Effect of recombinant factor VIIa as an adjunctive therapy in damage control for wartime vascular injuries: a case control study.
OBJECTIVE
Military casualties with vascular injuries often present with severe acidosis and coagulopathy that can negatively influence limb salvage decisions. We previously reported the value of a damage control resuscitation (DCR) strategy that can correct physiologic shock during simultaneous vascular reconstruction. The effect of recombinant factor VIIa (rFVIIa) on the repair of injured vessels and vascular grafts when used as an adjunctive therapy during DCR is unclear in the setting of wartime vascular injuries. The primary aim of this study was to assess the effect of rFVIIa use during DCR for vascular trauma and the impact on vessel repair.


METHODS
A retrospective two cohort case control study was performed using the Joint Theater Trauma Registry to identify patients with major vascular injury and DCR. Group 1 (n = 12) had DCR and repair of the injured vessels. Group 2 (n = 41) included early rFVIIa as an adjunctive therapy with DCR to control bleeding and perform simultaneous vascular reconstruction.


RESULTS
Age, injury severity score, presenting physiology, and operative time were similar between groups. Postoperative data show that early physiologic recovery from acidosis, coagulopathy, and anemia was associated with rFVIIa and DCR. Extremity graft failures in groups 1 and 2 (follow-up range, 10-26 months) were either from early thrombosis (1 vs. 5 p = 1), graft dehiscence (1 vs. 2 p = 0.55), or infection (1 vs. 1 p = 0.41) and were the result of inadequate soft tissue coverage or technical factors that eventually resulted in eight (15%) amputations. All cause mortality (group 1: 0% vs. group 2: 7.3%, p = 1) and amputation rates (group 1: 25% vs. groups 2: 12.2%, p = 0.36) were similar between the two groups.


CONCLUSIONS
DCR using rFVIIa is effective for controlling hemorrhage and reversing coagulopathy for severe vascular injuries. Early graft failures seem unrelated to rFVIIa use in the setting of wartime vascular injuries. No differences in amputation rate or mortality were seen. Although rFVIIa may be a useful damage control adjunct during vessel repair, the overall impact of this strategy on long-term outcomes such as mortality and limb salvage remains to be determined.
Fox
Charles J
CJ
Department of Surgery, Walter Reed Army Medical Center, Washington, DC 20307, USA. Charles.Fox@us.army.mil
Mehta
Sumeru G
SG
Cox
E Darrin
ED
Kragh
John F
JF
Salinas
Jose
J
Holcomb
John B
JB
D000138:Acidosis / Q000097:blood / Q000209:etiology; D000293:Adolescent; D000328:Adult; D001808:Blood Vessels / Q000293:injuries*; D016022:Case-Control Studies; D003029:Coagulants / Q000627:therapeutic use*; D015942:Factor VIIa / Q000627:therapeutic use*; D005260:Female; D006470:Hemorrhage / Q000097:blood / Q000209:etiology / Q000628:therapy*; D006801:Humans; D054542:Iraq War, 2003-2011; D023821:Limb Salvage; D008297:Male; D008889:Military Personnel; D017410:Practice Guidelines as Topic; D011994:Recombinant Proteins / Q000627:therapeutic use; D012042:Registries; D012189:Retrospective Studies; D014193:Trauma Centers; D014656:Vascular Surgical Procedures / Q000534:rehabilitation; D014950:Wounds, Penetrating / Q000150:complications*; D055815:Young Adult
D003029:Coagulants; D011994:Recombinant Proteins; C103587:recombinant FVIIa; D015942:Factor VIIa