血管损伤数据库，获取2004年至2012年在伊拉克/阿富汗有股腘动脉损伤且尝试进行重建的伤员信息。病例按初始动脉处理方式分组：在2级放置分流管（R2SHUNT）、在2级进行重建（R2RECON）以及在3级进行初始处理（R3MGT）。主要结局是肢体挽救；次要结局是肢体特异性并发症。进行描述性和组间比较统计，显著性定义为P≤0.05。
在257例病例中，除4例之外所有病例在撤离至德国前均进行了确定性重建（中位时间为2天）：46例R2SHUNT、84例R2RECON和127例R3MGT；所有组的中位肢体严重损伤评分均为6分。R2SHUNT组的中位肢体简化损伤评分——血管为4分（其他组为3分；P<0.05），且更可能伴有静脉损伤并接受筋膜切开术。分流管使用时间为5±3小时。约24%的R2RECON修复在3级进行了修订。各组间肢体挽救率相似，80%，且62%的截肢在受伤后48小时内进行。各组间肢体和复合移植物并发症发生率相似。血栓形成在R2SHUNT组（22%）比R2RECONST组（6%）或R3MGT组（12%）更常见（P = 0.03）。晚期（>48小时）血栓形成率相似，而60%的R2SHUNT血栓形成发生在受伤当天（与25%和0%相比，P = 0.003）。
分阶段处理股腘动脉损伤与初始在3级处理的肢体挽救情况相似。早期血栓形成可能是由于分流管故障，但不会导致肢体丢失。当前的军事实践指南是合适的，可能为 civilian 血管损伤管理方案提供参考。 （注：这里“civilian”原文有误，可能是“civil”，意为民用的、非军事的 ）
