Key Words:
trauma , vascular , Latin America , Bogota bag
Epidemiology
Approximately 5 million people die annually worldwide as the result of trauma or injury. Death from trauma represents 9% of the global mortality; and 90% of these deaths occur in developing countries, creating a public health problem. In nearly all countries, trauma or injury is the leading cause of death among people between 15 and 44 years of age. From 1996 to 2010 in Latin America, trauma was the third leading cause of death in all age groups following cardiovascular disease and malignancy. Homicide was the most common cause (60%) of traumatic death in Latin America followed by motor vehicle accidents (19%), suicide (6%), and injury during combat operations (6%) ( Fig. 33-1 ). While less commonly resulting in death, injury of the femoral vessels during performance of catheter-based, endovascular procedures has been an increasingly common cause of vascular trauma over the past decade. The largest trauma registries in Latin America are in Colombia and Brazil, while other countries do not have organized repositories because of limited resources or lack of political will. In aggregate, the morbidity and mortality from trauma in Latin America are similar to those of developed countries around the world.
In the context of all trauma admissions, recorded or documented vascular injuries are relatively rare. Vascular trauma in civilian centers in Latin America represents 0.65% to 1.14% of all trauma admission and is much more common in men (88%) than women (gender proportion of 12: 1). Almost three quarters of vascular injuries (71% of patients) in Latin America occur in those between the ages of 15 and 45 years. Penetrating trauma is responsible for 88% of cases of vascular injury with gunshot wounds most prevalent (60% of penetrating cases). Stab wounds account for about 28% of the penetrating vascular trauma cases and only about 8% of the vascular trauma in Latin America results from nonpenetrating causes. A small percentage of vascular trauma results from iatrogenic causes such as vascular access for endovascular procedures. Day-by-day violence is responsible for most cases of vascular trauma in Columbia and Latin America and most of this is in urban, civilian areas (78%). Vascular trauma during official military operations has represented only a small percentage (5%) of the region’s experience in the recent past.
Similar to other experiences with vascular trauma around the world, the extremities have a higher preponderance for injury than the torso and cervical regions. Almost two thirds of all vascular injury (62%) in Columbia and Latin America occurs in the extremities (33% lower and 29% upper). Abdominal and pelvic vascular trauma accounts for 17% of vascular injury followed by lesions in the thorax (12%) and cervical regions (9%). The majority of vascular trauma (62%) is arterial in nature although nearly a quarter of cases (22%) have multiple vascular injuries. Documented venous injury is present in 10% of cases of vascular trauma, and there is a preponderance of venous injury in the abdomen and pelvis compared to other anatomic locations ( Table 33-1 ). The amputation rate following extremity vascular injury is approximately 5% although long-term follow-up is difficult to achieve in Columbia and other parts of Latin America. Injury patterns associated with higher amputations rates and mortality include blunt popliteal artery trauma and penetrating injuries with a combined arterial and venous component. Early amputation rates in these more-complex injury patterns have been recorded to be 4% to 12% in different studies.
| Variable | Percentage (%) |
|---|---|
| Gender | |
| Male | 88 |
| Female | 12 |
| Age | 27 years |
| Mechanism of Injury | |
| Penetrating | 88 |
| Blunt | 8 |
| Other causes | 4 |
| Gunshot wounds | 60 |
| Stab wounds | 28 |
| Localization | |
| Upper limbs | 29 |
| Lower limbs | 33 |
| Cervical | 9 |
| Thoracic | 12 |
| Abdominal and pelvic | 17 |
| Surgical Treatment | |
| Primary repair | 30 |
| Vein graft | 55 |
| Prosthetic graft | 10 |
| Ligation | 5 |
| Amputation | 5 |
| Mortality | 7.5 |
Specific Systems of Care in the Region
In most hospitals in Columbia and Latin America, vascular trauma is managed by a general surgeon who is well suited due the wide range of injury patterns in the region. Like many other parts of the world, it is impractical to have a specialty-trained vascular surgeon in the emergency department (ED) 24 hours a day, 7 days a week for vascular trauma call. Nonetheless, with the advent of a new breed of vascular surgeons interested in trauma and an increase in specialized centers, specialty-trained vascular surgeons are becoming more involved in vascular injury in many locations. These types of centers have multidisciplinary teams composed of general and vascular surgeons as well as interventional radiologists and vascular technologists that provide more prompt and thorough diagnosis and treatment of vascular injury.
Regional Considerations for the Diagnosis and Management of Vascular Trauma
About 70% of patients with vascular trauma in Columbia and Latin American manifest some degree of hemodynamic shock. Two thirds (65%) of these patients are taken immediately to an operating room after the initial clinical assessment. The remaining patients undergo some form of imaging, most commonly computed tomography (CT) or contrast angiography. Even in the operating room, angiographic capability exists in more advanced medical centers in the form of a C-arm fluoroscopy unit. In such facilities, intraoperative angiography allows for the diagnosis of vascular trauma and endovascular treatment in some cases. More remote or lesser established medical centers in Latin America do not have C-arm fluoroscopic capability in the operating room; and, in these facilities, surgeons must rely on clinical examination and operative exploration to diagnose vascular trauma.
The continuous-wave Doppler machine is more commonly available in hospital settings in Columbia and Latin America and is a useful and more-basic way to assess limb perfusion in the setting of trauma. In patients who have normal hemodynamic measures, the Doppler may be used to calculate an injured extremity index (IEI) or ankle brachial index (ABI), which is more than adequate to assess for flow-limiting arterial injuries in a limb. The Doppler examination may need to be repeated in patients who are hypotensive or hypothermic as these conditions tend to reduce peripheral perfusion and may skew the ABI measurement. In some centers in Latin America, patients with a question of vascular trauma undergo duplex ultrasound as a noninvasive diagnostic measure. This modality is more sensitive than simple Doppler and is commonly performed by a vascular surgeon or vascular technologist under the supervision of a vascular surgeon. In most facilities patients who meet criteria for an angiogram will undergo this procedure in the initial 48 hours following the injury. In recent years select patterns of vascular injury such as pseudoaneurysm and arteriovenous fistulae may be repaired using catheter-based endovascular techniques such as placement of a covered stent. Some specialized centers in Latin America have the capability to perform contrast-enhanced CT angiography, which has been shown to have a sensitivity of 95% in the setting of trauma.
Most trauma in the authors’ geographic region occurs in the civilian setting; and thus the time from injury to surgical evaluation is relatively short, occurring within 3 hours of injury in 80% of cases. The improved trend in reducing prehospital times demonstrates the increased training and preparedness of first responders and ambulance crews in many cities in Latin America. It should be noted that prehospital times vary widely with some more remote or less developed areas having prehospital times that exceed 3 hours and in rare cases may even extend to 12 to 24 hours. In some Latin American countries, the movement of patients from the point of injury to the hospital emergency department is performed by local police or law enforcement personnel.
In general, first responders and ambulance crews in Latin America do not use tourniquets for extremity injuries. Instead first responders are mostly taught techniques for direct compression, and use of dressings for bleeding injuries and tourniquets are used only on select bases. In hospital hemorrhage, control of torso bleeding is pursued with expedited laparotomy, thoracotomy, or reduction of complex pelvic fractures with a sheet or external fixation. Resuscitative aortic occlusion via thoracotomy and clamping is used as a last resort in patients in cardiovascular collapse. The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) is yet to be used widely in Latin America, although interest is growing as efficacy is demonstrated in other parts of the world. Needless to say, resuscitation with whole blood or blood products is very much a part of these maneuvers to control hemorrhage from vascular trauma and is often accomplished with use of auto-transfusion and cell-saver devices.
Patients with major vascular injury and concomitant physiologic compromise (i.e., hypothermia, severe acidosis, shock) are often managed with the use of improvised or homemade temporary vascular shunts. In the authors’ experience, restoration of flow across a major vascular injury has been accomplished most commonly using nasogastric tubes or small-caliber chest tubes ( Fig. 33-2 ). In these cases, the improvised shunt is secured to each vessel end using free ties to allow for stabilization and eventual removal of the device at the time of formal vascular reconstruction.
