Medical Science Publication No. 4, Volume 1
AN ANALYSIS OF FOLLOWUP STUDIES ON 115 ACUTEVASCULAR REPAIRS*
MAJOR EDWARD J. JAHNKE,JR., MC
The improved management of acute vascular injuries, established duringthe Korean conflict, represents one of the most outstanding achievementsin the realm of war surgery. Although the incidence of amputation of alimb sustaining a major arterial interruption has been reduced from 49to approximately 15 percent, this does not fully demonstrate the valueof initial vascular repair. Many patients are now using a functionallyadequate limb which, in former years would have been, at best, simply aviable limb. However, few methods of management, regardless of how physiologicallyconceived or technically performed, are entirely satisfactory and thisis especially true when considering battle casualties and the problemsassociated with them.
During the period from August 1952 to December 1953 a total of 115 patientswho had initial major arterial repairs performed in Korea were studiedat this hospital. They represent only those patients who did not laterrequire amputation of the involved extremity. All who required amputation,prior to evacuation from the Far East, have been previously reported andwere excluded from this survey, our prime purpose being to evaluate theultimate status of the vascular system in those patients who were consideredsuccessfully treated. To this extent, the findings are selective in naturebut they do emphasize several important points. Probably their greatestvalue lies in the fact that they demonstrate that the results have notbeen perfect and much additional experimental and clinical investigationneeds to be done.
Functional vascular surveys were performed on all patients and consistedof: (1) gross physical evaluation of the blood supply to the limb, (2)pulsations in the peripheral arteries, (3) oscillometric and skin temperaturestudies, (4) exercise tolerance tests, (5) arteriography and (6) visualizationof the vascular repair if the limb was operated upon because of associatednerve or bone damage.
*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
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In the great majority of patients, an adequate blood flow and a patentarterial repair could be ascertained by simple physical examination ofthe extremity and palpation of the peripheral pulses. On this basis, 87patients were considered to have a functionally adequate circulation witha patent major arterial repair. Peripheral pulses were palpable in 93 patientsbut, in 6 of these, were markedly diminished and were believed due to collateralcirculation. This was later substantiated by arteriography. In 5 patientsperipheral pulsations, equal to those in the uninvolved extremity, wererecorded. However, in each instance thrombosis of the major channel wasdemonstrated by further study. Despite this occlusion, the collateral circulationwas extensive enough to prevent any evidence of arterial insufficiency.In 22 patients no peripheral pulses were demonstrated and each was provedlater to have a thrombosis of the arterial repair. Thus, of 33 later proventhromboses, 22 had no peripheral pulses, 6 had markedly diminished pulsesand 5 had excellent pulses. As would be expected from the known areas ofgreatest collateral circulation, of upper extremity occlusions which numbered16, only 7 had no peripheral pulses, 5 had diminished pulses and 4 hadexcellent pulses. In the lower extremity, where the collateral circulationis much less adequate, entirely different results were observed. Of 17patients with arterial occlusion, 15 had no pulses while only 1 each haddiminished or excellent peripheral pulsations.
Oscillometric and skin temperature studies proved to be of little additionalvalue in determining the adequacy of the circulation. With few exceptionsthe oscillometric readings corresponded closely to the palpable peripheralpulses. In several patients severely depressed readings were obtained inthe presence of rather good peripheral pulses but in each instance thevascular repair was shown to be occluded. In almost all patients with patentarterial repairs, the readings from the affected limb were either equalor only slightly depressed as compared to the uninvolved extremity. Theroom temperature thermocouple studies, on the other hand, showed no correlationwith the status of the major arterial channels.
An interesting observation was made in regard to the exercise tolerancetests. Several patients with patent arterial repairs were observed to havea paradoxical response to exercise, the oscillometric deflections decreasingrather than increasing. By arteriography, marked constriction was observedat the repair site. One might postulate that constriction and tension atthe suture line acts as an irritating factor during exercise and resultsin reflex vasospasm with diminution of the arterial inflow. Such a factormight well counteract the value of the repair and eventually lead to thrombosisat that site. Similar instances have been observed in patients with arteriovenousfistulas repaired
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under tension and with excessive constriction. If this conclusion betrue, it would suggest the inadequacy of determining functional capacityon the basis of arteriography or tests performed at rest. It would alsoindicate the importance of avoiding any significant degree of tension orconstriction at the suture line during performance of the vascular repair.
Arteriography was performed on the great majority of patients studiedand proved to be the best method of evaluating the status of the repair.All injections were made percutaneously using either 70 percent Diodrastor Urokon as the contrast media. Eight roentgenograms were taken at 0.8second intervals with the Sanchez-Perez rapid casette changer. Using thistechnic, demonstration of the arterial repair was excellent. It also permittedadequate visualization of the collateral circulation and the configurationof the distal main artery in those patients in whom thrombosis had developed.
Of the 115 patients studied, occlusions were found in 33 or 28.7 percent,a rate far higher than expected based on the results of several hundredvascular repairs performed in this hospital for other lesions. However,this figure loses some of its significance when it is remembered that notone patient in this entire series lost any part of a limb as a result ofarterial damage. Since most patients who were shown to have a late thrombosishad good peripheral pulsations prior to evacuation from the Far East, itcan be assumed that the repairs functioned at least long enough to preservethe viability of the limb.
Further analysis of this group of patients revealed a direct correlation,of statistical significance, between the type of repair performed and theoccurrence of late thrombosis. Occlusion occurred in only 18.8 percentof direct anastomoses as compared to 44.4 percent of lateral repairs, 47.4percent of autogenous vein grafts and 71.4 percent of homologous arterygrafts. These figures are difficult to explain with the exception of thelateral repairs. Here, thrombosis was probably the result of inadequatearterial débridement and it was felt that this method of managementshould rarely, if ever, be used. The difference in thrombosis rate betweenthe vein graft and the artery graft is not understood. In chronic vascularlesions as fistulas, aneurysms and segmental arterial blocks, either typeof graft can be employed with equal success. It is fair to state, however,that from the results thus far obtained, the artery graft should not beemployed in battle-injured arteries unless an adequate vein graft is notavailable.
Since an overall incidence of thrombosis of 28.7 percent was much higherthan expected, an attempt was made to analyze the possible causes withoutrespect to the type of repair performed. Several factors were uncoveredbut they failed to provide a cause in the majority of patients. In 21 or63.6 percent of all patients with throm-
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boses there was nothing found which could have explained the late failureof repair. In the remaining 12 or 36.4 percent a definite predisposingcause was found. Tension and constriction at the suture line was implicatedin 15.2 percent (5 cases) of patients. Infection was responsible in 12.1percent (4 cases); secondary hemorrhage in 6.1 percent (2 cases); and useof a damaged vein as a graft in 3 percent (1 case). From this it can beseen that all known causes were the result of technical errors which couldhave been prevented.
A study was then made of all patients with thromboses to see if therewas any correlation with some of the factors which influence the initialrepair. These factors are: (1) time lag, (2) wound size, (3) wound locationand (4) associated bone and nerve damage. The results seem to indicatethat time lag and wound size may be of some importance but in no instancewas there any statistical correlation. The presence of an associated boneor nerve injury would appear to create a situation which would predisposeto an increased incidence of thrombosis but again the figures did not substantiatethis impression.
Finally, let us consider the functional results in the 33 patients whohad occlusions. Sixteen occurred in the upper extremity. It has alreadybeen demonstrated that, because of the excellent collateral circulationthat exists in this area, symptomatic arterial insufficiency was unusual.Only one patient required additional treatment, which consisted of a secondaryrepair of the artery using a vein graft. More serious problems were encounteredin the 17 patients with thrombosed arterial repairs in the femoral andpopliteal areas. Only 3 were asymptomatic and 2 of these had excellentdistal pulses despite the major vascular occlusion present. Three otherpatients have not been completely evaluated because of associated injuries.The remaining 11 patients had definite symptoms of arterial insufficiency.In each instance a secondary vascular repair, employing a vein graft, wasbelieved indicated. Two patients refused treatment and one had a thrombosisextending into the posterior tibial artery which precluded any attemptat arterial restoration. In 8 patients, or 72.7 percent of those with symptomaticinsufficiency, the occluded segment of vessel was excised and the majorchannel restored by means of an autogenous saphenous vein graft. Thesevaried from 14 to 32 centimeters in length. In each instance the symptomsof insufficiency were relieved and a functionally viable limb resulted.
Summary and Conclusions
1. One hundred fifteen patients, with arterial repairs performed inKorea who did not lose a limb, were studied at Walter Reed Army Hospital.
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2. Complete organic and functional vascular surveys were performed onall patients.
3. Accurate physical examination was sufficient to determine the statusof the vascular system in the majority of patients.
4. By arteriography, late thrombosis had occurred in 33 or 28.7 percentof patients but in no instance did this require amputation of a limb.
5. Thrombosis occurred in 18.8 percent of direct anastomoses, 44.4 percentof lateral repairs, 47.4 percent of autogenous vein grafts and 71.4 percentof homologous artery grafts.
6. In 63.6 percent of patients no cause for the thrombosis could befound.
7. The factors which could be implicated were, in the order of importance,tension and constriction at the suture line, infection, secondary hemorrhage,and use of a damaged vein as a graft.
8. Time lag, wound size, wound location and associated bone and nerveinjury could not be correlated with the incidence of thrombosis.
9. Following thrombosis of the vascular repair, symptoms of insufficiencywere almost entirely limited to patients with lesions in the lower extremity.
10. Eight patients, or 72.7 percent of those with symptoms of insufficiency,had arterial continuity restored by a secondary grafting procedure withexcellent results.
11. The results of primary repair of battle-injured major arteries arenot entirely satisfactory and much experimental and clinical investigationremains to be done.
