Upper-extremity vascular injuries associated with ‘increased prevalence’ of nerve deficits

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Lindsay Gallo

Vascular injuries of the upper extremity are associated with a lower rate of limb loss but have an increased prevalence of nerve deficits after trauma, a new analysis comparing vascular trauma of the extremities reveals.

The investigators behind the study—delivered at the Vascular & Endovascular Surgery Society (VESS) annual winter meeting (Jan. 21–24)—set out to fill a gap in the peripheral vascular trauma literature, particularly with regard to upper-extremity injuries.

“The vast majority of these investigations focuses on trauma to the lower-extremity vasculature, despite the fact that upper-extremity arterial injuries comprise 30–40% of all vascular extremity injuries,” Lindsay Gallo, the first-named author on the research team from Emory University in Atlanta that carried out the analysis.

“Peripheral vascular trauma is frequently associated with concordant injuries and thus presents with unique challenges to injury management,” explained Gallo, a fourth-year medical student at Emory. “Possibly because of these complex injury patterns, survivors often suffer poor functional outcomes and long-term disability.”

The researchers delved into a level I trauma center’s registry to directly compare injury characteristics, surgical interventions and functional outcomes of upper- and lower-extremity vascular injuries. They performed a retrospective analysis of all patients aged 18 and over who were diagnosed with traumatic peripheral vascular injuries that required surgical intervention between January 2011 and December 2019. Indications for surgical intervention included active bleeding or ischemia of the extremity.

A total of 535 patients were included, with 234 (43.8%) having undergone upper-extremity repair. The data revealed that patients with upper-extremity injuries were more likely to be female (16.7% vs. 9%; p=0.007), have a pre-hospital tourniquet applied (21.8% vs. 12%; p=0.002), have associated nerve injuries (40.2% vs. 4.7%; p<0.0001), or present with bleeding (76.1% vs. 64.1%; p=0.002). However, vascular injuries of the upper extremity were less commonly associated with concomitant fractures (25.6% vs. 39.9%; p=0.0006), the authors found.

In terms of operative management, injuries to the upper extremity were more likely to be managed with vessel ligation (38% vs. 17.6%; p<0.0001), and less likely to be managed with concomitant fasciotomies (13.3% vs. 56.5%; p<0.0001), they demonstrated.

Postoperatively, upper-extremity injuries were associated with persistent nerve deficits (21.7% vs. 10%; p=0.0002), while those of the lower extremity had a higher incidence of 30-day limb loss, the researchers found. There were no significant differences in mortality, unplanned vascular reinterventions or 30-day readmissions, they added.

The group concluded: “Upper-extremity vascular injuries were more likely to present with active bleeding and preoperative nerve deficits—and more frequently managed with vessel ligation. Upper-extremity injuries are associated with a lower limb-loss rate, but have an increased prevalence of nerve deficits after trauma.”

Summarizing, Gallo ruminated on why such functional deficits are seen. “It’s possible that because upper-extremity vascular injuries less frequently present with ischemia and have lower rates of limb loss, there may be a delay in diagnosis, which could affect functional outcomes,” she said.

“The complex presenting injury patterns resulting from the concordant injuries seen with peripheral vascular trauma may also contribute to these functional deficits. Regardless, it’s paramount to maintain a high level of suspicion preoperatively and intraoperatively to identify the associated nerve injuries and to improve long-term functional outcomes.”

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