OUTCOME ANALYSIS OF UPPER LIMB VASCULAR TRAUMA – OUR INSTITUTIONAL EXPERIENCE

Dr. Shanmugavelayutham Chitravelu, Prof. Elancheralathan Kalyanaraman, Prof. G. Thulasikumar, Dr. B. Deepan kumar and Dr. S. Saravanan. Department of Vascular Surgery, Govt. Stanley Medical College, Chennai. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

In the era of urbanization and industrialisation Road Traffic Accidents and industrial accidents have become more common. Ours being a tertiary care center we receive lot of patients with Polytrauma. Vascular injury is commonly seen in high velocity injuries. This study is to analyze the outcomes of upper limb vascular injuries. Stanley medical college has dedicated vascular surgery department catering industrial worker from north Chennai

Materials & Methods:-
This is a prospective study from august 2015, and it is an ongoing study. We are submitting the interim report of the study till March 2018. All patients admitted with upper limb vascular trauma proximal to wrist were included in our study.
Most of the patients were in younger age group with no comorbid diseases, only two patients whose age was 47 and 51 had Diabetes Mellitus. Our patients were evaluated by clinical examination (Hard and Soft signs) 1 and using Hand Held Doppler. Hand held Doppler was our main tool. We did CT angiogram in the patients with suspected multilevel injuries to the vessels. Using Hand held Doppler, no flow was seen in 5 patients (5/32=15%), wrist pressure less than 50 mmHg seen in 20 patients (20/32=63%) and wrist pressure more than 50 mmHg in 7 patients (7/32=22%).
Primary end to end anastomosis done in 4 patients when the defect was less than 2 centimeters (4/32=13%) In injuries with defect more than 2 cm defect Reversed Saphenous Vein was used as conduit. Synthetic grafts were not used to prevent infection 2 . Anatomical bypass was done in 25 patients (25/32=78%), and extra anatomical bypass in 3 patients in severely crushed limbs with contamination (3//32=9%) 3 .   We did fasciotomies in most of patients, for those who had no flow status and those who presented after 6 hours. We did skin cover by relaxing incisions and Split Skin Graft primarily or secondarily in 8 patients (8/32=25%).
Since the possibility of vascular injury could be missed in blunt injury, it may be the one of the reasons that most patients presented 6 hours after the injury.
Penetrating injury was associated with wound infection more commonly (5/6 cases). Blunt injury caused mainly contusion thrombosis. In penetrating injury irregular tears and transactions were common.
Pseudoaneurysm and Blow out happened in one patient, brachial artery ligated on 5 th post operative day, but the limb was salvaged.
There was (100%) limb salvage with no mortality. Most of our patients presented more than 6 hrs after the injury. Arterial repair done first, followed by fracture stabilisation and nerve repair Our patients were evaluated by clinical examination (Hard and Soft signs) and Hand Held Doppler. Hand held Doppler was our main tool. We did CT angiogram in patients with suspected multilevel injuries. We have ligated the veins in cases with venous injury 4 , we didn't affect limb salvage. We did faciotomyin majority of cases (> 6 hr, associated venous injury). If both radial and ulnar arteries were injured we repaired both, because palmar arch integrity couldn't be assessed pre operatively. If one artery (either radial or ulnar) is injured and palmar arch is intact, we ligated the injured vessel, and if palmar arch is incomplete we repaired the injured artery 5 . Though graft thrombosis was seen in 2 patients, limbs were salvaged -(younger age, > 3-5 days, injury beyond profunda brachii) Since most of the injuries occurred were distal to profunda brachii, lean muscle mass of upper limb compared to lower limb,(decreased oxygen demand ) and very good collaterals around elbow joint, the limb salvage rates were high in upper limb vascular trauma.
Our limb salvage rate is comparable or even better than other studies.

Conclusion:-
Since upper limb vascular trauma commonly occurs in young individuals timely intervention in upper limb vascular injuries can save the limb and the life. This means they can be economically productive and lead an independent quality life.