title: Reperfusion strategies in the management of extremity vascular injury with ischaemia.
abstract: BACKGROUND
  Extremity injury with ischaemia is the most common pattern of vascular trauma and is a challenge for surgeons who must make decisions about the timing and mechanism of limb reperfusion. In modern military conflicts, effective use of limb tourniquets and rapid transport of the injured have increased the number of casualties who reach a medical service with potentially survivable vascular trauma. This report provides a review of extremity ischaemia and reperfusion following vascular trauma.
  
  
  METHODS
  A review was undertaken of extremity vascular injury with ischaemia, including a focus on adjuncts aimed at reducing reperfusion injury and improving neuromuscular recovery and limb salvage.
  
  
  RESULTS
  Findings from basic and clinical research support the need to restore perfusion to an ischaemic limb as soon as possible in order to achieve optimal neuromuscular recovery. Large-animal studies demonstrate that haemorrhagic shock worsens the impact of ischaemia on the neuromuscular structures of the limb and reduces the ischaemic threshold to as little as 1 h. Surgical adjuncts such as vascular shunts, fasciotomy, regional limb cooling and ischaemic conditioning may reduce the severity of ischaemic injury. Medical therapies have also been described including hypertonic saline, statins and ethyl pyruvate, which reduce the inflammatory response following limb reperfusion.
  
  
  CONCLUSIONS
  Contemporary translational research refutes a casual approach to extremity vascular injury with ischaemia, instead emphasizing expedited reperfusion. Surgical and medical adjuncts exist to expedite reperfusion and mitigate reperfusion injury. Additional research and development of these adjuncts is necessary to improve quality or functional limb salvage after vascular trauma.
authors.affiliation: United States Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas 78236, USA.
authors.forename: T J
authors.initials: TJ
authors.lastname: Percival
authors.forename: T E
authors.initials: TE
authors.lastname: Rasmussen
mesh_terms: D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D001132:Arm / Q000098:blood supply*; D001134:Arm Injuries / Q000628:therapy; D001166:Arteriovenous Shunt, Surgical / Q000379:methods; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D007036:Hypothermia, Induced / Q000379:methods; D007511:Ischemia / Q000628:therapy*; D057775:Ischemic Postconditioning / Q000379:methods; D019194:Ischemic Preconditioning / Q000379:methods; D007866:Leg / Q000098:blood supply*; D007869:Leg Injuries / Q000628:therapy; D008833:Microcirculation / Q000502:physiology; D008889:Military Personnel; D011773:Pyruvates / Q000627:therapeutic use; D015424:Reperfusion / Q000379:methods*; D012462:Saline Solution, Hypertonic / Q000627:therapeutic use; D016879:Salvage Therapy / Q000379:methods; D057772:Vascular System Injuries / Q000628:therapy*; D014857:Warfare
chemical_list: D000893:Anti-Inflammatory Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D011773:Pyruvates; D012462:Saline Solution, Hypertonic; C046522:ethyl pyruvate