Mehmet ÇAKICI, Ugursay KIZILTEPE, Çağdaş BARAN, Oktay KORUN, Mustafa SEREN, Ünsal HAN, Evren ÖZÇINAR

Üst ekstremite yaralanmalarında arter duvarı hasarının histopatolojik değerlendirmesi

Amaç: Bu çalışmada, üst ekstremite ezilme yaralanmaları arter duvarındaki histopatolojik değişikliklere göre değerlendirildi ve erken ve geç dönem klinik sonuçlar bildirildi. Çalışma planı: Şubat 2011 - Kasım 2013 tarihleri arasında üst ekstremite ezilme yaralanması olan 12 hastanın (9 erkek, 3 kadın; ort. yaş 33.3±11.7 yıl; dağılım 18-57 yıl) prospektif olarak toplanan verileri retrospektif olarak incelendi. Hastaların tümünün Ezilmiş Ekstremite Şiddet Skoru ≥7 idi ve tümünde ciddi vasküler yaralanma bulguları vardı. Ortopedik stabilizasyon sonrasında vasküler rekonstrüksiyon yapıldı. Hemodinamik stabilizasyon sonrasında, rutin olarak dijital substraksiyon anjiyografi çekildi. Revaskülarizasyon işlemi sırasında, hasarlı arter damarları çıkarıldı ve formalin solüsyonunda saklandı. Endotelyal şişme, intimal kalınlaşma, kas tabakasındaki hücresel vaküolizasyon, tunika medyadaki ödem ve nekrozun derecesi değerlendirildi. Bulgular: Yaralanma beş hastada işe bağlı kazalar ve yedi hastada motorlu araç kazaları ile ilişkiliydi. Tüm hastalara ven greft interpozisyonu uygulandı (12; %100). Primer açıklık oranı %75 idi ve bir hasta kaybedildi (30 günlük mortalite %8.3). On iki hastada üç amputasyon yapıldı. Medyan takip süresi 3.2 (dağılım: 2.1-3.7) yıl idi. Alınan örneklerin mikroskopik incelemesinde vasküler konjesyon ve trombüs oluşumu, ilerleyici subintimal diseksiyon ve elastik internanın membranında yırtılma olduğu belirlendi. Sonuç: Çalışma sonuçlarımız Ezilmiş Ekstremite Şiddet Skoruna göre amputasyon endikasyonu olsa da, ekstremite kurtarma işlemlerinin uygulanmasını önermektedir.

Histopathological evaluation of the arterial wall damage in upper limb injuries

Background: This study aims to evaluate the upper limb crush injuries according to the histopathological changes in the arterial vessel and to report the early and late clinical outcomes.Methods: We retrospectively analyzed of prospectively collected data of 12 patients (9 males, 3 females; mean age 33.3±11.7 years; range 18 to 57 years) with an upper extremity crush injury between February 2011 and November 2013. All the patients had a Mangled Extremity Severity Score of ≥7 and all had strong signs of vascular injury. Vascular reconstruction was performed after orthopedic stabilization. Digital subtraction angiography was routinely performed after hemodynamic stabilization. During the revascularization procedure, injured arterial vessels were harvested and stored in the formalin solution. The presence of endothelial swelling, intimal thickening, cellular vacuolization in the muscle layer, edema in the tunica media, and extent of the necrosis were evaluated.Results: Injuries were due to work-related accidents in five patients and motor vehicle accidents in seven patients. Vein graft interposition was performed in all patients (12; 100%). Primary patency rate was 75% and one patient died (30 -day mortality 8.3%). Three amputations were performed 12 patients. The median follow-up was 3.2 (range: 2.1 to 3.7) years. Microscopic examination of the specimens collected revealed vascular congestion and thrombus formation, progressive subintimal dissection, and rupture of the membrane of elastic interna.Conclusion: Our study results suggest performing limb salvage procedures, even if the Mangled Extremity Severity Scores indicate amputation.

PDF

___

24. Hasde AI, Ezelsoy M, Ozgur M, Aslan M, Kıs M, Mavi M. Analysis of upper extremity arterial injuries caused by gunshot wounds. Damar Cer Derg 2015;24:119-25.
23. Temizkan V, Ugur M, Senay S, Ucak A, Yilmaz AT. The effect of early endovascular intervention on the outcome of traumatic vascular injuries. Turk Gogus Kalp Dama 2013;21:63-8.
22. Ustunsoy H, Tuncozgır B, Sanli M, Topal M, Elbeyli L, Kanko M. Peripheral vascular injuries. Turk Gogus Kalp Dama 1999;7:140-3.
21. Andreev A, KAvrakov T, Karakolev J, Penkov P. Management of acute arterial trauma of the upper extremity. Eur J Vasc Surg 1992;6:593 -8.
20. Prichayudh S, Verananvattna A, Sriussadaporn S, Sriussadaporn S, Kritayakirana K, Pak-art R, et al. Management of upper extremity vascular injury: outcome related to the Mangled Extremity Severity Score. World J Surg 2009;33:857-63.
19. Joshi V, Harding GE, Bottoni DA, Lovell MB, Forbes TL. Determination of functional outcome following upper extremity arterial trauma. Vasc Endovascular Surg 2007;41:111-4.
18. Klocker J, Falkensammer J, Pellegrini L, Biebl M, Tauscher T, Fraedrich G. Repair of arterial injury after blunt trauma in the upper extremity- immediate and long-term outcome. Eur J Vasc Endovasc Surg 2010;39:160-4.
17. Fodor L, Sobec R, Sita-Alb L, Fodor M, Ciuce C. Mangled lower extremity: can we trust the amputation scores? Int J Burns Trauma 2012;2:51- 8.
16. Chen W, Su Y, Zhang Q, Zhang Y, Smith WR, Ma L, et al. A proposed new system of coding and injury classification for arteries in the trunk and extremities. Injury 2012;43:1539- 46.
15. Shanmuganathan R. The utility of scores in the decision to salvage or amputation in severely injured limbs. Indian J Orthop 2008;42:368-76.
14. Ly TV, Travison TG, Castillo RC, Bosse MJ, Mackenzie EJ. Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. J Bone Joint Surg Am 2008;90:1738-43.
13. Chan ADM, Hunter G. The mangled lower extremity: Long term outcome comparing amputation versus limb salvage. J Bone Joint Surg [Br] 1999;81.
12. Heitmann C, Levin LS. The orthoplastic approach for management of the severely traumatized foot and ankle. J Trauma 2003;54:379-90.
11. Akula M, Gella S, Shaw CJ, Mcshane P, Mohsen AM. A meta-analysis of amputation versus limb salvage in mangled lower limb injuries-the patient perspective. Injury 2011;42:1194-7.
10. Presarn ML, Helfet DL, Kloen P. Management of the mangled extremity. Strat Traum Limb Recon 2012;7:182-90.
9. Manord JD, Garrard CL, Kline DG, Sternbergh WC, Money SR. Management of severe proximal vascular and neural injury of the upper extremity. J Vasc Surg 1998;27:43.
8. Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M. Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. Evidence-Based Orthopaedic Trauma Working Group. J Orthop Trauma 2007;21:70-6.
7. Schirò GR, Sessa S, Piccioli A, Maccauro G. Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system. BMC Musculoskelet Disord 2015;16:372.
6. Slauterbeck JR, Britton C, Moneim MS, Clevenger FW. Mangled extremity severity score: an accurate guide to treatment of the severely injured upper extremity. J Orthop Trauma 1994; 8:282-5.
5. Pimple MK, Desai MM, Hira K. The utility of MESS in mangled extremities. Indian J Orthop 2002;36:8.
4. Frykberg ER. Advances in the diagnosis and treatment of extremity vascular trauma. Surg Clin N Am 1995;75:207-23.
3. Durrant CA, Mackey SP. Orthoplastic classification systems: the good, the bad, and the ungainly. Ann Plast Surg 2011;66:9-12.
1. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568-72.