Haney Lauren J, Bae Esther, Pugh Mary Jo V, Copeland Laurel A, Wang Chen-Pin, MacCarthy Daniel J, Amuan Megan E, Shireman Paula K
Long School of Medicine, The University of Texas Health Science Center San Antonio, San Antonio, Texas, USA.
South Texas Veterans Health Care System, San Antonio, Texas, USA.
Trauma Surg Acute Care Open. 2020 Dec 24;5(1):e000616. doi: 10.1136/tsaco-2020-000616. eCollection 2020.
Extremity vascular injury (EVI) causes significant disability in Veterans of the Afghanistan/Iraq conflicts. Advancements in acute trauma care improved survival and decreased amputations. The study of wartime EVI has relied on successful limb salvage as a surrogate for vascular repair. We used imaging studies as a specific measure of arterial repair durability.
Service members with EVI were identified using the Department of Defense Trauma Registry and validated by chart abstraction. Inclusion criteria for the arterial patency subgroup included an initial repair attempt with subsequent imaging reports (duplex ultrasound, CT angiography, and angiogram) documenting initial patency.
The cohort of 527 included 140 Veterans with available imaging studies for 143 arterial repairs; median follow-up from injury time to last available imaging study was 19 months (Q1-Q3: 3-58; range: 1-175). Injury mechanism was predominantly explosions (52%) and gunshot wounds (42%). Of the 143 arterial repairs, 81% were vein grafts. Eight repairs were occluded, replaced or included in extremity amputations. One upper extremity and three transtibial late amputations were performed for chronic pain and poor function averaging 27 months (SD: 4; range: 24-32). Kaplan-Meier analysis estimated patency rates of 99%, 97%, 95%, 91% and 91% at 3, 6, 12, 24, and 36 months, respectively, with similar results for upper and lower extremity repairs. Explosive and gunshot wound injury mechanisms had similar patency rates and upper extremity injuries repaired with vein grafts had increased patency.
Arterial repair mid-term patency in combat-related extremity injuries is excellent based on imaging studies for 143 repairs. Assertive attempts at acute limb salvage and vascular repair are justified with decisions for amputation versus limb salvage based on the overall condition of the patient and degree of concomitant nerve, orthopedic and soft tissue injuries rather than the presence of arterial injuries.
Therapeutic/care management, level IV.
在阿富汗/伊拉克冲突的退伍军人中，肢体血管损伤（EVI）会导致严重残疾。急性创伤护理的进步提高了生存率并减少了截肢率。战时EVI的研究一直将成功保肢作为血管修复的替代指标。我们使用影像学研究作为评估动脉修复耐久性的具体指标。
通过国防部创伤登记处识别出患有EVI的军人，并通过病历摘要进行验证。动脉通畅亚组的纳入标准包括首次修复尝试以及随后的影像学报告（双功超声、CT血管造影和血管造影）记录初始通畅情况。
527名研究对象中，有140名退伍军人进行了143次动脉修复并有可用的影像学研究；从受伤时间到最后一次可用影像学研究的中位随访时间为19个月（第一四分位数-第三四分位数：3-58；范围：1-175）。损伤机制主要为爆炸伤（52%）和枪伤（42%）。在143次动脉修复中，81%采用了静脉移植。8次修复出现闭塞、被替换或包含在肢体截肢中。因慢性疼痛和功能不佳进行了1次上肢和3次经胫骨晚期截肢，平均时间为27个月（标准差：4；范围：24-32）。Kaplan-Meier分析估计，在3、6、12、24和36个月时的通畅率分别为99%、97%、95%、91%和91%，上肢和下肢修复结果相似。爆炸伤和枪伤的损伤机制通畅率相似，采用静脉移植修复的上肢损伤通畅率有所提高。
基于对143次修复的影像学研究，与战斗相关的肢体损伤中动脉修复的中期通畅情况良好。积极尝试急性肢体挽救和血管修复是合理的，截肢与保肢的决策应基于患者的整体状况以及伴随的神经、骨科和软组织损伤程度，而非动脉损伤的存在。
治疗/护理管理（四级）
