Vascular Injury/Limb Ischmia
The evidence suggests that neither hard signs of vascular injury nor duration of limb ischemia are absolute factors in the decision for limb salvage vs. amputation. However, the panel recognizes that prolonged ischemia is detrimental and the interval to reperfusion should be kept to a practical minimum. The duration of lower extremity ischemia is directly correlated with adverse events.
Limb Salvage or Early Amputation
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: AOFAS, OTA

Rationale

RATIONALE:

Six low quality studies examined the effect of various vascular injury on patient outcomes. One study (Asensio, 2006) found that both coagulopathy in the operating room and having two or more hard vascular signs were significantly associated with higher odds of mortality. Hard signs of vascular injury can include the absence of distal pulses, expanding hematoma, palpable thrill, audible bruit and pulsatile bleeding. Additionally, a decrease in the number of patent arteries in the lower leg, was found to be associated with a higher risk of complications in patients as well as a higher risk of take-backs and a higher risk of an increase in total flap failures (Stranix, 2017). Another study (Doucet, 2011) looking at limb ischemia also found it to be predictive of failure of limb salvage. Three additional studies (Jain, 2013, Bennett, 2018, and Melton, 1997) examining ischaemic vascular injury, vascular injury and vein injury, failed to find significance between these factors and infection in the residual limb, AAOS F&A score, and secondary amputation respectively.

The evidence suggests that neither hard signs of vascular injury, nor duration of limb ischemia are absolute factors in the decision as to whether to pursue limb salvage or amputate the injured extremity. However, there is a consensus among the panel that a direct relationship exists between the duration of ischemia and adverse extremity outcomes, including amputation. Therefore, the panel recommends that steps be taken to promptly identify arterial injury and limb malperfusion and to limit the duration of extremity ischemia to a practical minimum. The panel also recommends performance of measures such as extremity fasciotomy and debridement of non-viable tissue to reduce the negative impact of ischemia and reperfusion injury.1 Additionally, attempts at limb salvage should not be continued in extremities that are unable to have perfusion maintained or restored. Both the available evidence and common sense are clear that when unable to restore or preserve limb perfusion, continued limb salvage efforts are inappropriate and ill-advised.

Arterial injury and extremity ischemia leads to adverse effects including injury to and death of skeletal muscle, peripheral nerves and other soft tissue components. Preclinical research demonstrates that hemorrhagic shock worsens the effect of extremity ischemia and reduces the neuro-muscular ischemic threshold to less than 3 hours.2 Recent clinical study from U.S. civilian trauma centers also demonstrates that minimizing the duration of extremity ischemia (to less than 3 hours) is associated with higher rates of limb salvage.3

Pre-clinical and retrospective human study of military and civilian patients confirms the utility of temporary vascular shunts as a damage control adjunct in restoring extremity perfusion.4,5 In this setting temporary vascular shunts perform best (i.e. stay patent) within a 4-6 hour time window and then are removed at the time of definitive vascular repair. Evidence suggests that vascular shunts are more effective in larger, more proximal extremity vessels, but that they cause no harm when placed as a damage control maneuver in smaller, more distal vessels.4 Clinical consensus is that the use of temporary vascular shunts can be used in certain extremity injury scenarios to limit ischemia and extend the window of successful limb salvage.6

Clinical outcomes studies demonstrate that approximately 30-40% of patients who have successful extremity salvage experience poor limb function and diminished quality of life (e.g. chronic pain, limited mobility and need for additional operations).7-9 Approximately 10-15% of patients who have successful limb salvage during the early phases of care elect to have a secondary amputation of the affected limb in the months and years following injury – most commonly due to chronic pain, recurrent infection or limited function/mobility.7-9

 

Additional Rationale References:

  1. 1. Percival TJ, Rasmussen TE. Reperfusion strategies in the setting of extremity vascular injury with ischemia. Brit J Surg 2012;99(Suppl 1):66-74.
  2. 2. Hancock HM, Stannard A, Burkhardt GE, Williams K, Dixon P, Cowart J, Spencer JR, Rasmussen TE. Hemorrhagic shock worsens neuromuscular recovery in a porcine model of hind limb vascular injury and ischemia/ reperfusion. J Vasc Surg 2011;53(4):1052-62.
  3. 3. Alarhayem AQ, Cohn SM, Cantu-Nunez O, Eastridge BJ, Rasmussen TE. Impact of time to repair on outcomes in patients with lower extremity arterial injuries. J Vasc Surg. 2019 May;69(5):1519-1523. doi: 10.1016/j.jvs.2018.07.075.
  4. 4. Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma 2006;61(1):15-21.
  5. 5. Subramanian A, Vercruysse G, Dente C, Wyrzykowski A, King E, Feliciano DV. A decade's experience with temporary intravascular shunts at a civilian level I trauma center. J Trauma. 2008 Aug;65(2):316-24; discussion 324-6.
  6. 6. Gifford SM, Aidinian G, Clouse WD, Fox CJ, Jones WT, Zarzabal L, Michalek JE, Propper BW, Burkhardt GE, Rasmussen TE. Effect of temporary vascular shunting on extremity vascular injury: an outcome analysis from the GWOT vascular initiative. J Vasc Surg 2009;50(3):549-55.
  7. 7. Scott DJ, Arthurs ZM, Stannard A, Monroe HM, Clouse WD, Rasmussen TE. Patient-based outcomes and quality of life after salvageable wartime extremity vascular injury. J Vasc Surg 2014;59(1): 173-179.
  8. 8. Perkins ZB, Yet B, Glasgow S, Marsh W, Tai NRM, Rasmussen TE. Long-term, patient-centered outcomes of Lower Extremity Vascular Trauma. J Trauma Acute Care Surg. 2018 Jul;85(1S Suppl 2):S104-S111.
  9. 9. Sharrock AE, Tai N, Perkins Z, White JM, Remick KN, Rickard RF, Rasmussen TE. Management and outcome of 597 wartime penetrating lower extremity arterial injuries from an international military cohort. J Vasc Surg. 2019 July 70(1):224-232.

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