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Vascular injuries of the extremities are a major challenge in a third world country
© Khan et al. 2015
Received: 2 January 2015
Accepted: 21 July 2015
Published: 30 July 2015
Traumatic vascular injuries of the extremities are a major challenge especially in the third world countries. These injuries are mostly due to poor traffic laws, street crimes, firearms and blast associated injuries. We therefore would like to share our 10 years of experience in dealing with vascular injuries in Pakistan.
This was a retrospective observational study conducted in the department of vascular surgery of Liaquat National Hospital, Karachi, Pakistan. Patients’ records were retrieved from the department and were reviewed. Cases with vascular injuries of upper and lower limb that presented with signs of salvageable limb and presented within 12 hours of injury were included in the study. Patients with more than 12 hours of presentation and in whom primary amputation was done, were excluded from the study.
There were 328 patients who presented with vascular injuries of the extremities that fell in the inclusion criteria. Limb salvage rate was 41 %, whereas 30-days perioperative mortality was 5.48 %. The major cause of limb loss was delay in presentation of more than 8 h of injury. Major vessels involved were popliteal artery (41.76 %), followed by femoral artery (27.43 %).
Vascular injuries are becoming a major contributor of limb loss in third world countries due to violence, terrorism and unavailability of vascular facilities. This morbidity can be reduced by improving law and order situation, evolving an effective emergency ambulatory system and with better training and provision of vascular services in remote areas so that the delay factor can be reduced.
Vascular trauma of the extremities are very common in third world countries. Vascular injuries secondary to penetrating trauma remains a significant cause of morbidity and mortality in both civilian and military population. These injuries constitute about 3 % of civilian injuries and around 7 % of combat associated trauma . In developing countries it is mostly due to motor vehicle accidents, street crimes, improvised explosive devices and industrial accidents. Liaquat National Hospital is one of the largest private sector tertiary care centre in Karachi, Pakistan and is one with busy trauma units with vascular surgery expertise in Karachi. Many victims of vascular trauma present to this centre not only from Karachi but from other areas of Pakistan and neighbouring countries like Iran, Iraq and Afghanistan. Being a developing country, our country lacks effective emergency ambulatory facilities, especially for trauma patients which is a major contributing factor for delayed presentation of these patients to tertiary care centers. Early recognition of vascular injuries is essential for prompt management. Delay may cause irreversible ischemic injuries which may result in impaired limb function or limb loss . Through this study we would like to share our 10 years of experience of dealing vascular injuries of the extremities in a tertiary care centre of a third world country like Pakistan, where lack of basic facilities and unavailability of expertise services remain a common problem.
This was a retrospective study of 10 years between January, 2002 and January, 2012 conducted in department of Vascular Surgery, Liaquat National Hospital, Karachi, Pakistan. Case records of all the patients presenting with traumatic injuries were reviewed for demographic profile, including age and gender, mechanism and location of injury, repair techniques, limb salvage rate and complication rates. The data was entered and analysed on Statistical Package for Social Sciences (SPSS) version 16 for frequencies and co-relations with significant p-value of <0.05. This study has been approved by the institute’s ethical review committee.
Salvageable limb was defined as the limb with signs of viability (warm, positive distal pulses, >90 % oxygen saturation and intact neurological signs), with repairable soft tissues and skeletal injuries. The inclusion and exclusion criteria were set as:
All the patients who presented with vascular injuries of extremities with or without associated orthopaedics and soft tissue injuries.
Presentation within 12 h with signs of viabilities.
Patients who presented with salvageable limbs with duration of >12 h from the injury.
Associated head injuries or major injuries to abdomen necessitating urgent attention first.
Non-salvageable limb (with major tissue loss/mangled limbs).
Delayed presentation i.e. after 12 h of injury with no signs of viability.
Post-operative complications in traumatic patients after vascular repair (n = 139)
The surgical repair of the arteries was with end to end primary anastomosis in 9.7 % (32) cases. Autologous saphenous vein grafts from opposite limb were used in 53.1 % (169) and polytetraflouroethylene (PTFE) grafts in 39.9 % (127) cases. In 8.5 % (28) patients venous repair was carried out which included femoral, popliteal and sub-clavian veins, while rests of the venous injuries were ligated. No shunts were placed between the two ends of vessels during the surgical repairs. Initial soft tissue cover for the repaired vessels was done in 18.9 % (62) cases.
Out of 67 patients who had associated nerve injuries, primary nerve repair was done in 59.7 % (40) cases, while in 40.2 % (27) cases the nerve was tagged with non-absorbable suture for secondary repair. Bony injuries, in 116 cases, were managed by orthopedic surgeons using bone fixation in 74.1 % (86) and splints in 25.8 % (30) cases. Fasciotomies were done in 34.5 % (110) cases to prevent and relief compartment syndrome, which were subsequently closed with primary closure in 32.7 % (36) and was covered with skin grafts in 67.2 % (74) patients. The main vascular complication was wound infection in 13.1 % (43) of the cases and the main non-vascular complication was acute renal failure in 9.7 % (32) (Table 1).
Post-operative vascular analysis was done by physical examination of distal pulses, oxygen saturation at toe level in all cases. Ankle Brachial Pressure Index (ABPI) was measured where it was possible. Post-operatively all patients were prescribed low molecular weight heparin for deep venous thrombosis prophylaxis, till their mobilization out of bed. Hospital stay varied from 5–35 days depending upon the severity of injury inclusive of bone and soft tissue injuries. Follow-up was done according to the specialties involved. In particular for vascular injuries follow up was done on 1st, 2nd and 4th week. Long term follow-up was lost in some cases as these patients were either residing in far off areas or due to poor affordability of these patients. All patients with soft tissue and bony injuries were also followed in the plastic and orthopedic outpatient basis simultaneously. 30-days perioperative mortality was 5.48 %. The causes of mortality were disseminated intravascular coagulation (DIC) in 38.3 % (7), pulmonary embolism in 22.2 % (4) patients, cardiopulmonary arrest leading to myocardial infarction (MI) in 27.7 % (5) patients and 11.1 % (2) died because of renal failure.
Traumatic vascular injuries of the limbs remain a significant challenge especially in third world countries. In our retrospective analysis of the patients presenting with vascular trauma at a tertiary care centre, majority of the trauma is associated with blunt injuries mainly road traffic accidents followed penetrating injuries by firearms and bomb blasts. This study contrasts with the studies from west, as majority of the vascular injuries are caused by penetrating injuries due to civil violence  and decade long war situation in neighbouring country.
Traumatic vascular injuries of the extremities are a major challenge especially in a third world country. Multiple factors involve in the prognosis of the affected limb. The most common factor involved is the delay in reducing ischemic reperfusion time. Other factor such as bone and nerve injuries and soft tissue deficits augments the chances of limb loss .
With the rising trend of violence, terrorism and un-availability of facilities in developing countries, vascular injuries are becoming a major contributor of limb loss associated with increased morbidity and mortality. The most common factor is the delay in presentation to vascular services. Provision of proper training for dealing with trauma patients and evolving effective emergency ambulatory services are the key for reducing vascular injury related complications.
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