title: Single centre experience of combat-related vascular injury in victims of Syrian conflict: Retrospective evaluation of risk factors associated with amputation.
abstract: OBJECTIVE
  To elucidate the risk factors associated with amputation in cases with combat-related vascular injury (CRVI).
  
  
  METHODS
  This retrospective study included 90 cases with CRVI treated between May 2011 and July 2013. The patients were divided into group I (n=69), in which the limb was salvaged and group II (n=21), in which the patients received amputation.
  
  
  RESULTS
  The overall and the secondary amputation rates were 23% and 18%, respectively. There were no amputations with the MESS of nine or less, increasing proportions of amputations at 10 and 11, with a level of 12 leading to 100% amputation rate. The mortality rate was 2%. Among the 52 (58%) cases with the mangled extremity severity score (MESS) ≥7, the limb salvage rate was 60%. The patients in group II were more likely to have a combined artery and vein injury (p=0.042). They were also more likely to be injured as a result of an explosion (p=0.004). Along with the MESS (p<0.001), the duration of ischemia (DoI) (p<0.001) were higher in group II. The rate of bony fracture (p<0.001) and wound infection (p=0.011) were higher in group II. For the overall amputation, the odds ratio of the bony fracture (OR: 61.39, p=0.011), nerve injury (OR: 136.23, p=0.004), DoI (OR: 2.03, p=0.003), vascular ligation (OR: 8.65, p=0.040) and explosive device injury (OR: 10.8, p=0.041) were significant. Although the DoI (p<0.001) and the MESS (p=0.004) were higher in whom a temporary vascular shunt (TVS) was applied, the utilisation of a TVS did not influence the amputation rate (p=1.0).
  
  
  CONCLUSIONS
  The DoI and the variables indicating the extent of tissue disruption were the major determinants of amputation. While statistically non-significant, the benefit of the application of a TVS is non-negligible. MESS is a valid scoring system but should not be the sole foundation for deciding on amputation. Extremities which were doomed to amputation with the MESS>7 seem to benefit from revascularisation with initiation of reperfusion at once. The validity of MESS merits further investigation with regard to the determination of a new cut-off value under ever developing medical management strategies.
authors.affiliation: Department of Cardiovascular Surgery, Ege University Faculty of Medicine, İzmir, Turkey. Electronic address: dresisli@gmail.com.
authors.forename: Emrah
authors.initials: E
authors.lastname: Şişli
authors.affiliation: Department of Cardiovascular Surgery, Dr. Sadi Konuk Education and Research Hospital, İstanbul, Turkey.
authors.forename: Ali Aycan
authors.initials: AA
authors.lastname: Kavala
authors.affiliation: Department of Cardiovascular Surgery, Antakya State Hospital, Hatay, Turkey.
authors.forename: Mustafa
authors.initials: M
authors.lastname: Mavi
authors.affiliation: Department of Cardiovascular Surgery, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey.
authors.forename: Osman Nejat
authors.initials: ON
authors.lastname: Sarıosmanoğlu
authors.affiliation: Department of Cardiovascular Surgery, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey.
authors.forename: Öztekin
authors.initials: Ö
authors.lastname: Oto
mesh_terms: D000328:Adult; D000671:Amputation, Surgical / Q000401:mortality / Q000706:statistics & numerical data*; D001753:Blast Injuries / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008026:Ligation; D023821:Limb Salvage / Q000401:mortality / Q000706:statistics & numerical data*; D008297:Male; D008887:Military Medicine; D012189:Retrospective Studies; D012307:Risk Factors; D013593:Syria / Q000453:epidemiology; D016896:Treatment Outcome; D014421:Turkey / Q000453:epidemiology; D014656:Vascular Surgical Procedures / Q000379:methods / Q000592:standards; D057772:Vascular System Injuries / Q000401:mortality / Q000601:surgery*
keywords: Amputation; Military medicine; Temporary vascular shunt; Vascular surgical procedures; Vascular system injury