Outcome after major renovascular injuries: A Western Trauma Association multicenter report

Background: Major renal vascular injuries are uncommon and are frequently a ssociated with a poor outcome. In addition to renal dysfunction, posttrauma tic renovascular hypertension may result, although the true incidence of th is complication is unknown. The objective of this study was to describe the factors contributing to outcome after major renovascular trauma. We hypoth esized that the highest percentage of renal salvage would be achieved by mi nimizing the time from injury to repair. Methods: This was a retrospective chart review over a 16-year period conduc ted at six university trauma centers of patients with American Association for the Surgery of Trauma grade IV/V renal injuries surviving longer than 2 4 hours. Postinjury renal function with poor outcome was defined as renal f ailure requiring dialysis, serum creatinine greater than or equal to 2 mg/d L, renal scan showing less than 25% function of the injured kidney, postinj ury hypertension requiring treatment, or delayed nephrectomy. Data collecte d for analysis included demographics, mechanism of injury, presence of shoc k, presence of hematuria, associated injuries, type of renal injury (major artery, renal vein, segmental artery), type of repair (primary vascular rep air, revascularization, observation, nephrectomy), time from injury to defi nitive renal surgery, and type of surgeon performing the operation (urologi st, vascular surgeon, trauma surgeon). Results: Eighty-nine patients met inclusion criteria; 49% were injured fron t blunt mechanisms. Patients with blunt injuries were 2.29 times more likel y to have a poor outcome compared with those with penetrating injuries. Sim ilarly, the odds ratio of having a poor outcome with a grade V injury (n = 32) versus grade IV (n = 57) was 2.2 (p = 0.085). Arterial repairs had sign ificantly worse outcomes than vein repairs (p = 0.005), Neither the time to definitive surgery nor the operating surgeon's specialty significantly aff ected outcome. Ten percent (nine patients) developed hypertension or renal failure postoperatively: three had immediate nephrectomies, four had arteri al repairs with one intraoperative failure requiring nephrectomy, and tno w ere observed. Of the 20 good outcomes for grade V injuries, 15 had immediat e nephrectomy, 1 had a renal artery repair, 1 had a bypass graft, 1 underwe nt a partial nephrectomy, and 2 were observed, Conclusion: Factors associated with a poor outcome following: renovascular injuries include blunt trauma, the presence of a grade V injury, and an att empted arterial repair. Patients with blunt major vascular injuries (grade V) are likely to have associated major parenchymal disruption, which contri butes to the poor function of the revascularized kidney. These patients may be best served by immediate nephrectomy, provided that there Is a function ing contralateral kidney.