Systemic anticoagulation in the setting of vascular extremity trauma

Melissa N Loja; Joseph M Galante; Misty Humphries; Stephanie Savage; Timothy Fabian; Thomas Scalea; John B Holcomb; Nathaniel Poulin; Joseph DuBose; Todd E Rasmussen; AAST PROOVIT Study Group

doi:10.1016/j.injury.2017.03.020

Systemic anticoagulation in the setting of vascular extremity trauma

Injury. 2017 Sep;48(9):1911-1916. doi: 10.1016/j.injury.2017.03.020. Epub 2017 Mar 20.

Authors

Affiliations

¹ University of California, Davis, Department of Surgery, Division of Vascular Surgery, 4860 Y Street, Suite 3400, Sacramento, CA 95817, USA. Electronic address: mloja@ucdavis.edu.
² Department of Surgery, Division of Trauma Surgery, University of California, Davis, Sacramento, CA, USA. Electronic address: jmgalante@ucdavis.edu.
³ Department of Surgery, Division of Vascular Surgery, University of California, Davis, Sacramento, CA, USA. Electronic address: mdhumphries@ucdavis.edu.
⁴ Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. Electronic address: ssavage2@IUHeath.org.
⁵ Department of Surgery, University of Tennessee, Memphis, TN, USA. Electronic address: tfabian@uthsc.edu.
⁶ Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA. Electronic address: tscalea@umm.edu.
⁷ Department of Surgery, Center for Translational Injury Research, University of Texas Health Sciences Center, Houston, TX, USA. Electronic address: John.Holcomb@uth.tmc.edu.
⁸ Department of Surgery, Eastern Carolina University Medical Center, Greenville, NC, USA. Electronic address: nathaniel.poulin@vidanthealth.com.
⁹ Department of Surgery, Divisions of Vascular and Trauma Surgery, University of California, Davis, USA. Electronic address: jjd3c@yahoo.com.
¹⁰ Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA. Electronic address: todd.e.rasmussen.mil@mail.mil.

PMID: 28377263
DOI: 10.1016/j.injury.2017.03.020

Abstract

Introduction: There is conflicting data regarding if patients with vascular extremity trauma who undergo surgical treatment need to be systematically anticoagulated. We hypothesized that intraoperative systemic anticoagulation (ISA) decreased the risk of repair thrombosis or limb amputation after traumatic vascular injury of the extremities.

Methods: We analyzed a composite risk of repair thrombosis and/or limb amputation (RTLA) between patients who did and did not undergo ISA during arterial injury repair. Patient data was collected in the American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry. This registry contains demographic, diagnostic, treatment, and outcome data.

Results: Between February 2013 and August 2015, 193 patients with upper or lower extremity arterial injuries who underwent open operative repair were entered into the PROOVIT registry. The majority were male (87%) with a mean age of 32.6 years (range 4-91) and 74% injured by penetrating mechanism. 63% of the injuries were described as arterial transection and 37% had concomitant venous injury. 62% of patients underwent ISA. RTLA occurred in 22 patients (11%) overall, with no significant difference in these outcomes between patients who received ISA and those that did not (10% vs. 14%, p=0.6). There was, however, significantly higher total blood product use noted among patients treated with ISA versus those that did not receive ISA (median 3 units vs. 1 unit, p=0.002). Patients treated with ISA also stayed longer in the ICU (median 3days vs. 1day, p=0.001) and hospital (median 9.5days vs. 6days, p=0.01).

Discussion: In this multicenter prospective cohort, intraoperative systemic anticoagulation was not associated with a difference in rate of repair thrombosis or limb loss; but was associated with an increase in blood product requirements and prolonged hospital stay. Our data suggest there is no significant difference in outcome to support use of ISA for repair of traumatic arterial injuries.

Keywords: Amputation; Anticoagulation; Extremity; Trauma; Vascular.

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Amputation, Surgical / statistics & numerical data*
Anticoagulants / therapeutic use*
Child
Child, Preschool
Extremities / physiopathology
Extremities / surgery*
Female
Humans
Limb Salvage
Male
Middle Aged
Prospective Studies
Thrombosis / prevention & control*
Treatment Outcome
United States
Vascular Patency / physiology*
Vascular Surgical Procedures*
Vascular System Injuries / complications
Vascular System Injuries / physiopathology
Vascular System Injuries / surgery*
Young Adult

Substances

Anticoagulants