Junctional traumatic vascular injuries after fall from horse

Abstract text (incl. references and figure legends)

Case History A 45-year old female who fell from a horse.

Clinical findings Hemodynamically instable patient with absence of motor function and sensory loss in the left leg.

Investigation/results Computed tomography (CT) revealed a comminuted pelvic open-book fracture. CT-angiography showed occlusion of the left external iliac artery and laceration of the left external iliac- and femoral vein.

Therapy and progressions Emergent surgical exploration was performed. Venorrhaphy of the lacerated external iliac- and femoral vein was performed. A right to left femoro-femoral crossover bypass was used to restore perfusion of the the left leg (Table 1). Ischemia time was estimated to be 6 hours.

Five months postoperatively, duplex ultrasound showed graft patency, with good distal perfusion of the left leg, and an ankle-brachial index of 1.0.

Comments The term junctional vascular injury is defined as vascular injury occurring at the junction of anatomically distinct regions. Major vascular structures bridge these junctional zones, making them prone to extensive damage and hemorrhage when injured, while acute bleeding control is complex. The majority of these injuries is repaired using interposition bypass grafts. It remains unclear whether autologous or synthetic grafts are best in the setting of acute vascular injury. Graft choice is generally dependent on graft availability, next to extent, instability, context, and type of vascular injury.

Several studies compared prosthetic and autologous grafts in the setting of acute vascular injury. However, the level of evidence of these studies is doubtful, due to lack of long-term follow-up, and heterogeneity in type of vascular injury and surgical management. Also, essential variables determining graft outcome are seldomly reported. Future research should include multicenter, retrospective database review, comparing all used grafts to determine which graft provides better long-term outcomes in traumatic junctional vascular injury.

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