title: Endovascular management for peripheral arterial trauma: The new norm?
abstract: BACKGROUND
  Endovascular therapy is well studied in atraumatic conditions; and there appears to be a growing interest in its application to traumatic injuries. The objective of this study is to compare open and endovascular techniques in the management of peripheral arterial trauma.
  
  
  METHODS
  This is a retrospective review of patients admitted to a Level I Trauma Center sustaining injuries to the subclavian, axillary, superficial femoral, and popliteal arteries. Demographics, surgical interventions, complications, and clinical outcomes were evaluated in patients requiring open or endovascular repair between 2009 and 2015.
  
  
  RESULTS
  Sixty-eight patients with 70 total arterial injuries were identified. There were 10 subclavian, 14 axillary, 15 superficial femoral, and 31 popliteal artery injuries. Endovascular (n=20) compared to open repairs (n=50) were more commonly performed: by vascular surgeons (90% vs. 54%, p=0.01); in older patients (median age: 38 years vs. 25, p=0.01); primarily involving upper extremity injuries (60% vs. 24%, p=0.01). Furthermore, endovascular repairs less commonly required fasciotomy (15% vs. 46%, p=0.03) and trended towards lower transfusion requirements (50% vs. 77%, p=0.06). Patients undergoing open repair had lower pre-hospital systolic blood pressures (110 vs. 120, p=0.03) and lower initial hematocrit (31.5 vs. 36.2, p=0.02). However, outcomes between groups were trending higher in the endovascular group with respect to limb salvage rates at discharge (94% vs. 89%), median length of stay (14days vs. 9), and median follow-up (288days vs. 92) compared to the open group, but the data were not statistically significant. There was increasing utilization of endovascular repair over time (7% of total procedures in 2009; 50% in 2014).
  
  
  CONCLUSIONS
  Overall, endovascular and open techniques were not statistically different in early outcomes. Endovascular therapy appears to provide some advantage when it comes to: challenging anatomy, decreasing blood product utilization, and minimizing physiologic derangement. However, patients with injuries resulting in free hemorrhage or significant external blood loss may still be best served with open repair. Despite this, given the increasing use of endovascular techniques, close collaboration is needed between trauma and endovascular specialists to properly select the optimal management for patients with peripheral arterial trauma.
authors.affiliation: Department of Surgery, Baylor College of Medicine, Houston, TX, USA. Electronic address: ganapath@bcm.edu.
authors.forename: Anand
authors.initials: A
authors.lastname: Ganapathy
authors.affiliation: Department of Surgery, Baylor College of Medicine, Houston, TX, USA. Electronic address: Ahmed.Khouqeer@bcm.edu.
authors.forename: Ahmed F
authors.initials: AF
authors.lastname: Khouqeer
authors.affiliation: Department of Surgery, Baylor College of Medicine, Houston, TX, USA. Electronic address: Samual.Todd@bcm.edu.
authors.forename: S Robb
authors.initials: SR
authors.lastname: Todd
authors.affiliation: Department of Surgery, Baylor College of Medicine, Houston, TX, USA. Electronic address: Joseph.Mills@bcm.edu.
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Mills
authors.affiliation: Department of Surgery, Baylor College of Medicine, Houston, TX, USA. Electronic address: rgilani@bcm.edu.
authors.forename: Ramyar
authors.initials: R
authors.lastname: Gilani
mesh_terms: D000328:Adult; D000792:Angiography; D001803:Blood Transfusion / Q000706:statistics & numerical data; D057510:Endovascular Procedures / Q000379:methods; D005260:Female; D006801:Humans; D007902:Length of Stay; D023821:Limb Salvage / Q000379:methods; D008297:Male; D016491:Peripheral Vascular Diseases / Q000175:diagnosis* / Q000601:surgery; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology; D057772:Vascular System Injuries / Q000175:diagnosis / Q000601:surgery
keywords: Endovascular therapy; Peripheral artery trauma; Vascular injury