Masood Ayesha, Danawar Nuaman A, Mekaiel Andrew, Raut Sumit, Malik Bilal Haider
General Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA.
Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA.
Cureus. 2020 Jun 6;12(6):e8473. doi: 10.7759/cureus.8473.
Extremity vascular trauma is a challenging surgical emergency in both civilian population and combat environment. It requires vigilant diagnosis and prompt treatment to minimize limb loss and mortality. A multidisciplinary team approach is required to deal with shock states, concomitant abdominal injuries, head injuries, and fractures with significant tissue loss and psychological stress. Anticoagulation is frequently used during traumatic vascular repair to avoid repair site thrombosis, postoperative deep venous thrombosis, and pulmonary embolism (PE). In this review article, we are going to search about how frequent is the use of anticoagulation in terms of limb salvage rates, and mortality rates or side effects of anticoagulation in terms of risk of bleeding episodes, and the need for future prospective studies. Extremity vascular trauma is managed by a variety of methods including open repairs, endovascular repairs, and nonoperative management. Most of the literature demonstrates the use of systemic or regional anticoagulation in the management of vascular injuries with the improvement in limb salvage rates and reduced morbidities but confounding factors lead to variable results. Some studies show an increased risk of bleeding in trauma patients with the use of anticoagulants in trauma settings without any significant effect on repair site thrombosis. More comprehensive studies and randomized controlled trials are needed to confirm the importance of perioperative anticoagulation while avoiding the confounding factors in terms of injury severity scores, ischemia time, demographics of patients, modes of injury, comorbidities, grades of shock, concomitant injuries that need anticoagulation like venous injuries or intracranial injuries that are contraindications to the use of anticoagulation, type of anticoagulation and expertise available as well as the experience level of the operating surgeon. Literature also reveals the use of new oral anticoagulants (e.g., dabigatran) to be associated with lesser bleeding episodes when compared to warfarin, so in future, we can check the feasibility of these agents to reduce the bleeding episodes and at the same time improve the limb salvage rates.
肢体血管创伤在 civilian population 和战斗环境中都是具有挑战性的外科急症。它需要警惕的诊断和及时的治疗，以尽量减少肢体丧失和死亡率。需要多学科团队方法来处理休克状态、伴发的腹部损伤、头部损伤以及伴有大量组织丢失和心理压力的骨折。在创伤性血管修复过程中经常使用抗凝治疗，以避免修复部位血栓形成、术后深静脉血栓形成和肺栓塞（PE）。在这篇综述文章中，我们将探讨抗凝治疗在肢体挽救率方面的使用频率，以及抗凝治疗在出血事件风险方面的死亡率或副作用，以及未来前瞻性研究的必要性。肢体血管创伤通过多种方法进行处理，包括开放修复、血管腔内修复和非手术治疗。大多数文献表明，在血管损伤的治疗中使用全身或局部抗凝治疗可提高肢体挽救率并降低发病率，但混杂因素导致结果各异。一些研究表明，在创伤环境中使用抗凝剂会增加创伤患者出血的风险，而对修复部位血栓形成没有任何显著影响。需要更全面的研究和随机对照试验来确认围手术期抗凝治疗的重要性，同时避免在损伤严重程度评分、缺血时间、患者人口统计学、损伤方式、合并症、休克分级、需要抗凝治疗的伴发损伤（如静脉损伤或使用抗凝治疗的禁忌症颅内损伤）、抗凝类型和可用专业知识以及手术医生的经验水平等方面的混杂因素。文献还表明，与华法林相比，新型口服抗凝剂（如达比加群）使用时出血事件较少，因此在未来，我们可以检查这些药物降低出血事件并同时提高肢体挽救率的可行性。
