Abstract:
ABSTRACT
Objective For more than half a century, surgeons who
managed vascular injuries were guided by a 6-hour
maximum ischaemic time dogma in their decision to
proceed with vascular reconstruction or not. Contemporary
large animal survival model experiments aimed at
redefining the critical ischaemic time threshold concluded
this to be less than 5 hours. Our clinical experience from
recent combat vascular trauma contradicts this dogma
with limb salvage following vascular reconstruction with
an average ischaemic time of 6 hours.
Methods During an 8-month
period of the Sri Lankan
Civil War, all patients with penetrating extremity vascular
injuries were prospectively recorded by a single surgeon
and retrospectively analysed. A total of 76 arterial injuries
was analysed for demography, injury anatomy and physiology,
treatment and outcomes. Subsequent statistical
analysis was performed to evaluate the impact of independent
variables to include; injury anatomy, concomitant
venous, skeletal trauma, shock at presentation and time
delay from injury to reconstruction.
Results In this study, the 76 extremity arterial injuries
had a median ischaemic time of 290 (IQR 225–375) min.
Segmental arterial injury (p=0.02), skeletal trauma
(p=0.05) and fasciotomy (p=0.03) were found to have
a stronger correlation to subsequent amputation than
ischaemic time.
Conclusions Multiple factors affect limb viability
following compromised distal circulation and our data
show a trend towards various subsets of limbs that are
more vulnerable due to inherent or acquired paucity
of collateral circulation. Early identification and prioritisation
of these limbs could achieve functional limb
salvage if recognised. Further prospective research should
look into the clinical, biochemical and morphological
markers to facilitate selection and prioritisation of limb
revascularisation.
