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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

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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

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no conflicts of interest

Klocker, SVS 2014_Boston

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* only studies published after 1990 involving more than 20 pts at least 6 months follow - up Author * PY Centre n

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

Toepel

2009 Regensburg

33 30% 70% 42 months

Introduction (1)

Klocker, SVS 2014_Boston

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* only studies published after 1990 involving more than 20 pts at least 6 months follow - up Author * PY Follow - up limb salvage patency functional status

determined by Myers

1990

6 months

100% 99%

n. a.

Fit ridge

1994

14 months

86% 100%

associated injury
location of injury

Van der S luis

1997

24 months

100

n. a.
persitent neural deficit
joint contractures

Manord

1998

43 months

98%

n. a.
blunt injury

Brown

2001

6 months

93.5%

n. a.
neurologic injury
blunt injuries

Toepel

2009

42 months

98% 100%

neurologic injury

Introduction (2)

Klocker, SVS 2014_Boston

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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

Patients and Methods (1)

Klocker, SVS 2014_Boston

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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 ultrasound (patency; diameter of grafts)

Patients and Methods (2)

Klocker, SVS 2014_Boston

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Patients and Methods (3)

Klocker, SVS 2014_Boston

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

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retrospective data collection

Endpoints:

 early and long-term patency  functional status (DASH Score)  vascular re-intervention  limb salvage  peri-operative mortality

Patients and Methods (4)

Klocker, SVS 2014_Boston

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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

Results (1) – Demographic Data

Klocker, SVS 2014_Boston

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Results (2) – Location of injuries

subclavian n=24 axillary n=22 brachial n=53 radial n=13 ulnar n=5

Klocker, SVS 2014_Boston

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Location n

n

nerve inj uries

%

nerve inj uries

n

rthopedic

inj uries

%

rthopedic

inj uries

subclavian 24

8 (all plexus) 33% 11 46%

axillary 22

16 (12 plexus) 73% 21 95%

brachial 53

14 (1 plexus) 26 % 29 55%

radial 13

1 8 % 2 15%

ulnar 5 0 %

2 40%

all

39 36% 65 60%

Results (3) – Concomitant Lesions

Klocker, SVS 2014_Boston

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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,

r 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

Results (1) – Early Outcome

Klocker, SVS 2014_Boston

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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)

Results (2) – Long-term Clinical Outcome

Klocker, SVS 2014_Boston

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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)

Results (3) – Long-term Clinical Outcome

n pts followed 65 % of pts followed 64 % secondary amputation vascular re-intervention

ccluded repairs

n = 2

long-term patency

97%

Klocker, SVS 2014_Boston

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DAS H S cores median follow-up period of 5.3 years

(range: 0.5-19.7)

Results (4) – Long-term Functional Outcome

[mean ± S D] [mean ± S D]

P (t-test)

gender [male vs. female] 20.9 ± 28.0 29.3 ± 36.4 0.4 age [>30 yrs vs. <30 yrs] 27.6 ± 30.7 17.9 ± 29.0 0.25 side of inj ury

[left vs. right]

22.6 ± 28.3 23.1 ± 32.1 0.95 mechanism of inj ury

[blunt vs. penetrating]

n. a.

Klocker, SVS 2014_Boston

DAS H S core: 0 = no functional impairment 100 = severe impairment

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DAS H S cores median follow-up period of 5.3 years

(range: 0.5-19.7)

Results (5) – Long-term Functional Outcome

YES

[mean ± S D]

NO

[mean ± S D]

P (t-test)

neurologic inj uries 43.2 ± 31.4 10.2 ± 21.1 <.001 subclavian 37.4 ± 39.6 axillary 44.7 ± 26.6 brachial 14.6 ± 24.5 <.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

DAS H S core: 0 = no functional impairment 100 = severe impairment

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Results (6) – Long-term Functional Outcome

Klocker, SVS 2014_Boston

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Klocker, SVS 2014_Boston

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Author * PY Centre n

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

Toepel

2009 Regensburg

33 30% 70% 42 months

ur series

Innsbruck

108 82% 18%

63 months

Summary (1)

Klocker, SVS 2014_Boston