Long-term Clinical Outcome and Functional Status after Arterial - PowerPoint PPT Presentation

Long-term Clinical Outcome and Functional Status after Arterial Reconstruction in Upper Extremity Injury Josef Klocker, MD, L. Pellegrini, MD, G. Fraedrich, MD Department of Vascular Surgery Medical University Innsbruck, Austria

no conflicts of interest Klocker, SVS 2014_Boston

Introduction (1) n % % Author * PY Centre patients blunt penetrating Follow - up Myers 1990 Houston 95 27% 73% 6 months Fit ridge 1994 Adelaide 114 46% 54% 14 months Van der S luis 1997 Toronto 25 76% 24% 24 months Manord 1998 New Orleans 46 39% 61% 43 months Brown 2001 Milwaukee 71 30% 70% 6 months 2009 Regensburg Toepel 30% 70% 33 42 months * only studies published after 1990 involving more than 20 pts at least 6 months follow - up Klocker, SVS 2014_Boston

Introduction (2) limb functional status Author * PY Follow - up salvage patency determined by Myers 1990 n. a. 6 months 100% 99% Fit ridge 1994 - associated injury 14 months 86% 100% - location of injury Van der S luis 1997 - persitent neural deficit 24 months 100 n. a. - joint contractures Manord 1998 - blunt injury 43 months 98% n. a. Brown 2001 - neurologic injury 6 months 93.5% n. a. - blunt injuries Toepel 2009 98% 100% - neurologic injury 42 months * only studies published after 1990 involving more than 20 pts at least 6 months follow - up Klocker, SVS 2014_Boston

Patients and Methods (1) retrospective data collection all patients who underwent repair of upper limb arterial injuries in our institution during a 20-years period were included, analyzed and followed Klocker, SVS 2014_Boston

Patients and Methods (2) retrospective data collection Data:  demographic parameters  mechanism of trauma and type of injury  location of arterial injury  presence of concomitant vein, nerve and/or bone injuries  details of arterial reconstruction  follow-up clinical (patency; diameter of grafts) ultrasound Klocker, SVS 2014_Boston

Patients and Methods (3) long-term left arm functional impairment DAS H (Disabilities of Arm, S houlder and Hand) Questionnaire Hudak et al., 1996 Offenbaecher et al., 2002 DAS H S core: 0 = no functional impairment 100 = severe impairment Klocker, SVS 2014_Boston

Patients and Methods (4) retrospective data collection Endpoints:  early and long-term patency  functional status (DASH Score)  vascular re-intervention  limb salvage  peri-operative mortality Klocker, SVS 2014_Boston

Results (1) – Demographic Data n = 108 patients who presented with 117 lesions of upper limb arteries after trauma underwent repair median age: 35.7 yrs (range: 2.5 - 87.6) 87 male ( 81% ) Trauma mechanism of lesions: n = 96 blunt ( 82% ) n = 10 penetrating ( 8.5% ) n = 11 iatrogenic ( 9.5% ) 43 patients (40% ) presented with limb ischemia Klocker, SVS 2014_Boston

Results (2) – Location of injuries subclavian n=24 axillary n=22 brachial n=53 radial n=13 ulnar n=5 Klocker, SVS 2014_Boston

Results (3) – Concomitant Lesions n % n % Location n nerve nerve orthopedic orthopedic inj uries inj uries inj uries inj uries subclavian 24 33% 46% 8 (all plexus) 11 axillary 22 16 (12 plexus) 73% 21 95% brachial 53 26 % 55% 14 (1 plexus) 29 radial 13 1 8 % 2 15% ulnar 5 0 0 % 2 40% all 39 36% 65 60% Klocker, SVS 2014_Boston

Results (1) – Early Outcome Intra-operative death: n = 0 Peri-operative death (30 day mortality): n = 5 4.6 % from cardiogenic shock (n=1), associated head (n=1) and abdominal (n=1) inj ury, or as a consequence of multiple trauma (n=2) Secondary patency rate ( at time of hospital discharge ): 99 % Early limb loss ( within 30 days after repair ): n = 2 1.9 % due to severe life-threatening wound infection Klocker, SVS 2014_Boston

Results (2) – Long-term Clinical Outcome All patients that survived with salvaged limbs ( n=101 ) were invited for follow-up studies: median follow-up period of 5.3 years (range: 0.5-19.7) Klocker, SVS 2014_Boston

Results (3) – Long-term Clinical Outcome All patients that survived with salvaged limbs ( n=101 ) were invited for follow-up studies: median follow-up period of 5.3 years (range: 0.5-19.7) n pts followed 65 % of pts followed 64 % 0 secondary amputation vascular re-intervention 0 occluded repairs n = 2 long-term patency 97% Klocker, SVS 2014_Boston

Results (4) – Long-term Functional Outcome DAS H S core: DAS H S cores 0 = no functional impairment 100 = severe impairment median follow-up period of 5.3 years (range: 0.5-19.7) [mean ± S D] [mean ± S D] P (t-test) 20.9 ± 28.0 29.3 ± 36.4 gender [male vs. female] 0.4 age [>30 yrs vs. <30 yrs] 27.6 ± 30.7 17.9 ± 29.0 0.25 side of inj ury 22.6 ± 28.3 23.1 ± 32.1 0.95 [left vs. right] mechanism of inj ury n. a. [blunt vs. penetrating] Klocker, SVS 2014_Boston

Results (5) – Long-term Functional Outcome DAS H S core: DAS H S cores 0 = no functional impairment 100 = severe impairment median follow-up period of 5.3 years (range: 0.5-19.7) YES NO P (t-test) [mean ± S D] [mean ± S D] neurologic inj uries 43.2 ± 31.4 10.2 ± 21.1 <.001 subclavian 37.4 ± 39.6 axillary 44.7 ± 26.6 14.6 ± 24.5 brachial <.001 forearm 1.3 ± 1.7 ischemia at time of inj ury 31.4 ± 34.4 14.4 ± 22.4 <.001 Klocker, SVS 2014_Boston

Results (6) – Long-term Functional Outcome Klocker, SVS 2014_Boston

Klocker, SVS 2014_Boston

Summary (1) n % % Author * PY Centre patients blunt penetrating Follow - up Myers 1990 Houston 95 27% 73% 6 months Fit ridge 1994 Adelaide 114 46% 54% 14 months Van der S luis 1997 Toronto 25 76% 24% 24 months Manord 1998 New Orleans 46 39% 61% 43 months Brown 2001 Milwaukee 71 30% 70% 6 months 2009 Regensburg Toepel 33 30% 70% 42 months our series Innsbruck 108 82% 18% 63 months Klocker, SVS 2014_Boston

Summary (2) limb functional status determined by Author * PY Follow - up salvage patency n. a. Myers 1990 100% 99% 6 months 1994 - associated injury Fit ridge 86% 100% 14 months - location of injury Van der S luis 1997 100 n. a. - persistent neural deficit 24 months - joint contractures 1998 - blunt injury Manord 43 months 98% n. a. Brown 2001 - neurologic injury 6 months 93.5% n. a. - blunt injuries Toepel 2009 98% 100% - neurologic injury 42 months - neurologic injury our series 98% 97% 63 months - location of injury - Ischemia at time of injury - cold intolerance Klocker, SVS 2014_Boston