Single centre experience of combat-related vascular injury in victims of Syrian conflict: Retrospective evaluation of risk factors associated with amputation

Objective: To elucidate the risk factors associated with amputation in cases with combat-related vascular injury (CRVI). Material and 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. (C) 2016 Elsevier Ltd. All rights reserved.