Nigerian Journal of Surgical Research Surgical Sciences Research Society, Zaria and Association of Surgeons of Nigeria ISSN: 1595-1103 Vol. 8, Num. 1-2, 2006, pp. 49-53

Nigerian Journal of Surgical Research, Vol. 8, No. 1-2 , 2006, pp. 49-53

Arterial trauma of the extremities. An Ivorian surgical experience(Côte d’Ivoire) 

¹H .Yangni-Angate, ¹G .Ayegnon, ¹C.H. Meneas, ² Y. Yapobi and ²M. Kangah

¹Department of Thoracic and Cardio-vasculary surgery University Hospital Center of Bouake And Institut de Cardiologie d’Abidjan  ²Department of Cardio-vasculary Institut de Cardiologie d’Abidjan ³Department f Anesthesia and Intensive Care Institut de Cardiologie d’Abidjan
Request for  reprints to Yangni-Angaté H  Department of Thoracic and Cardio-vasculary surgery University Hospital Center of Bouake And Institut de Cardiologie d’Abidjan E-mail : yangniangate@yahoo.fr

Code Number: sr06008

Abstract 

Objective: The goal of this retrospective study is to present our epidemiological , clinical and surgical experience of the arterial injuries of extremities for 23 years(1977 to 2000).
Materials and Methods: 35 patients  were operated on over the study period. Their case files have been reviewed and forms the subject of this study
Results:30 were  men and 5 women with an age range of  14 months - 63 years and a median age of 25.4 years. The etiology of these injuries were  side-arms(n=15),  fire arms (n=5) ,  road or work accident (n=6)  and iatrogenic (n=9 ). The injured arteries were: the femoral artery 18 , the popliteal artery 2 , the subclavian artery 2 the axillary artery 1 , the brachial artery 10 , the ulnar artery 1  ,the radial artery 1patient . Complete arterial rupture was the most frequent lesion n = 14. An  incomplete arterial rupture was  noted in 6 patients , and arterial thrombosis 6, a thrombosis coexisting with an intima damage in  1 case, and avulsion in 1, an arteriovenous fistula (n = 3) and a false aneurysm (n = 3).
Adjacent Injuries were encountered :Bone fractures (n = 9),  muscle tear (n = 10), nerve section(n = 12), vein section (n = 11), tendon section (n = 1), and haemothorax (n = 1) . Clinically most patients  presented with  complete or partial limb ischemia (28 patients). The arterial repair was by end to end anastomosis with saphenous vein (8 patients), or without graft (5 patients),  lateral suture (8 patients),  arterial clot extraction by balloon catheter (8 patients), direct vessel suture via  longitudinal venotomy (2 patient) or arterotomy (1 patient), an aneurysmectomy 1 case.
In one patient the  limb was  amputated because arterial repair was not possible; . There two 2 operative deaths due to reperfusion injury (1 case) and biliary peritonitis(1 case).
Conclusion: Arterial injury is a true surgical emergencies and repair should be urgent to avoid limb loss and  even death.

Key Words:  Limbs ,Arterial trauma , Surgery.

Introduction

Arterial injuries are true surgical emergensies.During their acute phase, signs of arterial trauma of the limb may be lacerations and bruises. Unrecognised at the initial stage, these traumas can evolve chronic injuries with a clinical setting where false aneurysms and artero venous fistulas are predominant.According to Aulong¹ , if “the diagnosis is sometimes obvious, it is generally debatable or misleading”. Indeed, errors or delays in the diagnosis have been reported by Jacob² with a rate estimated at 12 %. As a consequence, there is need for a good clinical assessment when encountered with any suggestion of arterial trauma of the limbs. The treatment is above all surgical^{3 4 5 6} and the various surgical techniques have well codified indicators⁷ . In Sub- Saharan Africa the characteristics of arterial trauma are still unknown due to the unavailability of studies related to this subject. In order to better understand the characteristics in Africa, we report a group of 35 Ivorian cases managed by us over a period of 23 years.

Material and Methods

Thirty five cases were managed within the 23 year period 1977 – 2000. Data was retrieved from their case files and anlysed retrospectively. ResultsTwenty nine presented in the acute phase following trauma and 6 presented late. Thirty of the patients were male and 5 female with a ra tio of 6:1. The age range was 14 months - 63 years with a mean of 25.4 years. The etiology of arterial traumawere: I, knives (n = 15) ii, guns (n = 5), iii, occupational accidents (n = 3) iv, road traffic accidents (n = 3) and v, iatrogenic following cardiac catheterisation (n = 8) and at blood transfusion (n = 1). The types of arterial lesions, were different in the arteries and veins (tables 1-2, 3, 4). Of the 29 patients presenting with acute arterial injury, 28 had complete ischemia.14 were incomplete and 14 had complete ischemia. There was total absence or clear diminution of the distal pulse of the affected artery . In one case, the distal arterial pulse was present despite the existence of a clinically demonstrable proximal lesion. Modes of presentation are varied as shown in (table 5) There was limb edema in 4 patients, Haemorrage in 9, hypovolemic shock in 4. Of 6 patients with Limb hematoma one did not have ischemia . Among patients presenting late 3, had false aneurysms and 3 had artero-venous fistulae . Two of the 3 false aneurysms, were compressive. The three artero -venous fistulae presented with arterial thrills and continuous systolic murmurs . One of them was complicated by a right cardiac deficiency; in a patient harboring an A-V fistula for a period of 25 years involving the left femoral artery and common femoral vein following a knife stab injury. There was no need for additional tests after bedside evaluation in 27 patients. It was necessary to conduct further tests in 3 patients presenting late with i, an artero-venous fistula, ii , a false aneurysm and an iii, obstructive arterial thrombosis. The study of pressures through external compression, a non invasive method, was never applicable. An arteriography was useful in 8 patients because of doubt in the anatomic definition of the injury in 7 patients and because of the necessity to make a precise diagnosis in one patient. The time interval from injury to surgical intervention was different: In 17 the patients surgery was within 10th hour:; 5 had surgery between 10 and 24 hours of injury: 7 were treated after 24th hours. All the patients had surgery. The surgical procedures carried out are listed on tables 6, 7. Arterial patency was established after surgery in 33 patients. Amputation was indicated in two patients with complete ischemia (primary and secondary).Outcome: Significant morbidity was encountered in a five patients with two deaths. In one patient each there was Renal insufficiency , Persistent limb disability and Persistent radial nerve paralysis. Two patients had wound infection and two patients died from I, biliary peritonitis and ii, late revascularization syndrome after arterial reconstruction in late presentation ( 24 hours after injury).

Discussion

Within 23 years, 35 cases were managed for arterial trauma of limbs with an annual frequency of 1.5 %. Arterial injuries appear not to be frequent in  civil practice, as is suggested in this study and an earlier Ivorian arterographical report ^8. Other authors have reported  annual frequencies ranging from 1.73 - 4.62 % ^9,10There is a male preponderance and the young and  active are affected ( 23 to 36 years) in most reports  ^{11 12 13}.The mean age in our study is  25.4 years .  The commonest etiologic agent differ among regions  and reporting from Nigeria  Igun, reported  road traffic  accidents as the most frequent cause in his study ¹⁴ ; with iatrogenic causes less often , compared to our experience.( 21 % of cases against 25.7 %).Knife cuts were the commonest cause of  limb injuries in our study similar to  findings in another report  by Olusanya Adeyemi Duro ¹⁵  and Eren¹⁶. In USA the commonest cause of arterial injury is gunshot¹¹ this may be due to easier assess to firearms in USA.The commonest injured vessels were the brachial  ,femoral and popliteal vessels and the lower limbs were most   commonly injured as reported in other studies. ^{8 3 7 14 16 17}We do not have any reason to this preferential localization to the lower limb.The predominance of knives causing arterial lesions in our study , could explain also  the dominance of the arterial rupture (57 %) in our sudy. This type of  injuries encountered has previously been reported by Igun¹⁴  and Drapanas ¹⁸ . Late presentation is not frequent in our experience and 90% of our patients  to presented early as in other studies.^9,20,21   Late lesions, (false aneurysms and arter-ovenous  fistulae) account for  17 % of all our injuries but this is conspicuously absent in the experience of Igun 14), though  Olusanya Adéyemi’s  Duro¹⁵  working in the same region as Igun has reported true aneurysms in his study.Lower limb  aneurysms are not identical in presentation and late lesions seem less numerous in civil practice. Associated nervous injuries were encountered in the upper limb Also noted were long bone fractures in  0.2% of  injuries and were most usually seen in the multiply injured patients following road traffic accidents.In the patients we managed suspicion of an arterial lesion was th presence of  lacerations and bruises with limb ischemia. Initial clinical assessment is sufficient  to  localize with precision an arterial injury. The predictive value of the clinical assessment is 100 %²². Additional  diagnostic test were not necessary in 77 % of our patients. The reliability of the clinical assessment has been reported by  Frykberg’s²². Arteriographical investigations to improve  anatomical description of the lesion and  enhance certainty of clinical assessment   could negatively lengthen the ischemic period and delay the surgical operation and may be avoided in this circumstances⁷ Arteriographical tests are useful in keeping permanent  reference of uncertain cases, and in the detection of lesions with many stages, in the appreciation of the arterial network permeability below the trauma and in the precision of the levels of arterial pathology.As demonstrated by Drapanas¹⁸  and Perry ²³  the palpation of a distal pulse does not prove with certainty the absence of proximal arterial lesions . We start to suspect arterial injury if there is a large post traumatic hematoma  on an arterial course as it was the case with on of  our patients. The beating characteristics of the hematoma though described in classical ways³⁷  may not be observed in case of recent arterial trauma. Its more complex in the patient with a hematoma that is non beating as seen in  6 of our patients. In our initial evaluation of recent arterial  limb injuries we must  look for the beating hematoma as aptly described in literature ³⁷ though sometimes it may not beat as encountered  in this study.The diagnosis of late lesions was not difficult. The three artero-venous  fistulae were presented  with the classical characteristics, and the false aneurysms were discovered through accidentally while investigating a swelling located on an arterial course.In some situations arteriography is needed.In the treatment of the patients there are several options to choose from:

i Surgical correction to establish the flow of blood is the ultimate goal.

ii, In the treatment of recent lesions options  are, direct end to end anastomosis without tension, this was done in  8-patients

iii, Anastomosis with  interposition of a venous graft, using the reverted internal lower limb vein where there is a long segment of vessel wall lost at injury.

iv, For the combined injury including bone fractures and arterial injuries, the arterial injury is given top priority to avoid  acute ischemia .We have not recorded vascular complications following   manipulation of fractures  after initial vascular repair. An aponerotomy incision  was carried out twice before the ischemic hour  (the 10^th hour), to restore arterial flow and  avoid acute ischemia,   edema and  muscle destruction. The shorter the interval between  injury and  surgery , the better the results  and the lower the amputation rate²⁴ . All  of our 17 patients that were operated within 10 hours were spared an amputation and had an uneventful  post-operative period.. On the contrary, there was significant morbidity, amputation and death   among patients presenting beyond  24 hours after trauma. Only 2 of our patients  presenting  within ischemicperiod  10 hours, had some post-operative complications. As similarly reported by  Lena and d’Allaines ²⁵ , we noticed that the risk of  surgery, amputation and complications was higher after the 24^th hour of ischemia. 

Conclusion

Arterial injuries are not frequent in civil practice. The ischemic limb should be operated as soon as possible to avoid  limb loss and other morbidity.

References :

1. Aulong J, Lahitte, Datcharry. A propos du traitement de 21 anévrismes arterial et artério-veineux post-traumatiques. Med Acad Chir, 1958 ; 84,  207-213.
2. Jacob JE. Traumas Vasculaires au Vietnam avec en particulier le syndrome du compartiment. Internat Surg, 1972 ; 57, 289-293.
3. Fingerhut A , Leppaniemi AK ; Androulakis G.A ; Archodovassilis F ; and al. The European experience with vascular injuries Surg Clin North Am, 2002 ; 82 : 175-88
4. Morale-Uribe Ch; Sanabria-Quiroga AE; Sierra-Jones J.M; Vascular Trauma in Columbia: experience of a level 1 trauma center in Medellin. Surg Clin North Am, 2002 ; 82 : 195-210
5. Sugrue M; Caldwell EM; Damours SK; Crozier JA; Deane SA Vascular Injury in Australia . Surg Clin North Am, 2002 ; 82 : 211-9
6. Rignault D, Paillier JL. Traumas arterial des limbs. Encycl. Med Chir , Paris, Techniques Surgicals, Vasculaire, 3.24, 12, 43025 et 43026.
7. Seka R, Adoh A, Moncany G, Kakou GM, Renambot J, Bertrand Ed. Etude artériographique portant sur 138 patients présentant une artériopathie des limbs inférieurs à Abidjan. Cardiologie Tropicale, 1991 ; 17 , 53-58
8. Enjalbert A, Gedeon A, Puel P, Castany R. Les traumas arterial recents des limbs. A propos de 31 cases traités surgicalment. Rev Med Toulouse, 1970 ; 6, 447-454
9. Goin JL, Montfort J, Le Neel JC, Lehoux J, Talman JC. A propos de 33 cases de lesions arterials majeures observées au cours des traumas des limbs. Ann Chir, 1972 ; 26, 991-1002
10. William D, Hardin JR, Ruary C, O’connell R.C, Adinolfi MF, Kertein MD. Traumatic Artérial Injuries of the Upper Extremity : Determinants of Disability. Am J Surg, 1985 ; 150, 266-270
11. Patel J, Cormier JM, Florent J. Les problèmes de therapeutic que pose l’association de lesions arterials et ostéo-articulaires traumatiques des limbs. J. Chir 1967 ; 93,  145-170
12. Richard TH, JuE-Denis P, Benhamou M., Petit Jean C, Kieffer E, Natali J. Traumas vasculaires graves et complexes des limbs : 96 cases. Mem Acad Chir 1984 ; 110,  711- 715.
13. Igun G.O, Nwadiaro HC, Sule AZ, Ramyil VM and Dakum NK. Surgical experiment with management of vascular injuries. West African Journal of Medecine, 2001 ;2, 102-106
14. Olusanya Adeyemi-Duro H. Traumatic Aneurysms and Artériovenous Fistula of the Upper Limb. West African Journal of Medicine, 1989 ; 2, 143-149
15. Eren N, Ozgen G, Ener BK, Solak H, Furtun K. Periphéral Vascular Injuries in children. J. Pediatr-Surg, 1991 ; 26, 1164-1168.
16. Rich NM, Hughes CW. The Management of Vascular Injuries. South Med Bull, 1969 ; 57, 36-42.
17. Drapanas T, Hewitt RL, Weichert RF, Smith AD. Traumas Vasculaires chez le civil. Evaluation critique du traitement au cours des 30 dernières années (artères centrales et périphériques). Ann  Surg 1970 ; 3, 351-360
18. Amrani M, Renoirte P, Fievez R, Vermondent J, Six CH. Fistulas arterio-veineuses traumatiques. Experiment de 9 cases. Journal des Maladies Vasculaires, 1991 ; 16, 234-237.
19. Delcour Wery D, Golzarian J, Azancot M, Grand C, Strucyven J. Iatrogenic Fémoral Pseudoaneurysm and Arterio-Venous Fistula : Nonsurgical Treatment. Radiol, 1991 ; 72, 91-94.
20. Rivers SP, Lee ES, Lyon RT, Monrad S., Hoff Man T, Veith # J. Successful Conservative Management of Iatrogenic Fémoral Arterial Trauma. Ann Vasc Surg 1992 ; 6, 45-49.
21. Frykbergg ER, Dennis JW, Bishop K, Laneve, Alexander RH. The reliability of Physical Examination in the Evaluation of Penetrating Extremity Trauma For Vascular Injury : Results at One Year. J Trauma 1991, 31, 502-511.
22. Perry  MO., Thal E.R Shires G.T. Traitement des blessures arterials (toutes localisations). Ann Surg 1971 ; 3, 403-408-
23. Saade B, Ashoush R. A propos de 108 places de l’artère poplitée pendant la guerre du Liban. Sem. Hôp. Paris, 1986 ; 62,  3396-3398
24. Lena A, D’allaines CC. Complications arterials des traumas fermés des limbs. Rapport au 65^e Congrès Français de Chirurgie, 65^e session PAF PARIS 1963

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