Vascular trauma in Colombia: Experience of a level i trauma center in medellín

INSTITUTIONAL EXPERIENCE IN VASCULAR TRAUMA

For the purposes of this article, a compilation was made of all patients with a diagnosis of vascular trauma from the surgical records of the HUSVP during a 5-year period from 1996 to 2000. A total of 843 patients were identified who had undergone surgery. Of these, 664 were available for analysis, which represents an under-reporting of 21.2%. This under-reporting is caused by the disappearance of clinical histories or incomplete data and is a widespread problem because of the absence of

CERVICAL VASCULAR TRAUMA

An analysis was made of 66 patients who had undergone surgery for vascular injury. The average age was 27.5 years, and 93.9% of patients were male. The distribution according to age showed that 83% were between 15 and 40 years of age. The most common penetrating mechanism of injury was stabbings (57.6%), followed by gunshots (40.9%) and blunt trauma (1.5%). The time between injury and hospital admission was 1 hour or less in 60% of patients. Approximately 42.4% of them arrived in shock, and

Arterial Injuries

Arterial injuries occurred in 49 (74.2%) of these patients. The distribution of carotid injuries by segments revealed injuries of the common carotid in 40.9%; internal carotid artery, 13.6%; vertebral artery, 15.2%; and external carotid artery, 4.5%.

Injuries of the vertebral artery occurred both in the cervical segment and in its intravertebral trajectory in five patients. The injuries were produced by stabbings in seven patients and gunshots in three patients. In all cases, surgical control

Venous Injuries

Isolated venous injuries were present in 17 patients and were injuries to the internal jugular vein. Management in all cases consisted of ligature. Six patients died, five of whom succumbed during the perioperative period, because of hypovolemic shock; one late death occurred secondary to associated injuries.

Diagnostic Methods

During the past 2 years there has been, within the authors' institution, an interest in exploring the usefulness of helical CT angiography for the diagnosis of cervical vascular injuries in patients who do not have an immediate indication for surgery. Of 155 patients in this study, 23 had vascular injuries (18 carotid injuries were managed surgically, and 5 vertebral artery ones were managed with endovascular therapy). Only one false-positive result was found. The sensitivity and specificity of

Endovascular Therapy

During the 1996–2000 period, the authors' invasive radiology group undertook endovascular treatment of venous and arterial injuries of the head and neck in 35 patients, 26 of whom were injured by gunshots and 9 by stabbings in anatomic areas posing difficult vascular surgical access. Angiography detected 44 injuries: 21 fistulas (11 vertebral, 8 cavernous, 1 carotid-jugular, and 1 external carotid), 16 pseudoaneurysms (6 of the external, 5 of the internal, and 2 of the common carotid; 2 of the

THORACIC VASCULAR TRAUMA

An analysis was made of 69 patients who underwent surgery for thoracic vascular trauma. The average age was 28.8 years, and 98.6% were male. Distribution according to age showed that 82.6% ranged from 15 to 40 years. Distribution of mechanism of injury was stabbings, 51.5%; gunshots, 39.7%; shotguns, 5.9%; and blunt trauma, 2.9%. The time between the injury and hospital admission was 1 hour or less in 79.7% of patients. Approximately 71% of patients arrived in shock. Given the conditions of the

ILIAC ARTERIAL TRAUMA

An analysis was made of 24 patients who underwent surgery for iliac arterial injuries. The average age was 31.3 years, and 83.3% were male. Distribution according to age showed that 91.7% of patients were between 15 and 40 years of age. The mechanism of injury was gunshots, 50.0%; stabbings, 25.0%; shotguns, 20.8%, and blunt trauma, 4.2%. The time between injury and hospital admission was 1 hour or less in 87.5% of the patients. Approximately 66.7% of them arrived in shock. Damage-control

VASCULAR TRAUMA OF EXTREMITIES

An analysis was made of 391 patients who underwent surgery or vascular injuries to the extremities. Their average age was 27.3 years, and 92% were male. Distribution according to age showed that 89.8% were between 15 and 40 years of age. The most common mechanism of injury was gunshots, 46.4%, followed by stabbings, 29.5%; shotguns, 11.8%; blunt trauma, 10.5%; and blast trauma, 1.8%. The time between the injury and hospital admission was 1 hour or less in 63.2% of patients and less than 6 hours

Arterial Injuries

Arterial injuries occurred in 353 patients (90.3%), 190 (53.8%) of them in the upper extremity and 163 (46.1%) in the lower one. Distribution by segments, lesion mechanism, type of repair, complications, and mortality is shown in Table 4, Table 5.

Venous Injuries

A total of 215 patients in this study sustained venous injuries, 113 (52.6%) of them occurring in the upper extremity and 102 (47.4%) in the lower one. Distribution by affected vessels, mechanism, and type of repair is shown in Table 6, Table 7.

Combined arterial and venous injuries occurred in 177 patients (45.2%). Distribution of combined injuries was as follows: axillary, 34 patients; brachial, 59; radioulnar, 2; femoral, 39; popliteal, 36; and infrapopliteal, 7.

Diagnostic Methods

Of the patients undergoing surgery, 74 (19%) were diagnosed by using angiography, including 51 arteriograms and 23 helical CT angiograms. Radiologic findings included obstruction in 48 patients (64.8%); pseudoaneurysm in 20 (27%); arteriovenous fistulas in 3 (4%), with extravasation of the contrast medium in 3 (4%).

During the past 2 years there has been an interest, within the authors' institution, in exploring the usefulness of helical CT angiography for the diagnosis of vascular injuries of

Complications

Approximately 27.9% of the patients had complications (thrombosis of the repair in 31 [7.9%], compartment syndrome in 26 [6.6%], fasciotomy infection in 22 [5.6%], and amputation in 15 [3.8%]). A total of 15 patients died (3.8%) (11 secondary to hypovolemic shock and 4 by late septic complications and multiple organic failure).

Of the amputated patients, 9 had injuries of the popliteal artery, 4 of the femoral, 1 of the brachial, and 1 of the infrapopliteal vessels.

Blunt trauma constituted a

SUMMARY

Trauma has become a major health problem in Colombia. The large number of trauma patients has made San Vicente de Paul Hospital of Medellín a major national referred trauma center.

Under-reporting is a major problem in Colombia, as in other underdeveloped countries, because of the absence of automated information systems. Despite this and limited financial health resources, time to definitive treatment, morbidity, and mortality are similar to those of centers in developed countries.

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