Management and Long Term Functional Outcomes of Upper Extremity Civilian Vascular Trauma
Colten A. Yahn*, Maha Haqqani, Andrea Alonso, Thomas Cheng, Alik Farber, Jeffrey J. Siracuse
Surgery, Boston University, Boston, MA
Objective. Evaluate the management of upper extremity vascular trauma (UEVT) and explore the long term functional consequences in patients.
Design. Single center, retrospective descriptive outcome analysis
Setting. Single center ACS-verified Level One trauma center; safety net hospital
Patients. All patients treated for UEVT, which included arterial and venous injuries from subclavian vessels to distal upper extremity, at Boston Medical Center between 2001 and Jan. 2023. Any patients who had at least 6 months of follow up post injury or were deemed medically cleared prior to 6 months (no further follow up scheduled).
Interventions. No interventions performed (retrospective)
Main Outcome Measures. Chronic pain, persistent functional deficits related to injury, long term opioid use, ability to return to work
There were 150 patients with UEVT. Mean age was 34 years and 85% were male gender. Race was 42% Black and 27% White. Mechanism was penetrating in 79%, blunt in 19%, and multifactorial in 2%. Within penetrating trauma, injuries were due to non-firearms (70%) or firearms (30%). Of blunt injuries, 28% were falls, 14% MCC, 14% MVC, and 3% crush injuries. Injuries were isolated arterial in 62%, isolated venous in 13%, and combined in 25%. Isolated arterial injuries included brachial (34%), radial (27%), ulnar (27%), axillary (8%), and subclavian (4%). The majority (80%) underwent open repair with autologous vein bypass (34%), primary repair (32%), vein patch (6%), or synthetic graft (3%); 21% required fasciotomies, of which 69% were prophylactic. A minority (1%) had an endovascular intervention with covered stent placement (50%) or balloon embolectomy (50%). Few patients (9%) required reoperation. Concomitant injuries included nerves (35%), bones (17%), and ligaments (16%). ICU admission was required in 45% and mean ICU LOS was 1.6 days. Mean hospital LOS was 6.7 days. Major amputation and in-hospital mortality rates were 1% and 4% respectively. Deaths were often associated with concomitant chest injuries (83%) and/or perioperative cardiac arrest (63%).
Many patients (72%) had at least 6 months follow-up. More than half of patients (56%) experienced chronic pain, motor (54%), and sensory (61%) deficits. Additionally, 41% had difficulty with activities of daily living. Of previously employed patients (57%), 60% had a delay in returning to work of 6 weeks or more. The majority of patients (81%) were discharged with opioids; of these, 16% were still using opioids at 6 months. A subsequent mental health diagnosis (PTSD, depression, or anxiety) was observed in 17%.
Conclusions. UEVT is associated with long-term functional impairments, adverse mental health outcomes, and opioid use. It is imperative to counsel patients before discharge and ensure appropriate follow-up and therapy to mitigate some of these adverse outcomes.
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