Etiology and Surgical Management of Penetrating Arterial Trauma of Limbs in Toamasina ()
1. Introduction
In Sub-Saharan African countries, vascular trauma is the most common cause of death and amputation. Vascular surgery is sometimes performed by both general surgeons due to lack of vascular surgeons in these countries. The prevalence of civilian vascular trauma is estimated at 4.5 cases per year in Sub-Saharan African countries [1]. In Antananarivo, vascular injuries account for 5.28% of reason for hospital admission in Vascular Unit [2] and trauma remains the leading reason (33%) of surgical procedures of limbs in Antananarivo [3]. The poverty and insecurity increased the risk of vascular trauma in Toamasina. However, the management of vascular trauma remains a challenge in low-income countries such as Madagascar due to delays in timing of admission for majority of victims. In addition, there is not any guideline available in management of victims of vascular trauma in Toamasina. The aim of this study was to describe etiology and surgical management of penetrating traumatic arterial injuries of limbs in Toamasina.
2. Materials and Methods
This study was performed in Morafeno Teaching Hospital in Toamasina, located in East region of Madagascar. It’s one of referral hospitals for vascular surgery in Toamasina. We conducted a retrospective and descriptive study among patients admitted to hospitalisation after penetrating arterial injuries due to trauma happened in Toamasina, an East region of Madagascar. This study included all victims of trauma of limbs which underwent surgical arterial repair due to the presence of penetrating arterial injuries, for 6 years-period (from 1st January 2017 to 31th December 2022) performed at Vascular Surgery Unit in Morafeno Teaching Hospital. Data were collected from patients’ folders stored in Vascular Surgery Unit, including all prehospital gestures, the preoperative management during admission at Emergency Unit, the surgical procedures and postoperative management. Demographic data, mechanism of injury, prehospital haemostasis gesture, clinical signs, type and location of arterial injury, associated injuries, surgical treatment and outcomes were analyzed. Data were recorded with Microsoft excel 2016, then analyzed with SPSS 21.0 software.
3. Results
Thirty-five cases of penetrating traumatic arterial injuries were recorded. The most victims were young, and the average age was 31.27 years old, ranging from 16 to 43 years. There was a male predominance (91.42%) with sex ratio of 10.66. Penetrating arterial injuries were due to stabs in 88.57% and gunshots in 11.42% (Table 1). Patients had a history of using improvised tourniquets (57.14%), compression bandages (31.42%) and skin suture (11.42%) to control the bleeding before their admission into hospital. The most common symptoms were external bleeding (68.57%), expanding and pulsatile hematoma (31.42%), pulse absents (88.5%) and paresthesia (91.42%). Lesions were lacerations (34.28%), transections (48.57%) and avulsions (17.14%). Arterial injuries were located in upper extremities in 22 cases (62.85%) and in lower extremities in 13 cases (37.14%). The most involved vessels were brachial artery (45.71%) followed by femoral artery (28.57%) (Table 2). There were associated injuries observed in some victims like soft tissue damage (34.28%), venous injuries (54.28%), nerve injuries (8.57%) and bone injuries (11.42%). In admission, all victims received medical treatment like painkill, antibiotics and massive crystalloid fluid perfusion to manage hemodynamics before surgery. Surgical arterial repair was performed between 6 to 12 hours after arterial trauma in more than half of cases (51.42%) (Table 3). Only nine victims (25.71%) underwent surgical repair before 6 hours after arterial trauma. Surgical procedures were end-to-end anastomosis (45.71%) (Figure 1), lateral arteriorrhaphy (25.71%), interposition of saphenous vein graft (17.14%) (Figure 2) and ligation (8.57%). Primary amputation of leg was performed for 1 patient (2.85%) after irreversible acute ischemia with large soft tissue damage. Two patients (5.71%) died during hospitalization due to polytraumatism after gunshots. The survival rate and the limb salvage rate were respectively 94.28% and 97.14%.
Table 1. Gender, circumstance of accident, control of bleeding before admission and clinical signs.
Gender/circumstance of accident/control of bleeding before admission/clinical signs |
Frequencies
(n = 35) |
Percentage
(%) |
Gender |
Male |
32 |
91.42 |
Female |
3 |
8.57 |
Circumstance of
accident |
Stabs wounds |
31 |
88.57 |
Gunshots wounds |
4 |
11.42 |
Control of
bleeding before
admission |
Improvised tourniquets |
20 |
57.14 |
Compression bandage |
11 |
31.42 |
Skin suture |
4 |
11.42 |
Clinical signs |
External bleeding |
24 |
68.57 |
Expanding and pulsatile hematoma |
11 |
31.42 |
Cold extremities |
32 |
91.42 |
Skin wound |
35 |
100 |
pulse absents |
31 |
88.5 |
paralysis |
4 |
11.42 |
Table 2. Characteristics of arterial injuries.
Characteristics of arterial injuries |
Frequencies (n = 35) |
Percentage (%) |
Type of arterial
injuries |
Laceration |
12 |
34.28 |
Transection |
17 |
48.57 |
Avulsion |
6 |
17.14 |
Location and
involved vessels |
Upper
extremities (n = 22) |
Brachial artery |
16 |
45.71 |
Radial artery |
5 |
14.28 |
Ulnar artery |
1 |
2.85 |
Lower
extremities (n = 13) |
Femoral artery |
10 |
28.57 |
Tibial artery |
2 |
5.71 |
Fibular artery |
1 |
2.85 |
Associated
injuries |
Soft tissues damage |
12 |
34.28 |
Venous injuries |
19 |
54.28 |
Nerves injuries |
3 |
8.57 |
Bones injuries |
4 |
11.42 |
Table 3. Delay between trauma and surgical procedures, surgical repair and outcomes.
Delay between trauma and surgical
procedures/surgical repair and outcomes |
Frequencies (n = 35) |
Percentage (%) |
Delay between
initial trauma
and surgical
procedures |
<6 hours |
9 |
25.71 |
6 - 12 hours |
18 |
51.42 |
12 - 24 hours |
5 |
14.28 |
>24 hours |
3 |
8.57 |
Surgical repair |
Lateral arteriorrhaphy |
9 |
25.71 |
End-to-end anastomosis |
16 |
45.71 |
Interposition of saphenous
vein graft |
6 |
17.14 |
Ligation |
3 |
8.57 |
Primary amputation |
1 |
2.85 |
Outcomes |
Survival |
33 |
94.28 |
Mortality |
2 |
5.71 |
Limb salvage |
34 |
97.14 |
Amputation |
1 |
2.85 |
Figure 1. Peroperative image of end-to-end anastomosis.
Figure 2. Peroperative image of reverse saphenous vein graft interposition.
4. Discussion
Penetrating arterial injuries due to trauma are a usual situation in Sub-Saharan African countries, contrasting in advanced countries where incidence of vascular trauma is extremely low, accounting 1.8% of trauma admission [4]. The true prevalence of arterial trauma remains unknown in Sub-Saharan African countries because most of victims mostly died before the admission in hospital. In Ethiopia, penetrating trauma are responsible for 89.4% of vascular injuries of extremities [5]. In addition, penetrating arterial injuries were usually underreported in Sub-Saharan African literature because all cases published by researchers included just only all patients who underwent surgery without patients who died before admission. So, these cases didn’t represent the true prevalence of arterial traumatic injuries of limbs in these countries.
Most research published a high prevalence of penetrating arterial trauma in young male people. This predominance of young people was seen in different African studies that the average age was 28 years in Nigeria [6], 27 years in Ethiopia [5] and 31 years in our study. Male predominance is still observed in most research in African countries and in advanced countries with a rate of 90% in Iran [7], 85% in Nigeria [8] and 85 in Texas [9]. This predominance of youth male could be explained by the high level of activity and mobility of the male gender that exposes them to various risk of trauma.
In advanced countries, penetrating arterial trauma of extremities was commonly due to road traffic accidents, but it was usually due to stabs or gunshots in Sub-Saharan African countries. This situation was observed in the study of Khan et al. and in the study of Thakur et al. that the rate of road traffic accidents was respectively 53% and 92% [10] [11]. In contrast, the most common causes of penetrating arterial injuries in Sub-Saharan African countries were gunshot wounds in South African study of Le Roux et al. (72%) [12] and in Tunisian study of Daly et al. (39%) [13]. Other studies showed a similar result of our study in the predominance of stabbing in circumstances of accident like the study of Nkomo et al. (65%) [14] and Daly et al. (53%) [13]. The predominance of gunshots and stabbings in Sub-Saharan African countries could be explained by the high rate of insecurity and banditism act related to poverty in population.
Most people used an impovised tourniquets (57%) and compression bandages (31%) to control the external bleeding before admission of victims. This situation was mostly observed in other African studies such in study of Nkomo et al. [14] and Fokou et al. [15]. Our result showed a similar result in the study of Fokou et al. with the predominance of using of compressing bandages (46%) and tourniquets (41%) [15]. The lack of medical transportation in low-income countries makes people to improvise something to stop the bleeding before the admission of victims. Tourniquets can be used to control hemorrhage before admission or before vascular control during surgery.
The diagnosis of penetrating arterial trauma of limbs is usually simple with the presence of hard signs of vascular trauma such as pulsatile bleeding, expanding and pulsatile hematoma, cold extremities and pulse absents. There is no role for routine imaging in penetrating arterial trauma of extremities. External pulsatile bleeding is the leading sign observed in most studies, accounting for 57% in our study, 78% in the study of Fokou et al. [15]. But our result contrasts with the study of Krüger et al., which absence of pulses (48%) is the leading sign of penetrating arterial trauma of limbs [16]. The presence of signs of acute ischemia of limb depends on quantity of external bleeding and time of using tourniquets before admission.
Type of arterial injuries are different according to studies. It usually depends on circumstances of accident and energy of trauma. Stabs with their low-energy trauma are responsible for laceration or transection, but gunshots are responsible for arterial avulsion due to high-energy of trauma. Transection is the most common type of arterial injury seen in our study (48.57%), followed by laceration (34.28%). Other African studies showed a similar result in the leading of transection in degree of injury, such as in study of Onakpoya et al. (67%) [6] and Nkomo et al. (46%) [14]. Other non-African studies showed too the predominance of transection like the study of Franz et al. (31%) [17].
Traumatical arterial injuries could be located in upper extremities or in lower extremities. This study showed a predominance of upper extremities (62%). Some studies showed a similar result with predominance of upper extremities in the location of arterial injuries. Upper extremities accounted respectively 73% and 57% in the study of Nkomo et al. [14] and Onakpoya et al. [6]. Brachial and femoral arteries were the most commonly involved vessels, as published by some researchers. Our study agrees with the literature in the predominance of brachial artery (45%) followed by femoral artery (28%). Some authors published the same result like Krüger et al. with brachial artery (41%) followed by femoral artery (30%) [16]. However, some studies showed a contrasting result, like predominance of tibial artery (29%) [18].
Associated injuries were still observed in some studies of traumatic arterial injuries like venous injuries, nerve injuries and bone injuries. Venous injuries are the most common associated injuries observed in our study (54%), in the study of Krüger et al. (31%) [16] and in the study of Hussein et al. (35%) [19]. Nerve injuries took usually second place among additional injuries, accounting for 29% in the study of Krüger et al. [16] and 26% in the study of Hussein et al. [19]. Some authors found a predominance of bone injuries associated with arterial injuries, such as Adeoye et al. (31%) [18] and Shakeri et al. (86%) [18]. These associated injuries sometimes need additional surgical repair to restore the right anatomical structure and functions of extremities. This situation could explain the extension of the surgical repair duration.
In low-income countries, the surgical management of penetrating traumatic arterial of limbs was usually late due to prolongation of admission in most victims, related to lack of medical transportation. In this study, half of victims underwent surgery between 6 to 12 hours after their initial vascular trauma. In the same way, other African studies showed too the delayed of time of presentation among victims of arterial trauma of extremities, such as the study of Gebregiorgis et al. that most of victims (42%) were admitted after 24 hours after the initial trauma [5] and the study of Onakpoya et al. which the majority of victims (63%) admitted 12 hours after the accident [6]. Adeoye et al. found that 55% of victims underwent surgery between 4 - 6 hours after vascular trauma [8]. The delayed of surgical management in our study could be explained by firstly, the lack of medical transportation and secondly by the poverty in population. In addition, most people can’t afford to pay the hospital costs in case of emergency. After vascular trauma, most of the victims needed again more time to search money or find another solution before admission to hospital.
Surgical revascularization must be done early to prevent ischemia of limb and to avoid risk of amputation. Surgical arterial repair depends on type of arterial injuries. Lacerations require usually simple lateral arteriorrhaphy to restore arterial vascularization. However, transections need end-to-end anastomosis to establish continuity of arterial segment. Lateral arteriorraphy and end-to-end anastomosis remain the most common surgical repairs in Sub-Saharan African studies. Our study showed a predominance of end-to-end anastomosis (45%) followed by lateral arteriorrhaphy (25%). Some authors found a similar result, such as Nwafor et al. whose study presented 30% of arteriorraphy and 27% of end-to-end anastomosis [1] and Adeoye et al. with 31% of end-to-end anastomosis followed by lateral repair (25%) [8]. The loss of arterial segment requires usually an interposition of vein to restore the continuity. Establishing the continuity of arterial segment by using reverse saphenous vein was the most common situation seen in low-income countries such Madagascar. It could be explained by availability of saphenous veins in emergency situation.
Although making salvage of limbs is one of aim of surgical management of penetrating arterial trauma of extremities, the outcome was variable and depended on type and/or mechanism of injury, the delay between accident and surgical repair and collateral blood supply. The rate of limb salvage was 97% in our study. Some studies showed a contrasting result, such as the study of Onakpoya et al. with a lower rate (64%) of limb salvage [6] and the study of Gebregiorgis et al. with 71% of limb salvage [5]. The hospital mortality rate was extremely lower than before admission accounted usually under 10% in Sub-Saharan African countries, like the studies of Adeoye et al. (6%) [8] and Hussein et al. (6%) [19]. In Western country, researchers found a lower rate of mortality than in African studies such as Altoijry et al. and Cho et al. with respectively 5% and 3% of hospital mortality rate [20] [21].
5. Limitations
The retrospective nature and the small size of the population studied constitute the main limitations of our study. This population of study was underestimated because it included only all patients who underwent surgical repair of penetrating arterial injuries.
6. Conclusion
Stabs were the most common cause of penetrating traumatic arterial injuries in Tamatave. Restoring the arterial flow to the distal extremity within six hours after the initial trauma remains the important key to keep off the limbs from the risk of amputation. But it’s usually difficult to perform the surgery at the right time because of late in admission of victims.