Table 1 summarizes the study group’s basic characteristics; abdominal vascular injury was present in 2949 patients (1.6% of all patients considered). Isolated arterial injury seen among 83.4% of these patients (n = 2459). There were 383 patients (13%) admitted with isolated venous injury and 107 patients (3.6%) had both arterial and venous injuries. Number of patients with ISS above 16 was 341 (89%) in patients with VI, 2236 (92%) in patients with AI, and 98 (92%) in patients with AVI. Blunt trauma was the most common mechanism responsible for abdominal vascular injuries in all three groups. Traffic injuries were common (n = 1720, 69.9%). Within the group of 230 assaulted patients, 179 (77.8%) sustained stabbing injuries and 51 (22.2%) patients had gunshot wounds. Out of the 2949 patients, 948 (32.1%) were hemodynamically unstable at the time of admission.
Table 1
Basic characteristics of 2949 patients with abdominal vascular injuries
|
arterial injury only
n = 2459
|
venous injury only
n = 383
|
mixed arterial and venous injuries
n = 107
|
Age (years)*
|
48.7 ± 19.1
|
44.0 ± 18.3
|
43.8 ± 17.6
|
Males
|
1831 (75%)
|
267 (70%)
|
83 (78%)
|
ISS ≥ 16
|
2236 (92%)
|
341 (89%)
|
98 (92%)
|
ISS*
|
33.8 ± 15.6
|
33.5 ± 16.5
|
35.9 ± 15.5
|
Penetrating trauma
|
230 (10%)
|
58 (16%)
|
29 (28%)
|
Prehospital shock
(syst. BP ≤ 90mmHg)
|
606 (33%)
|
95 (32%)
|
37 (47%)
|
Shock at ED admission
(syst. BP ≤ 90mmHg)
|
777 (35%)
|
125 (36%)
|
46 (47%)
|
Mechanism of injury
|
|
|
|
Traffic accident – Car/lorry
|
821 (34%)
|
120 (32%)
|
26 (24%)
|
Traffic accident - Motorcycle
|
344 (14%)
|
58 (15%)
|
12 (11%)
|
Traffic accident - Bicycle
|
96 (4%)
|
25 (7%)
|
5 (5%)
|
Traffic accident - Pedestrian
|
167 (7%)
|
38 (10%)
|
8 (8%)
|
High Fall (> 3 m)
|
438 (18%)
|
47 (13%)
|
15 (14%)
|
Low Fall (< 3 m)
|
143 (6%)
|
14 (4%)
|
3 (3%)
|
Gunshot
|
28 (1%)
|
13 (3%)
|
10 (9%)
|
Stabbing
|
140 (6%)
|
28 (7%)
|
11 (10%)
|
ISS: Injury Severity Score |
*mean with standard deviation |
The distribution of arterial and venous injuries in patients with relevant injuries (AIS ≥ 3) of head, thoracic, abdomen and extremities are shown in Table 2. All types of vessel injuries were more prevalent in patients with relevant abdominal trauma followed by relevant thoracic trauma as the second most common cause.
Table 2
Distribution of arterial and venous vessel injuries in patients with relevant injury (AIS ≥ 3)
Affected vessel
|
Relevant head trauma
n = 84544
|
Relevant thoracic trauma
n = 91437
|
Relevant abdominal trauma
n = 25426
|
Relevant injury of the extremities
n = 58555
|
Abdominal vascular injury
|
825 (0.9%)
|
1980 (2.1%)
|
3425 (13.4%)
|
1640 (2.8%)
|
Abdominal aortic or arterial injury
|
589 (0.7%)
|
1431 (1.6%)
|
2566 (10.1%)
|
1173 (2.0%)
|
Abdominal venous injuries
|
117 (0.1%)
|
271 (0.3%)
|
466 (1.8%)
|
229 (0.4%)
|
Inferior vena cava
|
48 (< 0.1%)
|
107 (0.1%)
|
153 (0.6%)
|
67 (0.1%)
|
Iliac vein
|
26 (< 0.1%)
|
42 (< 0.1%)
|
87 (0.3%)
|
84 (0.1%)
|
Other abdominal veins
|
45 (< 0.1%)
|
129 (0.1%)
|
153 (0.6%)
|
87 (0.1%)
|
Patients with higher abdominal AIS were more unstable and required blood transfusion more frequently. In this subgroup of patients, rate of cessation of the trauma resuscitation algorithm and going under emergency surgery was higher with increasing abdominal AIS (Table 3).
Table 3
Early clinical management in subgroups according to severity of abdominal vascular trauma
|
Controls
|
AIS-3
|
AIS-4
|
AIS-5
|
No. of patients
|
184276
|
1380
|
1323
|
211
|
Systolic BP ≤ 90 mmHg on admission
|
16399 (10%)
|
316 (25%)
|
500 (42%)
|
120 (64%)
|
Blood transfusion
|
22202 (12%)
|
530 (39%)
|
717 (56%)
|
133 (66%)
|
Massive transfusion
|
3831 (2%)
|
185 (14%)
|
282 (22%)
|
56 (28%)
|
Number of pRBC
|
0.7 ± 3.1
M: 0
|
3.8 ± 8.1
M: 0
|
6.3 ± 10.8
M: 2
|
8.0 ± 12.2
M: 4
|
Emergency surgery 1
|
2377 (3%)
|
87 (13%)
|
132 (21%)
|
24 (24%)
|
Emergency surgery 2
|
40905 (26%)
|
605 (51%)
|
751 (64%)
|
132 (71%)
|
WB-MSCT
|
127583 (70%)
|
1094 (80%)
|
974 (75%)
|
124 (60%)
|
Total numbers and percentages of each group are given with the total number of available datasets for each characteristic in parenthesis.
Total patient numbers may vary for each procedure and characteristic because of incomplete data transmission or transmission of basic datasets. Basic datasets do not include information on emergency/early surgery.
Massive transfusion: ≥ 10 units of packed red blood cells
Emergency surgery 1: immediate surgery requiring cessation of the implemented trauma resuscitation algorithm (2002 until 2015); Emergency surgery2: Intervention (since 2009, from a list of 7 critical interventions, in the ER or directly consecutive)
BP: blood pressure, pRBC: packed red blood cells, M: median, WB-MSCT: whole-body multi-slice computed tomography
Patients with VI or AVI had higher mortality rates within the first 24h as well as increased in-hospital mortality rates (Table 4).
Table 4
Impact of venous injury on patient outcomes after abdominal trauma
|
only arterial injury
n = 2459
|
only venous injury
n = 383
|
both arterial and venous injuries
n = 107
|
Mortality in first 24h
|
448 (18.2%)
|
83 (21.7%)
|
35 (32.7%)
|
Hospital mortality
|
689 (28.0%)
|
127 (33.2%)
|
47 (43.9%)
|
Multiple organ failure*
|
648 (47%)
|
114 (51%)
|
37 (65%)
|
Sepsis*
|
202 (15%)
|
31 (14%)
|
16 (28%)
|
Kidney failure*
|
223 (16%)
|
34 (15%)
|
18 (32%)
|
Days of mechanical ventilation
|
6.8 ± 12.2
M: 1
|
6.5 ± 11.4
M: 1
|
9.2 ± 19.2
M: 1.5
|
ICU length of stay (day)
|
11.6 ± 15.9
M: 5
|
11.1 ± 15.8
M: 5
|
16.3 ± 29.7
M: 3
|
Hospital length of stay
|
24 ± 26
M: 16
|
21 ± 23
M: 15
|
27 ± 38
M: 11
|
Blood transfusion
|
1120 (46%)
|
201 (53%)
|
81 (77%)
|
Massive transfusion (≥ 10 units of pRBC)
|
396 (16%)
|
86 (23%)
|
46 (44%)
|
FFP transfusion
|
766 (32%)
|
144 (38%)
|
67 (64%)
|
Average number of pRBC
|
4.7 ± 9.1
M: 0
|
6.3 ± 10.6
M: 2
|
13.0 ± 16.1
M: 8
|
* available only in patients with standard documentation (68% of all cases) |
pRBC: packed red blood cells, FFP: fresh frozen plasma, M: median |
Continuous variables presented with mean, SD, and median
Moreover, the rate of multiple organ failure, sepsis and kidney failure was higher in patients with VI or AVI. The mean hospital length of stay in patients suffering from AI, VI and AVI were 24, 21 and 27 days, respectively (Table 5).
Table 5
Results of logistic regression analysis with in-hospital mortality as dependent variable
Predictor
|
Coefficent (SE)
|
p-value
|
Odds Raio (OR)
|
95% confidence interval of OR
|
RISC II score
|
-0.96
|
< .001
|
0.383
|
0.379–0.388
|
Hospital level of care*
regional trauma center (level 2)
local trauma center (level 3)
|
0.04
0.02
|
.094
.620
|
1.04
1.02
|
0.99–1.10
0.93–1.12
|
Arterial injury in the abdomen**
|
0.43
|
< .001
|
1.54
|
1.35–1.77
|
Venous injury in the abdomen**
|
0.57
|
< .001
|
1.77
|
1.33–2.36
|
Constant term
|
-0.05
|
.001
|
|
|
The analysis is based on 164,370 patients; Nagelkerke’s R²=0.585 |
* reference group: supra regional trauma center (level 1) |
** reference group: no such injury documented |
Blood (BT) and fresh-frozen plasma (FFP) transfusion rate as well as rate of massive transfusion (MT) were higher in patients with VI compared to AI (BT: 201 (53%) vs. 1120 (46%), FFP: 144 (38%) vs. 766 (32%) and MT: 86 (23%) vs. 396 (16%)) (Table 4).
A multivariable logistic regression model was calculated to evaluate the potential impact of abdominal vascular injury on mortality. Further independent predictors were the RISC II score, massive transfusion, and hospital level of care. In this analysis, isolated VI and isolated AI were significantly related with hospital mortality. Venous trauma showed higher odds ratio for in-hospital mortality (isolate AI: OR: 1.31; 95%CI 1.14–1.50, p < 0.001; isolated VI: OR: 1.48; 95% CI 1.10–1.98, p = 0.010) (Table 5).