Identification of risk factors for arterial repair failures and lessons learned: Experiences from managing 129 combat vascular extremity wounds in the Sri Lankan War

BACKGROUND: In extremity vascular trauma, early complications occur at a rate of 13% to 44%. The most common of which are infection, dehiscence, thrombosis, and stenosis. Failure of the arterial repair, also called arterial blowout, has the potential for exsanguinating hemorrhage and poses a considerable challenge for the surgeon to save limb and life. METHOD: All adults with extremity vascular injuries admitted in 8-month period were prospectively recorded and retrospectively analyzed. Extremity vascular injuries in this group include those in which limb salvage attempted. 5 arterial blowouts in a recorded 87 arterial repairs were analyzed for demographics, presentation, management and outcome in the context of identifying most probable causative factors. RESULT: 5 arterial blowouts occurred out of 87 arterial repairs for a rate of 5.75%. These occurred at a mean of 14 days post-operatively. All patients were male with the majority of the injuries, 80%, resulting from gunshot wounds. All injuries were associated with severe soft tissue injury and clinical evidence of bacterial infection. Technical error, inadequate debridement, prolonged exposed vessel and unstable skeletal injury were noted as causative factors in addition to the commonly reported causes of repair failure. At a mean follow-up of 17 days, the arterial blowout cohort had 80% limb survival rate. CONCLUSION: Ischemic, damaged and contaminated military wounds lead to infections of varied degree. Delay in closure due to tight distal muscle compartments or severe persistent soft tissue infections, necessitating serial irrigation and debridement (I&D) of wounds, is the common chain noted leading to arterial blowout. To break this chain of events the authors suggest early identification of at risk limbs and aggressive soft tissue cover of the newly constructed repair. LEVEL OF EVIDENCE: Case series, level IV.