|Year : 2019 | Volume
| Issue : 1 | Page : 9-14
A descriptive study of the etiology and outcome of peripheral vascular injuries at the Aminu Kano Teaching Hospital
Tunde N Oyebanji1, Ismail M Inuwa1, Jameel Ismail Ahmad1, Shamsuddeen Muhammad2, Abdulrahman A Sheshe3, Lofty John C Anyanwu4
1 Cardiothoracic Unit, Department of Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Orthopedic Unit, Department of Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
3 General Surgery Unit, Department of Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
4 Pediatric Surgery Unit, Department of Surgery, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||5-Mar-2019|
Dr. Tunde N Oyebanji
Cardiothoracic Unit, Department of Surgery, Aminu Kano Teaching Hospital, PMB 3452, Kano
Source of Support: None, Conflict of Interest: None
Background: Peripheral vascular injuries (PVIs) are infrequent but their management could be hampered by delayed presentation and fraught with untoward morbidity or death. Herein, we describe the factors contributing to the morbidity and mortality of PVIs in this environment. Materials and Methods: Data relating to patients with PVIs between March, 2012 and March, 2018 were retrospectively collected from case folders and analyzed. Results: The records of 16 patients were analyzed. There were 13 (76.9%) males and 3 (23.1%) females. The male/female ratio was 4.3:1. The median age was 30 years (range, 10–52). The median duration between injury and presentation was 2.5 days. Nine (56.3%) PVIs were secondary to stab wounds; two (12.5%) occurred in intravenous drug abusers while the others were each of different etiologies. The superficial femoral artery was the most frequently injured vessel (six cases; 37.6%). Fourteen (87.5%) patients required surgery ranging from patch arterioplasty to reversed saphenous vein interposition graft. Two (12.5%) patients were managed conservatively. The mean length of stay for the overall patient population was 11.7 days. Ten patients (62.5%) had surgical site infections (SSIs) causing prolonged hospital admission. There were three deaths (18.8%), all occurring in patients with co-morbidities like chronic kidney disease (CKD) and sepsis. Conclusion: PVIs were infrequent in this environment and presentation is delayed. Reasonable limb salvage rates are possible depending on the severity of ischemia. SSIs may suggest prolonged hospital stay. Mortality appears to be heightened if there are underlying co-morbidities. More patients would however be required to statistically correlate these findings.
Keywords: Injury, peripheral, trauma, vascular
|How to cite this article:|
Oyebanji TN, Inuwa IM, Ahmad JI, Muhammad S, Sheshe AA, Anyanwu LC. A descriptive study of the etiology and outcome of peripheral vascular injuries at the Aminu Kano Teaching Hospital. Niger J Basic Clin Sci 2019;16:9-14
|How to cite this URL:|
Oyebanji TN, Inuwa IM, Ahmad JI, Muhammad S, Sheshe AA, Anyanwu LC. A descriptive study of the etiology and outcome of peripheral vascular injuries at the Aminu Kano Teaching Hospital. Niger J Basic Clin Sci [serial online] 2019 [cited 2019 Jul 19];16:9-14. Available from: http://www.njbcs.net/text.asp?2019/16/1/9/253405
| Introduction|| |
Peripheral vascular injuries (PVIs) involve injuries to the arteries and/or veins outside the chest or abdomen. PVI in the civilian setting are infrequent but are expected to increase because of urbanization with its attendant increase in violence or conflict and road traffic injuries. The magnitude of the problem in Nigeria is not known and available data are institution based.
Time is of essence in the management of PVI. Prognosis is good if treatment is instituted early. However, delay in treatment could result in limb loss from limb ischemia and mortality from hemorrhage. Limb-threatening ischemia may cause peripheral nerve (PN) dysfunction within few minutes of onset, and this may persist even after revascularization and affect long-term function in the affected extremity. The fact that time is sine qua non for the treatment of patients with PVI is surprisingly unknown to a large number of healthcare personnel. A number of local publications have mentioned delays in patients being referred to specialized centers.,, It should be emphasized that the ischemia time includes the pre-hospital time (often including delays in inter-hospital transfers) as well as the time that it takes to actually repair the injury.
Significant improvements have been achieved in the management of PVI in developed countries. Endovascular approaches are increasingly being incorporated into the management of PVI. Locally however, the healthcare system is not adequately developed to cater for this category of patients. Pre-hospital care is non-existent unlike in other climes. Patients have to travel great distances to seek for care because of the dearth of vascular surgeons in the country and often arrive at tertiary centers late with varying grades of infection of the surrounding soft tissues and or sepsis; compartment syndrome; and gangrene of extremities. Length of hospital stay, hospital expenses, morbidity, and even mortality risks are consequently heightened.
Our study aimed to determine the peculiarities in presentation, etiology, and outcome of management of PVI at the Aminu Kano Teaching Hospital.
| Materials and Methods|| |
This is a single-center retrospective descriptive analysis of records of patients with PVI that presented to the Accident and Emergency Department of the Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. Data relating to patients with PVIs between March, 2012 and March, 2018 were collected from case folders.
Records of patients with vascular injuries involving the vessels of the upper or lower limbs and neck region were retrieved for analysis. Patients with injuries involving the intrathoracic, abdominal, and intra-cerebral blood vessels were not included in the analysis.
Patients with “hard” signs of PVI such as active bleeding, rapidly expanding hematoma, any of the classical signs of arterial occlusion (pulselessness, pallor, paresthesia, pain, paralysis, poikilothermia = 6 “P”s), and a palpable thrill/audible bruit from injuries had emergency surgeries without recourse to selective diagnostic imaging. Hemorrhage was controlled by pressure dressing and patients that were symptomatic from significant hemorrhage or were in shock were resuscitated with intravenous crystalloids and blood. Patients with “soft” signs of vascular injury such as a history of arterial bleeding at the scene or in transit; proximity of a penetrating wound or blunt injury to an artery; a small non-pulsatile hematoma over an artery; and a neurologic deficit originating in a nerve adjacent to a named artery had duplex ultrasonography and/or computerized tomographic angiography with 3D reconstruction done, after stabilization, to detail the injury or specific pathology before any surgical intervention.
The basic principles for vascular repair were adhered to – which included adequate exposure, proximal and distal control before exploring the vascular injury, systemic heparinization with 100 IU/kg of unfractionated heparin before applying the vascular clamps and proximal and distal embolectomy to ensure good inflow and outflow before the repair. The method adopted for repair depended on the type of vascular injury.
Data selected for analysis included patient demographics, etiology, vessel injured and anatomical distribution of injury, duration between injury and presentation, distance travelled to seek for care, length of hospital stay, and surgical approaches and outcome. Data analysis were done with the Statistical Package for Social Sciences (SPSS) version 23 and results presented as numbers, percentages, and median as appropriate and also pictorially in the form of tables.
| Results|| |
The records of 16 patients were analyzed. There were 13 (76.9%) males and 3 (23.1%) females. The male/female ratio was 4.3:1. The age ranged from 10 to 52 years, the median being 30 years [Table 1]. Eleven of the patients (68.8%) were from within the Kano state while the rest (five patients; 31.2%) were referred from surrounding states. The average distance traveled by patients to AKTH was 180 km. The minimum time interval from injury to presentation at or referral to AKTH was 20 min while the maximum was 365 days. The median interval between injury and presentation was 2.5 days. Nine (56.3%) PVIs were secondary to stab wounds; two (12.5%) occurred in intravenous drug abusers while the others were each of different etiologies [Table 2]. The superficial femoral artery was the most frequently injured vessel, either alone (three cases; 18.8%) or in association with the femoral vein (three cases; 18.8%). The brachial artery was the next most injured vessel (three cases; 18.8%) [Table 3]. The median nerve was always involved in the cases of stab injuries to the brachial artery (two cases; 12.5%). The management method depended largely on injury type [Table 4]. Fourteen (87.5%) patients required surgery ranging from patch arterioplasty to reversed saphenous vein interposition graft. Two (12.5%) patients were managed non-operatively. The mean length of hospital stay for the overall patient population was 11.7 days (SD = 6; median, 10.5; range, 2–22 days). Ten patients (62.5%) had surgical site infections (SSIs) causing prolonged hospital admission [Table 5]. One patient (6.3%), who presented 5 days after a stab wound involving the popliteal artery and vein and with compartment syndrome, had above knee amputation for gangrene of the leg despite revascularization and fasciotomy. There were three deaths (18.8%), all occurring in patients with co-morbidities like chronic kidney disease (CKD) and sepsis, and at an average of 7 days postoperatively.
| Discussion|| |
PVI: Distribution and volume
PVI constitute 4–6% of major trauma in places that have comprehensive trauma registries trauma. Local data were collated by obtaining publications available from the Google scholar and PubMed using the following search words: “Injury”, “Nigeria”, “Peripheral”, “Trauma,” and “Vascular”. Lagos and Oyo states in southwest Nigeria had a combined total of 160 cases of PVI over a 20-year period.,, The South-South and South-East regions had 52 cases over a 6-year period.,,,, Adeoye et al. and Igun et al. reported 11 cases and 52 cases over a 2-year and a 10-year period, respectively, in the North-Central Nigeria. Only 15 cases of post-traumatic vascular emergencies were reported by Edaigbini et al. in North-West Nigeria over a 4-year period, similar to the findings in this study. Thus, only 289 cases (excluding ours) are available from the aforementioned search engines from 1990–2018. The low volume may be due to underreporting of PVI or late presentation with gangrene requiring orthopedic intervention. This assertion is buttressed by the paucity of reports from the North-eastern part of the country which has been engulfed by the Boko Haram insurgency for >6 years and the frequency of amputation following trauma.,, The regional distribution of PVI may be a result of the deleterious consequences of urbanization such as increased sophistication of crime, high-speed vehicular accidents, and ethnoreligious conflicts.
Most studies, including ours, show that PVI are commoner in males.,,,,,,,,,,, This may be because males are more likely to be involved in social conflicts or engage in riskier behaviors or travel more frequently than females. The median age observed in our study was similar to those of other studies,,,, and the reasons why PVI are prevalent in this age group are akin to those mentioned earlier. Most local publications refer to a delay in patient presentation to hospitals where vascular services are available,,,,,,, ultimately affecting outcome. We also experienced late presentation/referral of patients to our center, with the median duration of presentation being 2.5 days. This is dissimilar to experiences from other parts of the world where majority of patients present quite early and revascularization is carried out within the desired period of 6–8 h.,, Trauma care in these areas are characterized by efficient pre-hospital systems, which is both physician-led and exclusively dedicated to trauma. Contrariwise, in Nigeria the pre-hospital system is non-existent. The patient's first contact may be with healthcare personnel who are not familiar with the hard or soft signs of PVI. Further contributors to patients' late presentation include poverty and distance to be travelled because of the dearth of vascular surgeons and equipment. It must be stated, however, that there are varying grades of ischemia. “The severity of tissue ischemia depends not only on its duration but also on the level of arterial injury, extent of soft tissue damage, and the efficiency of collateral circulation”. Therefore, limbs may still be salvaged even if patients present outside the desired period. This may explain why, despite the delayed presentation of our patients, our operative salvage rate was 86%.
Mechanism and site of injury
Gunshot wounds are the most frequent causes of PVI. Stab wounds were however the commonest etiology in our patients, similar to the findings by Perkins et al. Stab wounds are commoner in places where weapons used in crime and conflicts are less sophisticated and firearms are difficult to procure. Other causes of vascular injuries include road traffic accidents with crush injuries, bottle stab wounds and machete cuts, fractures and dislocations, iatrogenic PVIs from angiographic procedures, dialysis and central venous catheter insertion, percutaneous coronary interventions, and so on. Inadvertent arterial puncture is another cause of vascular injuries and predisposes to the formation of infected pseudoaneurysms and or limb ischemia. The PVI in four of our patients were from inadvertent arterial punctures, three of whom developed pseudoaneurysms and one, limb ischemia. Blunt trauma usually accounts for 5–25% of PVI and our finding of 6.3% was no different. This patient was managed non-operatively with analgesics/anticoagulation.
Femoral or popliteal artery injuries usually constitute 50–60% of all extremity injuries and brachial artery about 30%. The superficial femoral artery (SFA) was the most injured vessel in our series (37.6%) followed by the brachial artery (18.8%). We had only one popliteal artery injury. Wani et al. on the other hand found the popliteal artery to be the most injured vessel (42.7%) in their series. Concomitant venous injury was associated with seven arterial injuries (43.7%), the most frequently affected being the superficial femoral vein (18.8%). Inadvertent intra-arterial injection of drugs following attempted venous injection requires special mention. Though rare, it can cause acute, severe extremity ischemia and gangrene from direct tissue destruction by the drug or drug precipitation and crystal formation within the distal microcirculation leading to ischemia and thrombosis. There is no universally accepted treatment protocol but drugs like lidocaine, stellate ganglion blocks, phentolamine, iloprost, urokinase, and heparin have been used with varying degrees of success. Surgical embolectomies have also been attempted. One of our patients presented 4 days after an intra-arterial injection. Exploratory surgery revealed thrombi in the entire vasculature of the upper limb, and attempt at surgical revascularization was unsuccessful. Despite subsequent heparin therapy, endogenous revascularization did not occur. She later died from sepsis.
Type of repair
Lateral repairs were our most frequent modality of repair. Five (31.3%) of our patients had simple lacerations that were amenable to lateral repairs. Simple arterial lacerations can often be repaired primarily without significantly compromising the vessel diameter. However, blunt injuries, crush, gunshot wounds, and so on causing significant damage to the vessel wall, which must be trimmed back to healthy tissues before proceeding with the repair, often demand more major strategies. Depending on the length of arterial segment lost, then end-to-end anastomosis (EEA), reversed venous interposition, and prosthetic interposition grafts have been employed. The former was the commonest procedure performed in many series.,, We used reversed basilic and saphenous vein grafts in the upper and lower limbs, respectively, when an interposition graft was required. Other authors have utilized reversed saphenous vein grafts in their management of brachial artery injuries., Prosthetic grafts have been safely utilized in the management of PVI. In the setting of severely limited autologous conduit, prosthetic grafts can be used for limb salvage even in contaminated wounds, though an extra-anatomic route should be considered in these scenarios. Thomas et al. utilized prosthetic grafts in eight cases while we used it in one case. Two pseudoaneurysms with defects in the anterior wall of the SFA were successfully repaired by patch arterioplasty. The patch was from the great saphenous vein soaked in heparinized saline. If there is concern about narrowing the diameter of a vessel, then the injury can be repaired with a vein patch. We repaired all venous injuries of the lower limbs. Venous repair is advisable when feasible as it relieves acute venous hypertension, compartment syndrome, and edema and enhances successful outcomes in extremity trauma. Lower limb veins can, nonetheless, be ligated if repair is deemed too complex or patient is unstable.
Endovascular therapy (ET) has seen increasing use in the management of PVI. Selected pseudoaneurysms and arteriovenous fistula may be amenable to embolization or endovascular stent grafts.,, It is particularly useful in older patients; those with higher injury severity score (ISS) and co-morbidities. It reduces wound complications and shortens the length of hospital stay. ET is not available locally but plans should be put in place to grow it in the grand scheme of manpower and infrastructure development in vascular surgery in Nigeria.
SSI was our most frequent morbidity (62.5%). This problem was also noted by other authors.,,, Majority of our patients presented with wide peri-injury soft tissue inflammation with or without infection. We managed these by intra-operative debridement and local advancement flaps to cover exposed vessels. Other strategies for soft tissue reconstruction that have been used in more compound injuries include split-thickness skin grafts, sartorius vascularized muscle flap, rotational and free flap tissue transfer for early graft or bony coverage because all effort must be made not to leave vessels exposed after PVI repair. Carrying out extensive procedures nonetheless need to be balanced against patients' stability vis-a-vis being delayed until risks of inadequate tissue viability and secondary infections have diminished.
Our amputation rate was 6.3% and was carried out in a patient that presented after 5 days with near complete transections of the popliteal artery and vein and compartment syndrome. Fasciotomy and revascularization failed to salvage the limb. Popliteal vascular trauma carries the greatest risk of limb loss of any PVI and amputation rates of 15% with combined popliteal arterial and venous injuries have been quoted. Locally, reported secondary amputation rates following PVI vary between 3.3–13.5%.,,, Cited risk factors for amputation include revascularization beyond 12 h, development of compartment syndrome, and severely mangled extremities.
The median nerve was the only PN injured in our series. There was one complete transection and one near-complete transection which were repaired primarily. Recovery of limb function was satisfactory, though a period of physiotherapy was required postoperatively. The radial and median nerves were the PN involved in the series by Wani et al. They deferred repair of their nerve injuries in contaminated cases for 6–8 weeks.
Mean length of stay for our patient population was 11.7 ± 6 days. The mean hospital stay in the publication by Adeoye et al. was 13 ± 11.72 days. While SSI was the primary cause of prolonged hospital stay in our patients, they had a high rate of nerve and orthopedic injuries which negatively affected the length of hospital stay. Skeletal trauma, soft tissue deficits, and a high ISS negatively impact the length of hospital stay.
There was 18.8% mortality in this series. Causes of death were acute pulmonary edema in one patient with CKD and sepsis in two patients. These patients died in an average of 7 days postoperatively. Igun et al. had a hospital mortality of 16% due mainly to hypovolemic shock, acute renal failure, and sepsis. Others had lower mortality but had septic shock as a cause of death. Pre-existing renal impairment has been reported as an independent risk factor for mortality in patients with iatrogenic vascular injuries. Because of the small number of patients in this study, we were unable to analyze the effect of pre-existing renal impairment on our patient outcome. Thus, more cases would be needed to statistically correlate the roles of sepsis, renal impairment, and mortality in patients with both iatrogenic and non-iatrogenic vascular injuries.
| Conclusion|| |
The number of cases PVI in our series is small but majority of them would require surgery. Delayed patient presentation is a problem and considerable effort needs to be put into developing our pre-hospital care. Reasonable limb salvage rates are however possible even following delayed presentation from the time of injury. This however depends on the degree of ischemia. The development of SSI may suggest prolonged hospital stay and mortality appears to be heightened if there are underlying co-morbidities. More patients would be required though to statistically correlate these findings.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]