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Early Fasciotomy in Patients with Extremity Vascular Injury is Associated with Decreased Risk of Adverse Limb
Outcomes: A Review of the National Trauma Data Bank
*Tze-Woei Tan, Jeffrey A. Kalish, Fernando Joglar, Naomi M. Hamburg, Timna Onigman, Denis Rybin, Gheorghe Doros,
Robert T. Eberhardt, Alik Farber Department of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
Objective: Lower Extremity (LE) arterial trauma and its treatment may lead to extremity compartment syndrome (ECS). In that
setting, the decision to perform fasciotomies is multifactoral and is not well delineated. We evaluated the outcomes of
patients with surgically treated LE arterial injury who underwent early or delayed fasciotomies.
Design: The National Trauma Data Bank (NTDB) was retrospectively reviewed.
Patients or Other Participants: Patients who had LE arterial trauma and underwent both open vascular repair and fasciotomies were identified. Exclusion criteria were additional non-LE vascular trauma, head or spinal cord injuries, crush injuries, burn injuries, and declaration of death on arrival. Patients were divided into those who had fasciotomies performed within 8 hours (Early Group) or > 8 hours after open vascular repair (Late Group). Comparative analyses ofdemographics, injury characteristics,
complications, and outcomes were performed
Intervention(s): Lower extremity fasciotomy
Main Outcome Measure(s): Mortality, major limb amputation, wound complication, length of ICU and hospital stay.
Results: Of the 1,469 patient admissions with lower extremity arterial trauma that met inclusion criteria there were 612 patients
(41.7%) who underwent fasciotomies. There were 543 and 69 patients in the Early and Late Fasciotomy Groups, respectively. There was no significant difference in age, injury severity, mechanism of injury, associated injuries, and type of vascular repair between the groups. A higher rate of popliteal artery injury was observed in the Early Fasciotomy Group (48.8% vs. 42%, P<.001). Patients in the Early Fasciotomy Group had lower amputation rate (8.5% vs. 24.6%, P<.001), lower infection rate (6.6% vs. 14.5%, P=.028) and shorted total hospital stay (18.5+20.7 days vs. 24.2+14.7 days, P=.007) than those in the Late Fasciotomy Group. On multivariate analysis, early fasciotomy was associated with a 4-fold lower risk of amputation (Odds Ratio 0.26, 95% CI 0.14-0.50, p<.0001) and 23% shorter hospital LOS (Means Ratio 0.77, 95% CI 0.64-0.94, P=.01).
Conclusions: Early fasciotomy is associated with improved outcomes in patients with lower extremity vascular trauma treated with
surgical intervention. Our findings suggest that appropriate implementation of early fasciotomy may reduce amputation
rates in extremity arterial injury.
TABLES AND CHARTS
Table 1. Injury Type, Severity and Associated Injuries in Early and Late Fasciotomy Groups
Characteristic |
Overall (N=612) |
Early Fasciotomy (N=543) |
Late Fasciotomy (N=69) |
p-value |
Injury Site, N (%) |
|
|
|
|
Iliac |
48 (7.8%) |
32 (5.9%) |
16 (23.2%) |
<0.001 |
Superficial Femoral |
202 (33%) |
180 (33.1%) |
22 (31.9%) |
|
Popliteal |
294 (48%) |
265 (48.8%) |
29 (42%) |
|
Tibial |
68 (11.1%) |
66 (12.2%) |
2 (2.9%) |
|
|
Injury Type, N (%) |
|
|
|
|
Blunt |
226 (36.9%) |
201 (37%) |
25 (36.2%) |
0.999 |
Penetrating |
386 (63.1%) |
342 (63%) |
44 (63.8%) |
|
|
Injury Severity, Mean + SD |
|
|
|
|
Presenting SBP, mmHg |
115.1+36.8 |
115.2+37.4 |
114.6+31.5 |
0.899 |
Presenting GCS |
13.7+3.4 |
13.7+3.4 |
13.5+3.6 |
0.682 |
Presenting ISS |
13.5+8 |
13.4+8.3 |
14.4+5.8 |
0.334 |
|
Associated Injuries, N (%) |
|
|
|
|
Fracture |
287 (46.9%) |
257 (47.3%) |
30 (43.5%) |
0.609 |
Nerve Injury |
61 (10%) |
55 (10.1%) |
6 (8.7%) |
0.833 |
Venous Injury |
240 (39.2%) |
219 (40.3%) |
21 (30.4%) |
0.118 |
|
Target Procedure, N (%) |
|
|
|
|
Repair |
384 (62.7%) |
341 (62.8%) |
43 (62.3%) |
0.966 |
Ligation |
101 (16.5%) |
89 (16.4%) |
12 (17.4%) |
|
Temporary Shunt |
127 (20.8%) |
113 (20.8%) |
14 (20.3%) |
|
Table 2. Complications and Outcomes in Early and Late Fasciotomy Groups
Characteristic |
Overall (N=612) |
Early Fasciotomy (N=543) |
Late Fasciotomy (N=69) |
p-value |
Complications, N (%) |
|
|
|
|
DVT |
31 (5.1%) |
27 (5%) |
4 (5.8%) |
0.769 |
PE |
4 (0.7%) |
4 (0.7%) |
0 (0.0%) |
0.999 |
Wound Infection |
46 (7.5%) |
36 (6.6%) |
10 (14.5%) |
0.028 |
|
Outcomes |
|
|
|
|
Lower Limb Amputation, N (%) |
63 (10.3%) |
46 (8.5%) |
17 (24.6%) |
<0.001 |
|
Total Length of Stay (days) |
|
|
|
|
Mean + SD |
19.1+20.2 |
18.5+20.7 |
24.2+14.7 |
0.007 |
Median and IQ-Range |
14 (8-23) |
14 (8-23) |
20 (12-33) |
|
ICU Length of Stay (days) |
|
|
|
|
Mean ± SD |
5.6+10 |
5.3+10.2 |
7.3+7.8 |
0.294 |
Median and IQ-Range |
2 (1-6) |
2 (1-5) |
3 (2-10) |
|
|
In-hospital Mortality, N (%) |
23 (3.8%) |
21 (3.9%) |
2 (2.9%) |
0.999 |
DVT; deep venous thrombosis, PE; pulmonary embolism, ICU; intensive care unit, IQ;interquartile
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