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The traumatized ischemic lower limb: a search for the optimal treatment
1Division of Cardiovascular Surgery, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Que.
Objective:
To improve the surgical results of closed injuries of the femoropopliteal arterial axis.
Design:
A retrospective study over 20 years.
Setting:
A university-affiliated hospital.
Patients:
Fifty-nine patients (95% male, mean age 29 years) with 63 blunt injuries to the femoropopliteal arterial axis, treated by eight surgeons.
Interventions:
Thrombectomy with saphenous vein patch arterioplasty; primary end-to-end anastomosis, saphenous vein interposition and saphenous vein bypass.
Main Outcome Measures:
Death rate, incidence and causes of amputation and late outcome of salvaged limbs.
Results:
The death rate was 8.5%, the amputation rate was 25% and the long-term disability of salvaged limbs was 80%. Earlier ablation of two infected extremities and of another one responsible for acute renal failure would have reduced the death rate to 3% at the expense of increasing the amputation rate to 35%. The level of arterial disruption, the degree of soft-tissue damage and the ischemia time greatly influenced limb survival and long-term disability. The ischemia time is the single factor that can be modified by the medical team. If its duration is less than 15 hours, the amputation rate decreases. However, the ischemia time should be reduced to less than 7 hours to assure limb salvage without sequela.
Conclusions:
Early diagnosis and priority of the arterial repair over associated orthopedic injuries are essential to reduce the ischemia time. Despite successful revascularization, early amputation is the only means of saving life in some cases.