Civilian upper extremity vascular injury: A National Trauma Data Bank study

Objective

Traumatic upper extremity vascular injuries (UEVIs) pose unique challenges as they are relatively rare injuries. There are various potential treatment modalities to address these injuries which may be influenced by the location of the injury, mechanism of injury, concomitant injuries, and overall patient status. Limited studies are assessing the outcomes of these different treatment modalities and most of the recent literature is focused on combat trauma. Herein we present the largest study of civilian UEVIs with over 7000 patients from a national databank.

Methods

The National Trauma Data Bank (NTDB) from 2017 was used to include subjects aged sixteen years and older presenting with UEVIs. These injuries were identified using ICD-10-CM codes with locations classified as subclavian, axillary, brachial, or distal. Isolated superficial injuries were excluded. Vascular procedures were classified using the ICD-10-PCS and specific procedures of interest included surgical amputation, ligation, primary repair, and endovascular stent placement. Demographic data and injury descriptors such as injury severity score (ISS) and mechanism of injury were compiled for all patients. Outcomes including surgical amputation and death were assessed for association with ISS using chi-square analysis and t-tests. Associations between treatment modality and odds of surgical amputation were modeled using logistic regression.

Results

Seven thousand and fifty patients were included in the analysis. Penetrating injuries accounted for 63 % of injuries while 35 % were blunt. A total of 234 deaths (3.3 %) occurred and 382 injuries involved traumatic amputation (5.4 %) as seen in Table 2. The commonly documented treatment modality was primary repair in 3072 patients (43.6 %) followed by surgical ligation in 1152 patients (16.3 %). Nine-hundred and forty-four patients (14.4 %) underwent endovascular stent placement, and 445 patients (6.3 %) underwent surgical bypass. Two hundred and seventy patients underwent surgical amputation (3.8 %). Patients who underwent surgical amputation had significantly higher mean ISS when compared with patients who did not (11.6 vs 9.7, P = .007) but a lower prevalence of death (1.1 % vs 3.4 %, P = .036). Those undergoing ligation or primary repair had significantly decreased odds of surgical amputation (OR ligation = 0.45; OR primary repair = 0.68; both p < .01) compared to those who underwent endovascular stent placement (OR = 1.62, P = .002).

Conclusions

Both penetrating and blunt civilian trauma may lead to significant UEVIs requiring surgical intervention. Surgical amputation was interestingly associated with lower mortality rates despite those patients having higher ISS. Open surgical interventions were associated with higher limb salvage rates compared to endovascular interventions.