Kaj Johansen

Objective criteria accurately predict amputation following lower extremity trauma.

MESS (Mangled Extremity Severity Score) is a simple rating scale for lower extremity trauma, based on skeletal/soft-tissue damage, limb ischemia, shock, and age. Retrospective analysis of severe lower extremity injuries in 25 trauma victims demonstrated a significant difference between MESS values for 17 limbs ultimately salvaged (mean, 4.88 +/- 0.27) and nine requiring amputation (mean, 9.11 +/- 0.51) (p less than 0.01). A prospective trial of MESS in lower extremity injuries managed at two trauma centers again demonstrated a significant difference between MESS values of 14 salvaged (mean, 4.00 +/- 0.28) and 12 doomed (mean, 8.83 +/- 0.53) limbs (p less than 0.01). In both the retrospective survey and the prospective trial, a MESS value greater than or equal to 7 predicted amputation with 100% accuracy. MESS may be useful in selecting trauma victims whose irretrievably injured lower extremities warrant primary amputation.

Open tibial fractures with associated vascular injuries: prognosis for limb salvage.

Open tibial fractures complicated by limb-threatening vascular injuries present an infrequent but difficult management problem. Twenty-three cases were reviewed with an ultimate amputation rate of 61% (22% primary, 39% delayed). Crush injuries, segmental tibial fractures, and revascularization delays of greater than 6 hours were associated with a bad outcome. Guidelines for primary amputation (crushing injuries, delay in revascularization, segmental tibial fractures) are proposed and implications of limb salvage are reviewed.

Rupture in small abdominal aortic aneurysms

BACKGROUND The decision of whether to repair small abdominal aortic aneurysms (AAAs), which are those that are less than 5 cm in diameter, remains controversial. METHODS We describe 161 consecutive patients who were seen at a single urban hospital with ruptured AAAs (rAAAs) and in whom aneurysm size was measured with ultrasound scanning, or rarely computed tomography, en route to the operating room. Eleven patients (6.8%) had AAAs that measured less than 5.0 cm. This group was compared with 150 patients who had rAAAs that were more than 5 cm. RESULTS The mortality rates were similar in both of the groups 70% for small rAAAs versus 66% for large rAAAs. No significant differences were seen between the patients with small and large ruptured aneurysms with respect to the prevalence rates of hypertension (60% vs 50%) or of cardiac disease (20% vs 22%). However, the prevalence rate of obstructive lung disease was significantly different (64% vs 25%; P =.02) as was the rate of diabetes (28% vs 3%; P =.004). Five aneurysms were measured at exactly 5 cm. This suggests that approximately 10% of all aneurysms that rupture in this series do so at 5 cm or less. CONCLUSION In view of the safety of elective repair as compared with the prohibitive risk associated with aneurysm rupture, patients who are at good risk with small AAA (between 4 and 5 cm) should be considered for elective aneurysm resection. For unclear reasons, obstructive lung disease and diabetes are associated with a significantly greater risk for rupture of small AAA. Patients with these risk factors should be given special consideration.

Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma?

Although highly accurate, contrast arteriography is a costly, invasive, and time-consuming method to rule out occult arterial damage in injured extremities. Accordingly the authors assessed the sensitivity and specificity of Doppler-derived arterial pressure measurements in trauma victims undergoing evaluation for possible extremity arterial damage. Arterial pressure index (API) was calculated (Doppler arterial pressure distal to injury/Doppler arterial pressure in uninvolved arm), but not used in clinical decision making in 100 consecutive injured limbs in 93 trauma victims. AH patients then underwent contrast arteriography. Twenty limbs had an API < 0.90 and an abnormal arteriogram, whereas 75 had both a normal API and a normal contrast study. One limb had a significant angiographic abnormality with an API > 0.90; two others had API < 0.90 but normal arteriograms. Two limbs with a normal API had false-positive arteriograms. When compared with arteriography, an API < 0.90 had a sensitivity of 87% and a specificity of 97% for arterial disruption in this series. Sensitivity and specificity rose to 95% and 97% when API was compared with clinical outcome. In the absence of obvious signs of arterial injury, API may be a reasonable substitute for screening arteriography in the traumatized extremity, particularly if close follow-up observation can be assured.

Critical appraisal of the angiographic portacaval shunt (TIPS)

The transjugular intrahepatic portacaval shunt (TIPS) is a novel angiographic method for achieving portal decompression without operation. Fifty-nine consecutive patients underwent a total of 80 consecutive TIPS procedures. The procedure was unsuccessful in 4 patients (7%) and initially succeeded in 55 (93%). Eighteen patients (30%) underwent 2 or more TIPS procedures during the same hospitalization due to technical difficulties, early rebleeding, shunt stenosis, or thrombosis. Early TIPS occlusion occurred in seven patients (12%) and led to recurrent variceal hemorrhage in five. Forty-two percent of the cases of persisting or recurrent bleeding were nonvariceal. Procedure-related complications occurred in 10% of TIPS procedures or 14% of patients. Twenty-three patients (39%) were actively bleeding at the time of the procedure, and, in 6 of these (26%), bleeding was never controlled. In-hospital mortality (25%) was related only to the presence of bleeding at the time of TIPS (56% for emergent versus 5.5% for non-emergent, p < 0.0001). Mortality was not related to the Child-Pugh classification. Hemodynamic stabilization, vasoconstrictor therapy, balloon tamponade, and sclerotherapy were underutilized in 30% to 40% of patients prior to TIPS. Aggressive medical management should be used to stop variceal hemorrhage prior to TIPS in all patients, regardless of the Child-Pugh classification. Prospective trials comparing TIPS with sclerotherapy and surgical shunt are required to demonstrate the proper role of this procedure in the management of portal hypertension and variceal hemorrhage.

Aortic sepsis: Is there a role for in situ graft reconstruction?

Conventional extraanatomic reconstruction for aortic sepsis is associated with a significant risk of operative death, as well as frequent late complications. We evaluated in situ aortic grafting in the treatment of primary or graft-related aortic infection. Eleven selected patients underwent in situ aortic graft reconstruction in the setting of mycotic aneurysm (n = 5), secondarily infected aortic aneurysm (n = 1), primary aortoenteric fistula (n = 1), and secondary aortoenteric fistula (n = 4). All patients survived: follow-up from 10 to 130 months reveals no evidence for graft thrombosis, pseudoaneurysm, new or recurrent aortoenteric fistula, or subsequent aortic operations in any patient. A literature review produced 110 cases of aortic sepsis managed by in situ aortic reconstruction during the last decade. Thirty-two patients (29%) either died in the operative period or suffered a lethal late complication associated with their aortic reconstruction. This mortality rate declined to 21% if patients undergoing incomplete removal of a contaminated graft were excluded, and to 19% with the addition of our 11 patients. Both our experience and that described in the literature suggest that, in properly-selected patients, in situ aortic graft replacement may be a rational treatment option for localized or circumscribed aortic sepsis.

Temporary Intraluminal Shunts: Resolution of a Management Dilemma in Complex Vascular Injuries

Complex vascular injuries of the extremities in which acute arterial insufficiency is combined with severe or prolonged shock, extended periods of ischemia, or associated fractures or soft-tissue injuries have unacceptably high limb loss rates, frequently because the allowable warm ischemia time for skeletal muscle is exceeded before adequate revascularization. In a 1-year period, ten patients with complex vascular injuries identified at our metropolitan trauma center underwent routine introduction of temporary plastic intravascular shunts at the site of vessel disruption, thus permitting immediate limb revascularization. This rapid reperfusion permitted appropriate attention to be directed toward skeletal fixation, soft-tissue debridement, and other procedures without the urgency usually associated with the presence of acute limb ischemia. Following various local and distant orthopedic or general surgical procedures, arterial and venous continuity were uneventfully re-established. This experience suggests that the routine use of plastic intraluminal shunts in complex vascular injuries of the extremities has the distinct potential of reducing the excess morbidity from prolonged acute arterial insufficiency noted in such injuries.

Noninvasive physiologic tests in the diagnosis and characterization of peripheral arterial occlusive disease

A panel of noninvasive tests has been developed to quantitate the functional disability associated with peripheral arterial obstructive diseases. The tests are useful in localizing the site of significant lesions, determining their physiologic significance, identifying postoperative benefit, and detecting progression of the disease.

Symmetrical peripheral gangrene (purpura fulminans) complicating pneumococcal sepsis.

Bacterial sepsis is only infrequently accompanied by peripheral ischemia. However, we have managed 10 patients with symmetrical peripheral gangrene (purpura fulminans) accompanying pneumococcal sepsis (Streptococcus pneumoniae) during the past 15 years at a single institution. In only two (20%) of these patients could vasoconstrictor administration be implicated as contributory to gangrene. The clinical scenario was characterized by pneumococcal bacteremia, admission to the medical intensive care unit, normal proximal arterial perfusion, and symmetrical full-thickness digital and distal extremity ischemia leading to cutaneous gangrene. Three (30%) of these patients died. The failure of anticoagulant and antiplatelet agents as therapy and the successful reversal of impending digital gangrene in one patient by sympathetic blockade suggest that the initial underlining pathophysiology is vasoconstrictive rather than thrombotic in nature. Effective management includes appropriate antibiotic therapy, avoidance of early operative intervention, conservative local débridement, and secondary skin grafting.

Duplex scanning for arterial trauma

Duplex sonography was evaluated as a potential screening examination for arterial trauma in 89 patients with 93 injuries, mostly to the extremities (n = 74) or the cervicothoracic region (n = 17). Among 60 scans performed solely because of wound proximity to nearby vascular structures, 4 (6.7%) were positive. Thirteen of 19 (68%) scans performed for clinical indications were positive. Six of 12 (50%) postoperative studies were abnormal, and each of 4 arterial injuries followed serially remained stable. Four false-negative duplex scans (4.3%) were recorded; no major arterial injuries were missed, and no false-positive studies were noted. Duplex sonography is rapid, noninvasive, inexpensive, and portable. Since it also appears to be reliable in diagnosing and localizing sites of arterial disruption, duplex scanning may be of value in screening patients with trauma for the presence of occult vascular injuries.