title: Outcomes of selective tibial artery repair following combat-related extremity injury.
abstract: OBJECTIVE
  Selective tibial revascularization refers to the practice of vessel repair vs ligation or observation based on factors observed at the time of injury. Although commonly employed, the effectiveness of this strategy and its impact on sustained limb salvage is unknown. The objective of this study is to define the factors most relevant in selective tibial artery revascularization and to characterize limb salvage following tibial-level vascular injury.
  
  
  METHODS
  The cohort of active-duty military patients undergoing infrapopliteal artery repair comprises the tibial Bypass group. A similarly injured cohort of patients that did not undergo operative vascular intervention (No Bypass group) was identified. All tibial vessel injuries were documented by angiography. Data were compiled via medical records and patient interview. The primary outcome measure was failure of limb salvage. Multivariate regression was performed to identify factors associated with revascularization and to describe factors associated with amputation.
  
  
  RESULTS
  Between March 2003 and September 2008, 135 of 1332 patients with battle-related vascular injuries had documented tibial vessel disruption or occlusion. Of these, 104 were included for analysis. Twenty-one underwent autologous vein bypass at the time of injury (Bypass group), and the remaining 83 patients were managed without revascularization (No Bypass group). Mean follow-up (39 vs 41 months; P = .27), age (25 vs 27 years; P = .66), and mechanism of injury (88% vs 92% penetrating blast; P = .56) were similar, but the No Bypass group had higher Injury Severity Scores (ISS; 16.3 vs 11.7; P < .01). Injury characteristics, including Gustilo III classification (49% vs 43%; P = .81) and nerve injury (55% vs 53%; P = 1.0), were similar. Subjects were more likely to receive tibial bypass with an increasing number of tibial vessel occlusions and documented ischemia on initial exam. However, of the 23 in the No Bypass group with initially unobtainable Doppler signals, 17 (74%) regained pedal flow following resuscitation and limb stabilization. Amputation rates were similar (23% vs 19%; P = .79), but the prevalence of chronic limb pain was lower in the Bypass group (10% vs 30%, respectively; P = .08). Cox regression analysis of amputation-free survival demonstrated an association between mangled extremity severity score >5 (hazard ratio [HR], 2.7; P = .01) and amputation.
  
  
  CONCLUSIONS
  This report provides outcomes data for wartime tibial vascular injury, which supports a selective approach to tibial artery revascularization. Clinical factors such as ISS and degree of ischemia guide which patients are best suited for tibial vascular repair, while injury-specific characteristics are associated with amputation regardless of revascularization status.
authors.affiliation: Department of Surgery, San Antonio Military Medical Consortium, Lackland Air Force Base, San Antonio, Texas 78236, USA.
authors.forename: Gabriel E
authors.initials: GE
authors.lastname: Burkhardt
authors.forename: Mitchell
authors.initials: M
authors.lastname: Cox
authors.forename: W Darrin
authors.initials: WD
authors.lastname: Clouse
authors.forename: Chantel
authors.initials: C
authors.lastname: Porras
authors.forename: Shaun M
authors.initials: SM
authors.lastname: Gifford
authors.forename: Ken
authors.initials: K
authors.lastname: Williams
authors.forename: Brandon W
authors.initials: BW
authors.lastname: Propper
authors.forename: Todd E
authors.initials: TE
authors.lastname: Rasmussen
mesh_terms: D000328:Adult; D000671:Amputation, Surgical; D005121:Extremities / Q000098:blood supply*; D006801:Humans; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D016015:Logistic Models; D008889:Military Personnel; D016016:Proportional Hazards Models; D011859:Radiography; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D016909:Tibial Arteries / Q000000981:diagnostic imaging / Q000293:injuries / Q000601:surgery*; D013997:Time Factors; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler; D014680:Veins / Q000637:transplantation*; D014857:Warfare; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D055815:Young Adult