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Vol 17, No 1-2 (2015)
Original articles
Published online: 2016-06-30
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Fasciotomy as an element of treatment in acute lower limb ischemia syndrome and reperfusion syndrome

Dariusz Stańczyk, Damian Ziaja, Jacek Kostecki, Wojciech Żelawski, Krzysztof Ziaja
Chirurgia Polska 2015;17(1-2):7-22.

open access

Vol 17, No 1-2 (2015)
Original articles
Published online: 2016-06-30

Abstract

Background. Acute ischemia of the lower limbs and reperfusion syndrome may be complicated with acute compartment syndrome of the lower limbs. The treatment of choice is then fasciotomy. Inadequate treatment may lead to dangerous and life-threatening complications, including death. The aim of this study was the analysis of fasciotomy, as an element of treatment of acute ischemia of the lower limb and reperfusion syndrome.

Material and methods. Analysis of 173 patients (30 women and 143 men) was performed. The patients were treated within 10 years in the Department of General and Vascular Surgery, Angiology and Phlebology in Katowice because of acute ischemia of the lower limbs or reperfusion syndrome and which had the fasciotomy performed using Patman’s method. Additionally, partial analysis of 1,880 patients hospitalized in the same time due to acute ischemia of the lower limbs was also performed. This patients had not been subjected to fasciotomy. Patients were divided into two groups: I — the cause of acute ischemia was vascular injury, II — the causes of acute ischemia were peripheral vascular diseases (PVD).

Results. Patients with fasciotomy on admission were qualified to 2a and 2b degree of ischemia, whereas without fasciotomy to 1 and 2a. The most frequent cause of ischemia in group with fasciotomy was occlusion of vascular prosthesis — 29.5%, while vascular injury was present in 16.2%; the group without fasciotomy the most frequent cause was arterial embolus which occurred in 43.6%, while vascular injury was present in 7%. The main indications for fasciotomy in group with vascular injury were injury of popliteal vessels and fracture of bones of crus; whereas in group with diseases of peripheral blood vessels the main indications were swelling of the limb, local tenderness on palpation of the crus and prolonged time of ischemia by over 6 hours. The mean duration of ischemia after vascular injury was on the level 6.75 hours and in the patients with other PVD reached 30 hours. Fasciotomy was the most frequently performed during revascularization procedures — in case of injury or in distant day after revascularization — in case of diseases of peripheral blood vessels. The lack of improvement with the necessity of amputation occurred in 35.8% of injured patients and 38.6% of PVD. There was not any death within the group with vascular injury, whereas in the group of diseases of peripheral blood vessels mortality rate was on the level of 10.3%, and the main causes of death were acute myocardial infarction and acute circulatory insufficiency.

Conclusions. Compartment syndrome in acute lower limb ischemia is a dangerous, limb-threatening and in case of inadequate treatment also life-threatening condition, with the risk of amputation on the level of 35–39% and mortality rate on the level of 10%. Compartment syndrome in acute lower limb ischemia due to vascular injury has similar risk of limb amputation as in diseases of peripheral blood vessels but has lower risk of death. Early fasciotomy in relation to revascularization procedure decreases the risk of amputation. Indications for fasciotomy still remain unclear and mainly are based on knowledge and experience of vascular surgeon. Complexity of issue of acute limb ischemia, vascular injuries, bone injuries and often poor general condition order to treat these patients in highly specialized centers in multispecialty teams with continuous access to laboratory and specialist imaging diagnostics.

Abstract

Background. Acute ischemia of the lower limbs and reperfusion syndrome may be complicated with acute compartment syndrome of the lower limbs. The treatment of choice is then fasciotomy. Inadequate treatment may lead to dangerous and life-threatening complications, including death. The aim of this study was the analysis of fasciotomy, as an element of treatment of acute ischemia of the lower limb and reperfusion syndrome.

Material and methods. Analysis of 173 patients (30 women and 143 men) was performed. The patients were treated within 10 years in the Department of General and Vascular Surgery, Angiology and Phlebology in Katowice because of acute ischemia of the lower limbs or reperfusion syndrome and which had the fasciotomy performed using Patman’s method. Additionally, partial analysis of 1,880 patients hospitalized in the same time due to acute ischemia of the lower limbs was also performed. This patients had not been subjected to fasciotomy. Patients were divided into two groups: I — the cause of acute ischemia was vascular injury, II — the causes of acute ischemia were peripheral vascular diseases (PVD).

Results. Patients with fasciotomy on admission were qualified to 2a and 2b degree of ischemia, whereas without fasciotomy to 1 and 2a. The most frequent cause of ischemia in group with fasciotomy was occlusion of vascular prosthesis — 29.5%, while vascular injury was present in 16.2%; the group without fasciotomy the most frequent cause was arterial embolus which occurred in 43.6%, while vascular injury was present in 7%. The main indications for fasciotomy in group with vascular injury were injury of popliteal vessels and fracture of bones of crus; whereas in group with diseases of peripheral blood vessels the main indications were swelling of the limb, local tenderness on palpation of the crus and prolonged time of ischemia by over 6 hours. The mean duration of ischemia after vascular injury was on the level 6.75 hours and in the patients with other PVD reached 30 hours. Fasciotomy was the most frequently performed during revascularization procedures — in case of injury or in distant day after revascularization — in case of diseases of peripheral blood vessels. The lack of improvement with the necessity of amputation occurred in 35.8% of injured patients and 38.6% of PVD. There was not any death within the group with vascular injury, whereas in the group of diseases of peripheral blood vessels mortality rate was on the level of 10.3%, and the main causes of death were acute myocardial infarction and acute circulatory insufficiency.

Conclusions. Compartment syndrome in acute lower limb ischemia is a dangerous, limb-threatening and in case of inadequate treatment also life-threatening condition, with the risk of amputation on the level of 35–39% and mortality rate on the level of 10%. Compartment syndrome in acute lower limb ischemia due to vascular injury has similar risk of limb amputation as in diseases of peripheral blood vessels but has lower risk of death. Early fasciotomy in relation to revascularization procedure decreases the risk of amputation. Indications for fasciotomy still remain unclear and mainly are based on knowledge and experience of vascular surgeon. Complexity of issue of acute limb ischemia, vascular injuries, bone injuries and often poor general condition order to treat these patients in highly specialized centers in multispecialty teams with continuous access to laboratory and specialist imaging diagnostics.

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Keywords

fasciotomy, compartment syndrome, reperfusion syndrome, acute ischemia of the lower limbs

About this article
Title

Fasciotomy as an element of treatment in acute lower limb ischemia syndrome and reperfusion syndrome

Journal

Chirurgia Polska (Polish Surgery)

Issue

Vol 17, No 1-2 (2015)

Pages

7-22

Published online

2016-06-30

Bibliographic record

Chirurgia Polska 2015;17(1-2):7-22.

Keywords

fasciotomy
compartment syndrome
reperfusion syndrome
acute ischemia of the lower limbs

Authors

Dariusz Stańczyk
Damian Ziaja
Jacek Kostecki
Wojciech Żelawski
Krzysztof Ziaja

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