ALTERNATIVES IN THE MANAGEMENT OF PENETRATING INJURIES TO THE ILIAC VESSELS

Background: The high mortality and morbidity rates after iliac vessel injuries remain a challenging problem for trauma surgeons, Several con troversial issues surround the management of iliac vessel injuries, in cluding the value of abbreviated laparotomy, the role of extra-anatomi c bypass reconstruction (EABR), the use of vascular prostheses in the presence of contamination, and the need and timing for fasciotomy, Met hods: Retrospective review of the records of patients who sustained an injury to the iliac vessel between 1987 and 1996, Results: A total of 64 patients were treated, including 23 with isolated iliac vein injur ies, 17 with arterial injuries, and 24 with combined arteriovenous inj uries. Vascular prostheses were placed in 17 patients with arterial in juries, including 12 with associated intestinal wounds. Graft infectio n did not occur. Of the 24 patients with combined injuries, 11 underwe nt abbreviated laparotomy and 1 died, Five deaths, however, occurred i n 13 patients in whom no attempts were made for damage control laparot omy, Significant differences between survivors and nonsurvivors includ ed final arterial pH, final prothrombin time, length of hypotension, a nd number of transfusions, Arterial ligation with EABR was performed i n five patients and failed in two. Deep venous thrombosis and pulmonar y embolism occurred in four patients, in three of them after venous in juries were ligated, The overall mortality rate was 23%. Conclusion: O ur findings show that (1) abbreviated laparotomy reduces mortality in iliac injuries; (2) EABR should be performed early after stabilization to prevent limb ischemia; (3) the use of vascular prostheses with ass ociated intestinal injuries did not appear to increase the incidence o f graft infection; and (4) after vein ligation, early fasciotomy and p rophylaxis against extremity swelling, deep venous thrombosis, and pul monary embolism should he considered.