RS22 - Association Between Time to Revascularization and Amputation in Military Lower Extremity Vascular Injuries

Objectives: Expeditious revascularization is key to limb salvage after arterial injuries, but the relationship between delay and amputation risk is not well-defined in military trauma. We aimed to explore amputation risk based on time to revascularization in a cohort of military injuries.

Methods: A military vascular injury database (2004-2012) was queried for femoropopliteal injuries that underwent revascularization. Time from injury to initial revascularization (shunt or reconstruction) was divided into groups of 3h, 3-6h, 6-9h, and >9h and injury, treatment, and outcome characteristics compared across these groups.

Results: Times were available for 120 cases. Shunting was more common in limbs revascularized earlier, while fasciotomy was more common with later revascularization. Amputation rates were 10% < 3h (n=10), 21% 3-6h (n=63), 24% 6-9h (n=33), and 50% >9h (n=14, P=0.085, Figure). The mean revascularization time for amputated limbs was 442+/-348 min vs 347+/-183 min for salvaged limbs (P=0.057). Amputation was performed in 19% of limbs revascularized in < 6h vs 32% revascularized >6h from injury (P=0.112). At >9h, however, the amputation rate was 50% vs 21% < 9h (P=0.016). Fractures were more common in >9h limbs than < 9h (79% vs 44%, P=0.016), but limb injury severity was otherwise similar. Among 91 salvaged limbs, neither vascular nor other limb complications were predicted by time to revascularization. (Table) All seven salvaged >9h limbs had a limb complication, most commonly infection (71%), and three (42%) required a skin graft to close fasciotomies, which were universally performed.

Conclusions: Limb loss was associated with time to revascularization in military femoropopliteal arterial injuries, with best results seen with revascularization within 3 hours. Half of limbs with a >9h revascularization delay underwent amputation. Arterial shunting for damage control was associated with earlier revascularization and should be considered a mainstay of combat casualty vascular care.