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A critical appraisal of impact of compounding factors in limb salvage decision making in combat extremity vascular trauma
  1. Amila S Ratnayake1,
  2. M Bala2,
  3. C J Fox3,
  4. A U Jayatilleke4,
  5. S P B Thalgaspitiya5 and
  6. T J Worlton6
  1. 1Department of General Surgery, Army Hospital Colombo, Colombo, Sri Lanka
  2. 2General Surgery and Trauma Unit, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
  3. 3Vascular Surgery, Denver Health Medical Center, Denver, Colorado, USA
  4. 4Postgraduate Institute of Medicine, University of Colombo, Colombo, Western, Sri Lanka
  5. 5Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
  6. 6Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
  1. Correspondence to Dr T J Worlton, General Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; taworlto{at}


Objective For more than half a century, surgeons who managed vascular injuries were guided by a 6-hour maximum ischaemic time dogma in their decision to proceed with vascular reconstruction or not. Contemporary large animal survival model experiments aimed at redefining the critical ischaemic time threshold concluded this to be less than 5 hours. Our clinical experience from recent combat vascular trauma contradicts this dogma with limb salvage following vascular reconstruction with an average ischaemic time of 6 hours.

Methods During an 8-month period of the Sri Lankan Civil War, all patients with penetrating extremity vascular injuries were prospectively recorded by a single surgeon and retrospectively analysed. A total of 76 arterial injuries was analysed for demography, injury anatomy and physiology, treatment and outcomes. Subsequent statistical analysis was performed to evaluate the impact of independent variables to include; injury anatomy, concomitant venous, skeletal trauma, shock at presentation and time delay from injury to reconstruction.

Results In this study, the 76 extremity arterial injuries had a median ischaemic time of 290 (IQR 225–375) min. Segmental arterial injury (p=0.02), skeletal trauma (p=0.05) and fasciotomy (p=0.03) were found to have a stronger correlation to subsequent amputation than ischaemic time.

Conclusions Multiple factors affect limb viability following compromised distal circulation and our data show a trend towards various subsets of limbs that are more vulnerable due to inherent or acquired paucity of collateral circulation. Early identification and prioritisation of these limbs could achieve functional limb salvage if recognised. Further prospective research should look into the clinical, biochemical and morphological markers to facilitate selection and prioritisation of limb revascularisation.

  • vascular surgery
  • trauma management
  • orthopaedic & trauma surgery

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Correction notice This article has been corrected since it first published. Reference 9 has been added to the Introduction section.

  • Contributors ASR: data collection, data analysis, data interpretation, writing. MB: data interpretation, critical revision, literature search. CJF: data interpretation, critical revision. AJ: data analysis, data interpretation, writing. SPBT: data collection, critical revision. TJW: data interpretation, writing, critical revision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.