Single centre experience of combat-related vascular injury in victims of Syrian conflict: Retrospective evaluation of risk factors associated with amputation

• Published in: Injury 2016-09, Vol.47 (9), p.1945-1950
• Main Authors: Şişli, Emrah, Kavala, Ali Aycan, Mavi, Mustafa, Sarıosmanoğlu, Osman Nejat, Oto, Öztekin
• Format: Article
• Language: English
• Subjects: Adult; Amputation; Amputation - mortality; Amputation - statistics & numerical data; Blast Injuries - mortality; Blast Injuries - surgery; Female; Humans; Injury Severity Score; Ligation; Limb Salvage - mortality; Limb Salvage - statistics & numerical data; Male; Military Medicine; Orthopedics; Retrospective Studies; Risk Factors; Syria - epidemiology; Temporary vascular shunt; Treatment Outcome; Turkey - epidemiology; Vascular surgical procedures; Vascular Surgical Procedures - methods; Vascular Surgical Procedures - standards; Vascular System Injuries - mortality; Vascular System Injuries - surgery; Vascular system injury
• ISSN: 0020-1383; 1879-0267
• DOI: 10.1016/j.injury.2016.03.030

Abstract Objective To elucidate the risk factors associated with amputation in cases with combat-related vascular injury (CRVI). Material and Methods This retrospective study included 90 cases with CRVI treated between May 2011 and July 2013. The patients were divided into group I (n = 69) in which the limb was salvaged and group II (n = 21) in which the patients received amputation. Results The overall and the secondary amputation rates were 23% and 18%, respectively. There were no amputations with the MESS of 9 or less, increasing proportions of amputations at 10 and 11, with a level of 12 leading to 100% amputation rate. The mortality rate was 2%. Among the 52 (58%) cases with the mangled extremity severity score (MESS) ≥7, the limb salvage rate was 60%. The patients in group II were more likely to have a combined artery and vein injury (p = 0.042). They were also more likely to be injured as a result of an explosion (p = 0.004). Along with the MESS (p < 0.001), the duration of ischemia (DoI) (p < 0.001) were higher in group II. The rate of bony fracture (p < 0.001) and wound infection (p = 0.011) were higher in group II. For the overall amputation, the odds ratio of the bony fracture (OR: 61.39, p = 0.011), nerve injury (OR: 136.23, p = 0.004), DoI (OR: 2.03, p = 0.003), vascular ligation (OR: 8.65, p = 0.040) and explosive device injury (OR: 10.8, p = 0.041) were significant. Although the DoI (p < 0.001) and the MESS (p = 0.004) were higher in whom a temporary vascular shunt (TVS) was applied, the utilization of a TVS did not influence the amputation rate (p = 1.0). Conclusions The DoI and the variables indicating the extent of tissue disruption were the major determinants of amputation. While statistically non-significant, the benefit of the application of a TVS is non-negligible. MESS is a valid scoring system but should not be the sole foundation for deciding on amputation. Extremities which were doomed to amputation with the MESS > 7 seem to benefit from revascularization with initiation of reperfusion at once. The validity of MESS merits further investigation with regard to the determination of a new cut-off value under ever developing medical management strategies.