Outcomes After Anticoagulation for Traumatic Arterial Injuries of the Extremity | Clinical Pharmacy and Pharmacology | JAMA Surgery | JAMA Network
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Table 1.  Data Characteristics
Data Characteristics
Table 2.  Multivariable Analysis
Multivariable Analysis
1.
Fox  N, Rajani  RR, Bokhari  F,  et al; Eastern Association for the Surgery of Trauma.  Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline.  J Trauma Acute Care Surg. 2012;73(5)(suppl 4):S315-S320.PubMedGoogle ScholarCrossref
2.
Melton  SM, Croce  MA, Patton  JH  Jr,  et al.  Popliteal artery trauma: systemic anticoagulation and intraoperative thrombolysis improves limb salvage.  Ann Surg. 1997;225(5):518-527.PubMedGoogle ScholarCrossref
3.
Scalea  TM, DuBose  J, Moore  EE,  et al.  Western Trauma Association critical decisions in trauma: management of the mangled extremity.  J Trauma Acute Care Surg. 2012;72(1):86-93.PubMedGoogle ScholarCrossref
4.
Klocker  J, Falkensammer  J, Pellegrini  L, Biebl  M, Tauscher  T, Fraedrich  G.  Repair of arterial injury after blunt trauma in the upper extremity: immediate and long-term outcome.  Eur J Vasc Endovasc Surg. 2010;39(2):160-164.PubMedGoogle ScholarCrossref
Research Letter
Pacific Coast Surgical Association
October 2016

Outcomes After Anticoagulation for Traumatic Arterial Injuries of the Extremity

Author Affiliations
  • 1Division of Vascular Surgery, University of California–Davis, Sacramento
  • 2David Grant Medical Center, Travis AFB, Sacramento, California
  • 3Division of Trauma Surgery, University of California–Davis, Sacramento
JAMA Surg. 2016;151(10):986-987. doi:10.1001/jamasurg.2016.1686

The use of systemic anticoagulation to prevent thrombosis is a standard protocol for vascular surgeons during repair of blood vessels. However, in the setting of traumatic vascular injuries, concomitant intracranial hemorrhage, soft tissue injury, or solid organ lacerations may preclude its use for vascular repair. Conflicting data exist as to whether patients with vascular extremity trauma require anticoagulation when undergoing surgical treatment.1,2 This project was undertaken to determine whether anticoagulation during arterial repair or bypass decreased the risk for repair thrombosis or limb amputation after traumatic vascular injury of the extremities.

Methods

All trauma patients admitted to the University of California–Davis Medical Center between 2006 and 2015 who required urgent surgery for vascular injuries were retrospectively reviewed. Patients who had vessel ligation or endovascular repair were excluded. Demographics, injury specifics, intraoperative systemic anticoagulation, and details about the vascular repair were collected. The University of California–Davis institutional review board approved this study; patient consent was waived owing to the retrospective nature of the study.

The primary outcome was a composite end point of repair failure and limb loss during the initial hospitalization. Secondary outcomes included bleeding complications associated with use of anticoagulation. All variables were tested for significance with regard to adverse outcomes using univariate logistic regression analysis. A multivariate logistic regression model was created using age, sex, intraoperative anticoagulation use, and all variables exhibiting a P value less than .20 in univariate analysis.

Results

After exclusion of patients with incomplete records (n = 10), data were collected on 123 unique trauma patients (Table 1). Systemic intraoperative anticoagulation was administered in 69 patients (56%). Those who received intraoperative anticoagulation had a lower Injury Severity Score (mean [SD], 13 [8]) compared with patients who did not receive anticoagulation (mean [SD], 18 [11]) (P < .002). There was a slightly higher rate of penetrating trauma in patients who did not receive anticoagulation (n = 35; 65%) compared with those who did (n = 40; 58%) (P = .08). Eight patients who received intraoperative anticoagulation had repair failure (n = 5) and/or amputation (n = 4) vs 7 patients (amputation: n = 1 and reoperation: n = 6) who did not receive anticoagulation.

There was no difference in time from injury to operative repair, type of repair, length of surgery, or mean blood loss, and univariate analysis showed none of these variables affected risk for repair failure or limb loss. In multivariable analysis, intraoperative systemic anticoagulation did not significantly decrease the risk for repair failure or limb loss (Table 2). An increased Mangled Extremity Severity Score was predictive of repair failure and limb loss (odds ratio, 1.50; 95% CI, 1.06-2.26; P = .03). Postoperative anticoagulation use was also associated with a trend toward worse outcomes, but this was not statistically significant (odds ratio, 3.71; 95% CI, 1.06-17.40; P = .06). The use of intraoperative heparin was also not found to increase operative blood loss (mean [SD], 638 [745] mL vs 926 [745] mL; P = .23) or bleeding complications (42% with vs 45% without; P = .95) between patients who received anticoagulation and those who did not.

Discussion

In this single-center cohort with extremity vascular repair, intraoperative systemic anticoagulation was not associated with decreased risk for repair failure or limb loss. Increased Mangled Extremity Severity Score did correlate with worse outcomes. In other studies, a Mangled Extremity Severity Score greater than 7 was highly predictive of limb loss.3 We have not used the calculated score at the initial time of trauma to guide attempted limb salvage but it is useful when counseling patients about the potential for recovery.

Postoperative anticoagulation use was highly predictive of repair failure and amputation. Klocker et al4 recommended the use of postoperative anticoagulation after vascular repair to improve outcomes after extremity vascular repair; these authors did not account for the severity of the extremity injury. Our results suggest these limbs likely were not salvageable to begin with and use of postoperative anticoagulation as an adjunct does not change this outcome.

Although this study is limited, until a larger multicenter registry is undertaken, we do not recommend routine intraoperative or postoperative anticoagulation.

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Article Information

Corresponding Author: Misty Humphries, MD, Division of Vascular Surgery, University of California–Davis Medical Center, 4860 Y St, Ste 3400, Sacramento, CA 95817 (mdhumphries@ucdavis.edu).

Published Online: July 13, 2016. doi:10.1001/jamasurg.2016.1686.

Author Contributions: Dr Humphries had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Humphries, Blume, DuBose, Galante.

Acquisition, analysis, or interpretation of data: Humphries, Blume, Rodriguez, DuBose.

Drafting of the manuscript: Humphries, Blume, Galante.

Critical revision of the manuscript for important intellectual content: Humphries, Rodriguez, DuBose.

Statistical analysis: Humphries, Blume.

Obtained funding: Humphries.

Administrative, technical, or material support: Humphries, Blume.

Study supervision: Humphries, DuBose, Galante.

Conflict of Interest Disclosures: Dr Humphries is a KL2 scholar with the University of California–Davis Center for Translational Science Center. No other disclosures were reported.

Funding/Support: This study was supported by grant UL1 TR 000002 and linked award KL2 TR 000134 from the National Center for Advancing Translational Sciences, National Institutes of Health.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Previous Presentation: This study was presented at the 87th Annual Meeting of the Pacific Coast Surgical Association; February 14, 2016; Kohala Coast, Hawaii, and is published after peer review and revision.

References
1.
Fox  N, Rajani  RR, Bokhari  F,  et al; Eastern Association for the Surgery of Trauma.  Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline.  J Trauma Acute Care Surg. 2012;73(5)(suppl 4):S315-S320.PubMedGoogle ScholarCrossref
2.
Melton  SM, Croce  MA, Patton  JH  Jr,  et al.  Popliteal artery trauma: systemic anticoagulation and intraoperative thrombolysis improves limb salvage.  Ann Surg. 1997;225(5):518-527.PubMedGoogle ScholarCrossref
3.
Scalea  TM, DuBose  J, Moore  EE,  et al.  Western Trauma Association critical decisions in trauma: management of the mangled extremity.  J Trauma Acute Care Surg. 2012;72(1):86-93.PubMedGoogle ScholarCrossref
4.
Klocker  J, Falkensammer  J, Pellegrini  L, Biebl  M, Tauscher  T, Fraedrich  G.  Repair of arterial injury after blunt trauma in the upper extremity: immediate and long-term outcome.  Eur J Vasc Endovasc Surg. 2010;39(2):160-164.PubMedGoogle ScholarCrossref
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