• Zane B Perkins, Alexander J Kersey, Joseph M White, Alexis L Lauria, Brandon W Propper, TaiNigel R MNRMCentre for Trauma Sciences, Queen Mary University of London, London, UK.Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK., and Todd E Rasmussen.
• Centre for Trauma Sciences, Queen Mary University of London, London, UK.
• Ann. Surg. 2022 Sep 1; 276 (3): 532538532-538.

IntroductionThe 6-hour threshold to revascularization of an ischemic limb is ubiquitous in the trauma literature, however, contemporary evidence suggests that this threshold should be less. This study aims to characterize the relationship between the duration of limb ischemia and successful limb salvage following lower extremity arterial trauma.MethodsThis is a cohort study of the United States and UK military service members injured while serving in Iraq or Afghanistan between 2003 and 2013. Consecutive patients who sustained iliac, femoral, or popliteal artery injuries, and underwent surgery to attempt revascularization, were included. The association between limb outcome and the duration of limb ischemia was assessed using the Kaplan-Meier method.ResultsOne hundred twenty-two patients (129 limbs) who sustained iliac (2.3%), femoral (56.6%), and popliteal (41.1%) arterial injuries were included. Overall, 87 limbs (67.4%) were successfully salvaged. The probability of limb salvage was 86.0% when ischemia was ≤1 hour; 68.3% when between 1 and 3 hours; 56.3% when between 3 and 6 hours; and 6.7% when >6 hours ( P <0.0001). Shock more than doubled the risk of failed limb salvage [hazard ratio=2.42 (95% confidence interval: 1.27-4.62)].ConclusionsLimb salvage is critically dependent on the duration of ischemia with a 10% reduction in the probability of successful limb salvage for every hour delay to revascularization. The presence of shock significantly worsens this relationship. Military trauma systems should prioritize rapid hemorrhage control and early limb revascularization within 1 hour of injury.Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

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