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An Analysis of Followup Studies on 115 Acute Vascular Repairs

Medical Science Publication No. 4, Volume 1

AN ANALYSIS OF FOLLOWUP STUDIES ON 115 ACUTE VASCULAR REPAIRS*

MAJOR EDWARD J. JAHNKE, JR., MC

The improved management of acute vascular injuries, established during the Korean conflict, represents one of the most outstanding achievements in the realm of war surgery. Although the incidence of amputation of a limb sustaining a major arterial interruption has been reduced from 49 to approximately 15 percent, this does not fully demonstrate the value of initial vascular repair. Many patients are now using a functionally adequate limb which, in former years would have been, at best, simply a viable limb. However, few methods of management, regardless of how physiologically conceived or technically performed, are entirely satisfactory and this is especially true when considering battle casualties and the problems associated with them.

During the period from August 1952 to December 1953 a total of 115 patients who had initial major arterial repairs performed in Korea were studied at this hospital. They represent only those patients who did not later require amputation of the involved extremity. All who required amputation, prior to evacuation from the Far East, have been previously reported and were excluded from this survey, our prime purpose being to evaluate the ultimate status of the vascular system in those patients who were considered successfully treated. To this extent, the findings are selective in nature but they do emphasize several important points. Probably their greatest value lies in the fact that they demonstrate that the results have not been perfect and much additional experimental and clinical investigation needs to be done.

Functional vascular surveys were performed on all patients and consisted of: (1) gross physical evaluation of the blood supply to the limb, (2) pulsations in the peripheral arteries, (3) oscillometric and skin temperature studies, (4) exercise tolerance tests, (5) arteriography and (6) visualization of the vascular repair if the limb was operated upon because of associated nerve or bone damage.


*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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In the great majority of patients, an adequate blood flow and a patent arterial repair could be ascertained by simple physical examination of the extremity and palpation of the peripheral pulses. On this basis, 87 patients were considered to have a functionally adequate circulation with a patent major arterial repair. Peripheral pulses were palpable in 93 patients but, in 6 of these, were markedly diminished and were believed due to collateral circulation. This was later substantiated by arteriography. In 5 patients peripheral pulsations, equal to those in the uninvolved extremity, were recorded. However, in each instance thrombosis of the major channel was demonstrated by further study. Despite this occlusion, the collateral circulation was extensive enough to prevent any evidence of arterial insufficiency. In 22 patients no peripheral pulses were demonstrated and each was proved later to have a thrombosis of the arterial repair. Thus, of 33 later proven thromboses, 22 had no peripheral pulses, 6 had markedly diminished pulses and 5 had excellent pulses. As would be expected from the known areas of greatest collateral circulation, of upper extremity occlusions which numbered 16, only 7 had no peripheral pulses, 5 had diminished pulses and 4 had excellent pulses. In the lower extremity, where the collateral circulation is much less adequate, entirely different results were observed. Of 17 patients with arterial occlusion, 15 had no pulses while only 1 each had diminished or excellent peripheral pulsations.

Oscillometric and skin temperature studies proved to be of little additional value in determining the adequacy of the circulation. With few exceptions the oscillometric readings corresponded closely to the palpable peripheral pulses. In several patients severely depressed readings were obtained in the presence of rather good peripheral pulses but in each instance the vascular repair was shown to be occluded. In almost all patients with patent arterial repairs, the readings from the affected limb were either equal or only slightly depressed as compared to the uninvolved extremity. The room temperature thermocouple studies, on the other hand, showed no correlation with the status of the major arterial channels.

An interesting observation was made in regard to the exercise tolerance tests. Several patients with patent arterial repairs were observed to have a paradoxical response to exercise, the oscillometric deflections decreasing rather than increasing. By arteriography, marked constriction was observed at the repair site. One might postulate that constriction and tension at the suture line acts as an irritating factor during exercise and results in reflex vasospasm with diminution of the arterial inflow. Such a factor might well counteract the value of the repair and eventually lead to thrombosis at that site. Similar instances have been observed in patients with arteriovenous fistulas repaired


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under tension and with excessive constriction. If this conclusion be true, it would suggest the inadequacy of determining functional capacity on the basis of arteriography or tests performed at rest. It would also indicate the importance of avoiding any significant degree of tension or constriction at the suture line during performance of the vascular repair.

Arteriography was performed on the great majority of patients studied and proved to be the best method of evaluating the status of the repair. All injections were made percutaneously using either 70 percent Diodrast or Urokon as the contrast media. Eight roentgenograms were taken at 0.8 second intervals with the Sanchez-Perez rapid casette changer. Using this technic, demonstration of the arterial repair was excellent. It also permitted adequate visualization of the collateral circulation and the configuration of the distal main artery in those patients in whom thrombosis had developed.

Of the 115 patients studied, occlusions were found in 33 or 28.7 percent, a rate far higher than expected based on the results of several hundred vascular repairs performed in this hospital for other lesions. However, this figure loses some of its significance when it is remembered that not one patient in this entire series lost any part of a limb as a result of arterial damage. Since most patients who were shown to have a late thrombosis had good peripheral pulsations prior to evacuation from the Far East, it can be assumed that the repairs functioned at least long enough to preserve the viability of the limb.

Further analysis of this group of patients revealed a direct correlation, of statistical significance, between the type of repair performed and the occurrence of late thrombosis. Occlusion occurred in only 18.8 percent of direct anastomoses as compared to 44.4 percent of lateral repairs, 47.4 percent of autogenous vein grafts and 71.4 percent of homologous artery grafts. These figures are difficult to explain with the exception of the lateral repairs. Here, thrombosis was probably the result of inadequate arterial débridement and it was felt that this method of management should rarely, if ever, be used. The difference in thrombosis rate between the vein graft and the artery graft is not understood. In chronic vascular lesions as fistulas, aneurysms and segmental arterial blocks, either type of graft can be employed with equal success. It is fair to state, however, that from the results thus far obtained, the artery graft should not be employed in battle-injured arteries unless an adequate vein graft is not available.

Since an overall incidence of thrombosis of 28.7 percent was much higher than expected, an attempt was made to analyze the possible causes without respect to the type of repair performed. Several factors were uncovered but they failed to provide a cause in the majority of patients. In 21 or 63.6 percent of all patients with throm-


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boses there was nothing found which could have explained the late failure of repair. In the remaining 12 or 36.4 percent a definite predisposing cause was found. Tension and constriction at the suture line was implicated in 15.2 percent (5 cases) of patients. Infection was responsible in 12.1 percent (4 cases); secondary hemorrhage in 6.1 percent (2 cases); and use of a damaged vein as a graft in 3 percent (1 case). From this it can be seen that all known causes were the result of technical errors which could have been prevented.

A study was then made of all patients with thromboses to see if there was any correlation with some of the factors which influence the initial repair. These factors are: (1) time lag, (2) wound size, (3) wound location and (4) associated bone and nerve damage. The results seem to indicate that time lag and wound size may be of some importance but in no instance was there any statistical correlation. The presence of an associated bone or nerve injury would appear to create a situation which would predispose to an increased incidence of thrombosis but again the figures did not substantiate this impression.

Finally, let us consider the functional results in the 33 patients who had occlusions. Sixteen occurred in the upper extremity. It has already been demonstrated that, because of the excellent collateral circulation that exists in this area, symptomatic arterial insufficiency was unusual. Only one patient required additional treatment, which consisted of a secondary repair of the artery using a vein graft. More serious problems were encountered in the 17 patients with thrombosed arterial repairs in the femoral and popliteal areas. Only 3 were asymptomatic and 2 of these had excellent distal pulses despite the major vascular occlusion present. Three other patients have not been completely evaluated because of associated injuries. The remaining 11 patients had definite symptoms of arterial insufficiency. In each instance a secondary vascular repair, employing a vein graft, was believed indicated. Two patients refused treatment and one had a thrombosis extending into the posterior tibial artery which precluded any attempt at arterial restoration. In 8 patients, or 72.7 percent of those with symptomatic insufficiency, the occluded segment of vessel was excised and the major channel restored by means of an autogenous saphenous vein graft. These varied from 14 to 32 centimeters in length. In each instance the symptoms of insufficiency were relieved and a functionally viable limb resulted.

Summary and Conclusions

1. One hundred fifteen patients, with arterial repairs performed in Korea who did not lose a limb, were studied at Walter Reed Army Hospital.


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2. Complete organic and functional vascular surveys were performed on all patients.

3. Accurate physical examination was sufficient to determine the status of the vascular system in the majority of patients.

4. By arteriography, late thrombosis had occurred in 33 or 28.7 percent of patients but in no instance did this require amputation of a limb.

5. Thrombosis occurred in 18.8 percent of direct anastomoses, 44.4 percent of lateral repairs, 47.4 percent of autogenous vein grafts and 71.4 percent of homologous artery grafts.

6. In 63.6 percent of patients no cause for the thrombosis could be found.

7. The factors which could be implicated were, in the order of importance, tension and constriction at the suture line, infection, secondary hemorrhage, and use of a damaged vein as a graft.

8. Time lag, wound size, wound location and associated bone and nerve injury could not be correlated with the incidence of thrombosis.

9. Following thrombosis of the vascular repair, symptoms of insufficiency were almost entirely limited to patients with lesions in the lower extremity.

10. Eight patients, or 72.7 percent of those with symptoms of insufficiency, had arterial continuity restored by a secondary grafting procedure with excellent results.

11. The results of primary repair of battle-injured major arteries are not entirely satisfactory and much experimental and clinical investigation remains to be done.