POPLITEAL ARTERY TRAUMA - SYSTEMIC ANTICOAGULATION AND INTRAOPERATIVETHROMBOLYSIS IMPROVES LIMB SALVAGE

Objective This study was conducted to evaluate those factors associate d with popliteal artery injury that influence amputation, with emphasi s placed on those that the surgeon can control. Summary Background Dat a Generally accepted factors impacting amputation after popliteal arte ry injury include blunt trauma, prolonged ischemic times, musculoskele tal injuries, and venous disruption. Amputation ultimately results fro m microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. Methods Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic time s) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studi ed. Severity of extremity injury was quantitated by the Mangled Extrem ity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). Afte r univariate analysis, logistic regression analysis was performed to i dentify the independent risk factors for limb loss. Results One hundre d two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating tr auma. there were 25 amputations (25%; 11 primary and 14 secondary). Pa tients with totally ischemic extremities (no palpable or Doppler pulse ) more likely were to be amputated (31% vs. 13%; p < 0.04). All requir ing primary amputations had severe soft tissue injury and three had po sterior tibial nerve transection; the average MESS was 7.6. Logistic r egression analysis identified independent factors associated with seco ndary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MES S (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no co mplications with either heparin or urokinase. Conclusions Minimizing i schemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputat ion. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvag e. The authors recommend the use of these agents to maximize limb salv age in association with repair of popliteal artery injuries.