This was an observational (retrospective cohort) study. Present study included 60 patients who underwent operative intervention for extremity vascular injuries over a period of one and half year period between October 2018 to March 2020. Study was performed by single vascular unit at Cardiothoracic Vascular Department of Medical College, Jabalpur.

As, it is a retrospective study hence, no new intervention was done. Study was done in accordance with the Helsinki declaration and its amendments.

Present study included all patients who presented with extremity vascular injuries at emergency department. Patients with unsalvageable extremity injury and requiring primary amputation were excluded from the study. All patients were resuscitated according to advanced trauma life support protocols [8]. Relevant demographic characteristics, including age, gender, mechanism of trauma, timing of presentation, anatomical site of injury and length of hospitalisation were collected from hospital records. All patients were assessed by clinical examination. Clinical history of six P’s; Pulselessness, Poikilothermia, Pallor, Pain, Paresthesia or Paralysis as well as clinical hard and soft signs of vascular injury (arterial bleeding, expending pulsatile hematoma) were used in diagnosis. It was confirmed by use of vascular Doppler. All patients underwent surgical intervention either primary repair or interposition autologous vein graft. Associated bony injury was also attended at the same time. Surgical complications were graded according to Clavien-Dindo classification. It is classification system of surgical complications. It is based on type of therapy needed to correct the complications [9].

Successful outcome was recorded in form of limb salvage. All patients underwent handheld Doppler after completion of revascularisation and postoperative period. Effect of delayed presentation on limb salvage was also analysed. Analysis was done with SPSS, IBM Corp, version 21. Fisher-exact test was used to compare limb salvage rate in two groups having median revascularisation time more than six hours and less than six hours.

A total of 60 patients were evaluated of whom 55 (91.6%) were males. The mean age was 24.8±7.0 years (range 5-35 years). Penetrating trauma was present in 32 patients (53.3%) and blunt trauma in 28 patients (46.6%). Overall Road Traffic Accidents (RTA), 43 cases (71.6%), was the single most common cause of extremity vascular injury in both penetrating and blunt trauma [Table/Fig-1].

Most of the patients presented with acute bleeding i.e., 32. In patients presenting with bleeding, the commonest vessel injured was brachial artery in 18 out of 32 (56.25%). Popliteal artery injury was the most common vessel involved in 12 out of 26 (46.15%) cases of acute ischemia. Interposition vein grafts were the most common methods of repair in 42 out of 60 cases (70%) [Table/Fig-2]. Associated skeletal trauma and concomitant vein injury was present in 20 patients (33%) and in 25 patients (41.6%), respectively.

The overall complication rate was 43.3% [Table/Fig-3]. Grade II complications were most common requiring blood transfusion in eight patients (13.3%). Wound infection was mostly associated with lower limb trauma and was present in six patients (10%). They were treated with appropriate antibiotic as per culture report, and frequent dressings. Four of them had Klebsilla and two of them had E. coli in culture report. All were treated with imipenam and amikacin. Revision surgery for vascular repair was required in five patients (8.3%) due to secondary haemorrhage. Secondary amputation was done in seven patients (11.6%).

Limb salvage could be achieved in 53 out of 60 patients (88.3%). Cause of limb loss was graft occlusion in three patients and infection related graft failure in four patients. The median time to revascularisation was 9.04 hours. It was less than six hours in 23 patients and more than that in the remaining patients. On comparison, it was found that amputation rate was high with delayed presentation (13.5% vs 8.7%), but it was not statically significant (p=0.57) [Table/Fig-4].

Now-a-days incidence of vascular trauma is increasing [10]. The most common population affected by vascular trauma was young males. It is consistent with the findings of other studies [11-13]. However, mechanism of trauma varies in different societies. Approximately, 90% of arterial injuries resulted from penetrating trauma and 10-50% occurred due to blunt injury, as per the western study [7]. In this study, we had 53% cases due to penetrating trauma and 47% cases due to blunt trauma. But in areas of civil unrest and war zones gunshot and firearm injury is the primary cause [14].

Patients may present with bleeding or they may present later with symptoms of vascular insufficiency or embolisation, pseudoaneurysm or arteriovenous fistula. In this study 32 patients (53.3%) had presented with acute bleeding, 26 patients (43.3%) had acute limb ischemia and two patients (3.3%) had pseudoaneurysm. It is consistent with the wartime study from Srilanka, where 43% patients presented with bleeding, 44% presented with ischemia and 13% presented with pseudoaneurysm [15].

Anatomic site of injuries varies in different studies [12,16]. In most studies, especially those from war injuries and road traffic injury femoral artery is the most commonly injured vessel followed by popliteal and brachial arteries [17-19]. In present study, most common injured vessel was brachial followed by popliteal artery.

The diagnosis was made based on the clinical examination and Doppler study. It reduces the time to diagnosis and cost involved in routine angiography. Case based approach was applied in this study. Number of trials has shown that clinical examination alone is sufficient for the diagnosis of vascular injury in acute situations [20]. This study had six cases of multiple external injuries and with soft signs of vascular injury. Angiography was done in these cases. Ramanathan A et al., and Hafez HM et al., also has suggested that angiography is required to identify the site of arterial injury in these types of situations [21,22].

In patients with concomitant bone injury, skeletal fixation was done mostly external followed by vascular repair. It is strongly advocated in some series [23]. While some studies have mentioned the importance of reducing ischemia time by proceeding with vascular reconstruction first [16,22,24].

Mechanism and anatomical site of injury usually determines type of reconstruction. Depending on these two factors, frequency of reconstruction methods varies [25]. In this study, vascular reconstruction was performed by using an interposition vein graft mostly.

In this series, median revascularisation time was 9.04 hours. Amputation rate was high with delayed presentation but not statistically significant. As reported in the literature, the significant factor associated with increased limb loss is the time lapse demonstrated between injury and operation [26,27]. The increased time interval decreases successful outcome of repair due to progressive ischemia and thrombosis. The clinical implication of this study is that the prompt and precise management of vascular injury improves patient survival and limb salvage. This study has demonstrated it even in delayed presentation.

Small sample size, lack of comparison, randomisation and retrospective design were the limitations of the study. In this study angiography was performed only in six cases with multiple external injuries and with soft signs of vascular injury.

Young males were most common sufferers from vascular injury in present center. The most common etiology was penetrating trauma due to RTA. Brachial artery was the most common vessel injured and active bleeding was the most common presentation. Limb salvage rate in patients having median revascularisation time less than six hours was 91.3% and for those more than six hours it was 86.4%. The delayed presentation of vascular trauma should not be denied for surgical intervention. An aggressive approach should be continued to salvage the limb after establishing muscle viability.