Vascular injury pattern and workload; A tertiary care center experience from Sri Lanka

Abstract

Article

Key words

Vascular injury, incidence, Sri Lanka, National Hospi­tal Sri Lanka (NHSL),

Vascular repair, Causes of vascular injuries, Time duration, Admission times,Delay from admission

Abstract:

Introduction

Vascular injuries can lead to life-threatening haemorrhage and limb-threatening ischemia if not addressed promptly.  In Sri Lanka the number of limb vascular injuries are increasing due to the increase in road traffic accidents (RTA). This study describes the characteristics of patients who were operated on following vascular injuries at the Accident and Emergency department theatre of the National Hospital Sri Lanka (NHSL) from 2023 January to 2023 December.

Methods

This study was a retrospective  study done at the Accidents and Emergency department theatre of the National Hospital Sri Lanka (NHSL). Patient information was collected from the theatre registry. The data on age, gender, mode of admission, mechanism of injury, associated injuries, type of vascular repair done, type of skeletal fixation done, duration of the surgery and time duration from admission to theatre were collected.  Patients with incomplete records were excluded.

Results

There were 64,274 admissions to NHSL, Accident and Emergency (A & E) department from January to December of 2023. 14,616 (22.74%) of patients underwent surgeries at the A & E theatre complex. 103 of the admissions had vascular injuries, which needed surgical interventions. Therefore, vascular interventions account for 0.7 % of the total number of major surgeries. 90 cases were males (n = 90, 87.38%). The mean age was 37.13 years (15 to 73). The commonest cause for vascular injuries is RTA (n=46, 44.66%).50.47% had  lower limb vascular injuries (n=54). 52.83% (n=56) were managed with the reversed saphenous vein (RSVG) interposition graft.

Conclusions

According to the results of this study, 0.16% of A & E admissions required vascular surgical interventions. 0.7% of surgeries were vascular surgeries. The commonest cause for vascular injuries was RTA (n=46, 44.66%). The majority, 52.83% (n=56) of the vascular repairs were done using RSVG. The outcome details are not presented in this study. This is a main drawback. Future countrywide study is needed to come to further conclusions.

Introduction

Unintentional or violence-related trauma causes 4.4 million deaths around the world and it accounts for 8% of all deaths. Road traffic accidents (RTA), homicides, and suicides are the three leading causes of mortality in ages 5 to 29 [1]. 0.4 to 1.6 % of all trauma patients sustain vascular injuries worldwide [2]. However vascular injuries are responsible for 20% of all deaths related to trauma [3]. Vascular injuries can lead to life-threatening hemorrhage and limb-threatening ischemia if not addressed promptly.

Vascular injuries occur due to penetrating and blunt trauma. Trauma can show a spectrum of patterns of injuries like laceration, transection, pseudoaneurysm, contusion, intimal flaps, intimal disruption, and external compression .

The first urgent vascular repair was done in 1759 by Dr. Hallowell after being encouraged by his colleague Dr. Richard Lambert. Before that, vascular injuries were managed with ligation only and led to high morbidity and mortality. To minimize the consequences of ligation of injured vessels, various types of methods are used to restore blood flow. Primary anastomosis, synthetic and autologous vascular grafts, temporary intravascular shunts (TIVS), and endovascular techniques are some of the methods of vascular restoration .

Vascular injuries are very common in third-world countries like Sri Lanka due to the increasing number of road traffic accidents (RTA), industrial trauma, and interpersonal violence. Out of all causes, RTA is the leading cause [4].

Methodology

This study was a retrospective analysis of all patients who were operated on following vascular injuries at the Accident and Emergency department theatre of the National Hospital Sri Lanka (NHSL) from 2023 January to 2023 December. Patient information was collected from the theatre registry. The data on age, gender, mode of admission, mechanism of injury, associated injuries, type of vascular repair done, type of skeletal fixation done, duration of the surgery and time duration from admission to theatre were collected.  Patients with incomplete records were excluded. Data were analyzed with computer software.

Results

There were 64,274 admissions to NHSL, Accident and Emergency (A & E) Department from January to December of 2023. 14,616 (22.74%) of patients underwent surgeries at the A & E theatre complex. 1772 (2.76%) and 12844 (19.99%) of them were major and minor surgeries respectively.

103 of the admissions had vascular injuries, which needed surgical interventions. Therefore, vascular interventions account for 0.7 % of the total number of major surgeries done at the A & E theatre complex, NHSL.

Number of the patients in the study was 103. The majority of them were males (n = 90, 87.38%). The mean age was 37.13 years (15 to 73). The age and gender distribution of the study group is presented in Table 1.

Table 1 Age and gender distribution

The commonest cause for vascular injuries is RTA (n=46, 44.66%) and it is followed by interpersonal violent activities like assaults with sharp weapons and stabbing. Etiological distribution is presented in Graph 1.

Graph 1Causes of vascular injuries

50.47% of all vascular trauma involved lower limb vessels (n=54). The distribution of the anatomical location and the vessels injured are shown in Graph 2 and Table 2.

Table 2 Anatomical Distribution of Vascular Injuries

The modality of the vascular surgical intervention depended on the anatomical site of the injury, type of the injury, duration from the time of injury to the hospital admission, and associated other injuries. 52.83% (n=56) were managed with an interposition graft with the reversed saphenous vein (RSVG). Very small segment contusions, where the intimal injury is minimal were managed with thrombectomy alone (n=10, 9.43%). The types of vascular intervention for injuries are presented in Graph 3.

Graph 3 Types of Vascular Surgical Interventions

Mode of admissions

49.51% (n=51) of admissions were transferred from local hospitals and the rest were direct admissions.

patients with vascular injuries were admitted to the NHSL between 20:00h to 00:00h (n=26). Minimum admissions reported from 0800h to 1200h.

Admission times of patients with vascular trauma are shown in Graph 5.

Surgical interventions for vascular injuries are carried out by the vascular surgical team with the liaison of orthopedic and plastic surgical teams most of the time. 44.66% (n=46) surgeries took 2 to 4 hours. The mean time is 4.4 hours for surgery. Time durations for surgical interventions are shown in Graph 6 .

A total of 440 hours within a year were spent on vascular surgeries.

Graph 6 Time duration for vascular surgical interventions

Most of the admissions with vascular injuries underwent appropriate surgical intervention within 1 to 2 hours after admission (n=40). The mean delay is 2.6 hours. Delay from the admission to the theatre was analyzed and shown in Graph 7.

Discussion and conclusions

According to the results of this study, 0.16% of A & E admissions required vascular surgical interventions. 0.7% of surgeries were vascular surgeries and some of them were combined surgeries with orthopedic, plastic, or general surgical teams.

Male preponderance is an observed fact in the context of vascular injuries and 80% to 99% of vascular injuries occur in males in most studies [5], our data is also consistent with these data, 87.38% of vascular trauma occurs in males.

In our study, the commonest cause for vascular injuries was RTA (n=46, 44.66%). When comparing this with data from other parts of the world, gunshots, stabs, and assaults are the predominant causes in some studies [6]. Some studies show RTA is the predominant cause

50.47% (n=54) of vascular trauma involves the lower extremity vessels and popliteal artery injury is the commonest injury in the lower limb(n=30) Brachial artery injury is the commonest upper limb vessel injury and accounts for 25.47% of the population. There are similar studies some are showing lower limb injuries than upper limb [7], and others vice versa. The common vessels injured in the upper and lower limbs in our study are consistent with other studies.

The majority, 52.83% (n=56) of the vascular repairs were done using RSVG. Usually vascular trauma due to blunt trauma comes with long-segment contusions, and crush injuries in RTA. It requires tension-free repair after removing the damaged part of the vessel. This is consistent with studies done in other places.

59.8% (n=58) of vascular trauma admissions reach the theatre within the first two hours of admissions. The mean delay from admission to the theatre for vascular surgical intervention is 2 hours and 36 minutes. The timing from the admission to the theatre depends on the severity of the vascular trauma, degree of extremity ischemia, pre-hospital delay following the trauma, and associated other injuries.

A total of 440 hours of theatre time were spent from 2023 January to 2023 December for vascular trauma and the mean time for surgery is 4 hours and 24 minutes.

Our study has limitations. This study only includes the data of patients who underwent vascular surgical intervention by vascular surgeons at the A & E theatre complex for 2023 year. This data does not include on-arrival deaths due to vascular trauma, and vascular trauma where vascular surgical intervention was not needed like unsalvageable limbs. Since this is a retrospective study, only the patients with complete data were included in the study. The number of patients in the study is not adequate to get the exact prevalence and pattern of vascular injuries in the population. In addition the outcome details are not presented in this study. This is a main drawback. Future countrywide study is needed to come to further conclusions.

Acknowledgements : None

CRediT statement : DR: data collection,  article writing JA: data collection,  writing-reviewing and editing,RC,MW: review

Funding :The authors received no financial support for the research, authorship, and/or publication of this article.

Competing interests: The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Patient consent for publication: Not applicable.

Ethics approval This study: Not applicable.

Data availability statement: Not applicable.

Supplemental material: Not applicable.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license. See: http://creativecommons.org/licenses/by-nc/4.0/.

Artificial intelligence: Generative artificial intelligence or artificial intelligence assisted technologies were not used in preparation of this article

ORCID iD

Dulanjana Ranasinghe https://orcid.org/0000-0001-5106-9436

Joel Arudchelvam https://orcid.org/0000-0002-4371-4527

Rezni Cassim https://orcid.org/0000-0002-4826-6196

Mandika Wijeyaratne https://orcid.org/0000-0001-9073-5446

References

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