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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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