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 Table of Contents  
Year : 2022  |  Volume : 29  |  Issue : 4  |  Page : 334-340

Vascular injuries: Aetiology, presentation and management outcomes at a tertiary hospital in Lagos, Nigeria

1 Department of Surgery, Faculty of Clinical Sciences, Cardiothoracic Surgical Unit, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Surgery, Faculty of Clinical Sciences, Neurosurgical Unit, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria

Date of Submission11-Aug-2022
Date of Decision09-Sep-2022
Date of Acceptance06-Oct-2022
Date of Web Publication27-Oct-2022

Correspondence Address:
Ezekiel Olayiwola Ogunleye
Department of Surgery, Faculty of Clinical Sciences, Cardiothoracic Surgical Unit, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi Araba
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_221_22

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Vascular injuries lead to haemorrhagic shock and distal limb ischaemia, especially with an arterial injury. This life-threatening state mandates urgent evaluation and intervention to save life and limbs. The treatment aims to restore blood flow and replace lost blood within the golden hours, stabilising cardiovascular haemodynamics and averting irreversible ischaemic damage. The aim of this study was to analyse the clinical profile of vascular injuries, management and outcomes in our institution. Materials and Methods: This retrospective study covered the period from January 2015 to December 2021. Information of interest were extracted from the medical records of each participant. The results from the data analysis were presented in charts and tables. Results: Seventy-four patients aged 15–78 years (mean 32.30 ± 13.75 years) were included in this study. The male-to-female ratio was 3.6:1. The most common causes were gunshot injury, road traffic accident and iatrogenic injuries. The mean duration from injury to presentation was 9.85 h and mean duration from presentation to restoration of flow was 7.3 h. The most common injured artery was the femoral artery, whereas the most common vein was inferior vena cava. Primary vascular repair was done in majority of the cases. Amputation was performed in 18.9% with loss of viability of the limb. Conclusion: Vascular injury though relatively uncommon remains a challenging and life-threatening disease predominantly in young adult males. Urgent intervention prevents limb loss and mortality. Favourable outcome is accomplished by improving emergency healthcare delivery and well-equipped vascular centres with adequately trained personnel in the nation's hospitals.

Keywords: Amputation, ischaemia, management, vascular injury, vascular repair

How to cite this article:
Ogunleye EO, Olusoji OO, Kanu OO. Vascular injuries: Aetiology, presentation and management outcomes at a tertiary hospital in Lagos, Nigeria. Niger Postgrad Med J 2022;29:334-40

How to cite this URL:
Ogunleye EO, Olusoji OO, Kanu OO. Vascular injuries: Aetiology, presentation and management outcomes at a tertiary hospital in Lagos, Nigeria. Niger Postgrad Med J [serial online] 2022 [cited 2022 Dec 4];29:334-40. Available from: https://www.npmj.org/text.asp?2022/29/4/334/359765

  Introduction Top

Advances in vascular trauma therapy are frequently reported in the context of great eras of conflict or war. Haemorrhage is the most common complication of major vascular trauma, and this is where medieval surgical practice began. Controlling haemorrhage after vascular damage has been a major issue for humans for centuries and major form of management was application of topical treatments such as cautery, bandages and antihaemorrhagic agent that works by contracting tissue to seal injured blood vessels.[1]

Galen started vessel ligation to a manage vascular injury in the second century but this was abandoned; however, Ambroise Pare resurrected it in the 16 century, and this continued till the beginning of the 19th and early 20th centuries when direct vessel repair techniques began. The French surgeon Alex Carrel started end-to-end arterial anastomosis which earned him the Nobel prize in 1912.[1]

The transition from vessel ligation to novel techniques of end-to-end anastomosis, saphenous vein graft interposition was pleasantly highlighted by the reduction in amputation rate in popliteal artery injury in World War 1 from 100% to 32% in the Korean conflict in 1952.[2] The inclusion of arteriography coupled with the improved vascular techniques further reduced the amputation rate to 13% in the subsequent Vietnam war which ended on 30, April 1975.

The arrival of the wounded in battle hospitals was observed to be a determining factor in the successful management of vascular injuries and the Korean war was the first conflict zone to see widespread usage of aeromedical evacuation and casualty arrival times decreased considerably and surgeons successfully handled previously fatal injuries.[3]

Vascular trauma, though rare, constitutes a major health challenge most especially in underdeveloped countries with poor healthcare delivery system. The threat of limb loss or death from exsanguination from vascular injury accounts for the associated clinical apprehension and the need for urgent intervention to stop the haemorrhage and restore blow flow. It is a public health problem commonly seen in men in their third to fourth decade of life.[4]

Vascular injury can be caused by blunt or penetrating mechanism. While blunt trauma is responsible for about half of all trauma deaths, vascular injury from blunt trauma is infrequent and death from blunt vascular injury is even rarer.[5] Penetrating trauma causes the vast majority of vascular injuries, 89% of vascular injuries in the Middle east military conflict were caused by piercing mechanisms such as fragment wounds from bombs (64%) or gunshot wounds (25%).[6] Penetrating trauma is also common in civilian setting, particularly in urban areas, where the frequency can be as high as 90% with gunshot wounds accounting for the majority of cases.[1]

Haemorrhage occurs when all the layers of a vessel are either partially disrupted (lacerations) or circumferentially divided resulting in transection. The resulting bleeding may be controlled by the surrounding tissue thereby creating a haematoma which may or may not be pulsatile. Exsanguination might occur if the bleeding is not tamponaded.

Other immediate repercussions of vascular damage include thrombosis and spasm. When intima is damaged and subendothelial tissues are exposed to the blood circulation, thrombosis ensues. The thrombosis may propagate and obstruct or embolise causing vascular obstruction and distal ischaemia whilst vascular spasm occurs when a vessel is strained or contused and it may cause segmented occlusion.

Pseudoaneurysm and arteriovenous fistula are the two other outcomes of vascular injury which may present on a subacute or chronic basis.[7] There are two types of clinical presentations in patients with vascular injury, those who present with hard signs and those with soft signs of vascular injury. The hard signs include pulsatile bleeding, expanding or pulsatile haematoma, absent distal pulse, signs of distal ischaemia (pain, pallor, pulselessness, paresthesia, poikilothermy and paralysis) and palpable thrill or audible bruit. These signs indicate serious vascular injury with threat of limb loss, therefore, urgent vascular intervention is indicated to control bleeding and restore vascular flow.[8],[9]

The soft signs include stable haematoma, history of pre-hospital haemorrhage, wound in close proximity to know vessel and peripheral nerve deficit. The soft signs need further investigation to establish a detailed diagnosis before definitive intervention.[10]

Investigations commonly done include ankle-brachial index (ABI), colour Doppler ultrasound, computerised tomography angiography (CTA), magnetic resonance angiography and conventional angiography.

The goal of revascularisation is to restore blood flow within the gold hours of 6–8 h beyond which the muscles and nerves may not be able to tolerate the ischaemic injury leading to the onset of myonecrosis.[11] Prolonged ischaemic time before intervention increases the likelihood of reperfusion injury. This is characterised by the development of local and systemic inflammatory response following the restoration of blood flow after a prolonged period of ischaemia. The associated widespread microvascular dysfunction often leads to multiple organ failure syndrome with associated 30%–40% mortality postoperatively in the intensive care unit.[12]

Therefore, intervention should be prompt and immediate to achieve total recovery and avoid limb loss. Treatment modality primarily remains the open traditional approach though endovascular procedures are gaining popularity in the management of vascular injuries. The surgical options include primary repair with end-to-end anastomosis or graft interposition when there is a segmental loss of more than 2 cm in transected vessels. Laceration can be repaired by primary closure or patch repair.

Endovascular procedures when appropriate include coil embolisation and deployment of stents either bare metal stents or covered stents. The management of vascular injuries continues to be very challenging particularly in developing countries where all indices of efficient and adequate healthcare delivery system are grossly deficient in quality and quantity. The purpose of this study was to retrospectively analyse the aetiology, clinical presentation, treatment modalities and outcomes of treatment of vascular injuries in our hospital.

  Patients and Methods Top

This study was a retrospective analysis of all patients with vascular injury who presented to the Accident and Emergency (A and E) Department of the Lagos University Teaching Hospital from January 2015 to December 2021. The patients' parameters assessed from the case notes, theatre registers included age, gender, aetiology of the vascular trauma, named artery or vein affected, mode of presentation, investigations conducted and type of surgical intervention and outcome were analysed. Ethical clearance was sought and obtained from the relevant authorities (ADM/DSCST/HREC/APP/5365).

All statistical analyses were performed using the SPSS software version 20 (IBM Corp. Armonk NY, USA). The continuous variables were presented in mean standard deviation and categorical variables were presented in frequencies (%). The Fischer's exact and Pearson Chi-square tests were used to analyse the categorical variables (P = 0.005).

Each of the patients had a thorough physical examination and resuscitation in accordance with the principles of advanced trauma life support protocols.

We looked for the hard and soft signs of ischaemia with handheld Doppler used to aid in diagnosis and CTA was requested when there was doubt about vascular injury. The decision to proceed with revascularisation or amputation in cases who presented beyond the golden hours of 6–8 h was based on the viability of the distal muscles in the limb, and this is based collectively on the presence or otherwise of hard signs of vascular trauma on clinical examination. Non-viable limbs which are cold, pulseless and insensate or frankly gangrenous are booked for amputation with the consent of the patient. Actively bleeding wounds were controlled by pressure dressings or tourniquet application and urgently transferred to the theatre while resuscitation is ongoing concomitantly.

The incisions for the extremity injuries were longitudinal and based on the location of the injury and made to provide room for proximal and distal control, heparinisation was done systemically and embolectomy was done to achieve free blood flow before anastomosis. Autologous vein graft from the contralateral leg was preferred, but polytetrafluoroethylene (PTFE) graft was used in some cases when the autologous vein graft was unsuitable or not available and the wound was not contaminated.

For concomitant vascular injury and skeletal fractures, bony stabilisation took precedence before vascular repair except in severely ischaemic limb with high risk of loss of viability if vascular intervention was delayed. The threshold for fasciotomy was very low and it was often performed as indicated when the compartmental syndrome was present or anticipated due to the nature of the injury.

Intra-abdominal vascular injuries were approached through a longitudinal midline incision to the peritoneal cavity, the abdominal cavity was cleared of blood and clots and the area of injury identified and clamped with Satiskin vascular clamps before repair.

Cervical penetrating vascular injuries were approached through anterior longitudinal incision anterior to the sternocleidomastoid muscle, clot and blood evacuated with proximal and distal control obtained, vascular repair was performed. All the repaired vessels and interposition grafts were covered with muscle and soft tissues to avoid desiccation.

The procedures were carried out under general anaesthesia with 5000 units of unfractionated heparin administered intravenously before commencement of anastomosis. Pre-operative intravenous antibiotics continued postoperatively for about a week before commencement of oral antibiotics.

Return of distal pulsations in the repaired artery confirms successful repair and this was further confirmed with Doppler examination.

Anticoagulation continued postoperatively with intravenous unfractionated heparin for 5 days postoperatively and thereafter continued with oral antiplatelet agent like aspirin for a month.

Patients with unsalvageable limb were offered amputation at the appropriate level of the extremity.

  Results Top

The patient population was 74 and consisted of 58 males (78.4%) and 16 females (21.6%) with a male-to-female ratio of 3.63:1, with age ranging from 15 to 78 years and a mean age of 32.30 ± 13.75 years. 68.9% (51) of the patients were in economically productive age group of 20–50 years, [Table 1].
Table 1: Socio-demographics characteristics

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Gunshot injuries were the most common cause of vascular injury (31.1%) closely followed by road traffic accident and iatrogenic injury, each accounting for 27% [Figure 1]. Vascular injury was the most common in the lower limbs occurring in 42 cases out of 74 (58.1%), whereas the upper limbs vascular injury cases were 18 (24.1%). Truncal vascular trauma occurred only in the neck in seven cases (9.1%) and abdomen (8.1%). There was no thoracic vascular injury recorded during the study.
Figure 1: Aetiology of vascular injury

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Femoral artery injury occurred in 32 out 74 cases (43.2%) and was the most common injured vessel whilst brachial artery was the second most common vessel occurring in 9 cases (12.2%). Inferior vena cava (IVC) injury occurred in 8.1% of the cases and was the most common venous vascular injury followed by the internal jugular vein (4.1%) [Figure 2]. The mean interval between injury and presentation was 9.85 h (3–26 h) while duration between presentation and restoration of flow ranged from 2.5 to 15 h with a mean of 7.3 ± 3.21 h. Forty-seven patients presented with bleeding (63.5%), 20 patients (27.0%) presented with ischaemic symptoms, three patients each had haematoma and pseudoaneurysms at presentation, constituting 4.1%.
Figure 2: Vessels injured and frequency. AA: Axillary artery, BA: Brachial artery, CA: Carotid artery, EJV: External jugular vein femoral artery, IVC: Inferior vena cava, IJV: Internal jugular vein, PA: Popliteal artery, RA: Radial artery, TA: Tibial artery, UA: Ulnar artery

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The patterns of vascular injuries were transection in 48.6% (n = 36), laceration 37.8% (n = 28), A-V fistula 8.1% (n = 6) and pseudoaneurysm 5.4% (n = 4) fistula. Associated injuries include skeletal fracture in 27.02% (n = 20) and nerve injury occurred in 8.1% (n = 6) [Figure 3].
Figure 3: Patterns of injury

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Fogarty embolectomy was performed routinely to clear the vascular lumen of clots before repair. Vascular repair was done in 47 patients (63.5%) and this included end-to-end anastomosis in 31 patients (41.9%) and lateral arteriography in 16 patients (21.6%), [Figure 4]. Interposition graft was used in 10 cases (13.5%) with reversed saphenous vein graft used in six cases and PTFE graft used in the remaining four cases. Three vessels were ligated with no consequential distal ischaemia having been transected for over 24 h before presentation. All the aneurysms and pseudoaneurysms were excised and the vessels were repaired. Fourteen patients (18.9%) had amputation of the limbs due to loss of viability from prolonged ischaemia resulting from the late presentation. The amputations include two from the upper limb due to brachial artery injury and 12 from the lower limb due to femoral and popliteal arteries injuries. There were 6 mortalities (8.1%) in this study unstable haemodynamics (3 cases) due to injuries IVC and internal jugular vein. Three others had ichaemia-reperfusion injuries due to late presentation and delayed intervention time greater than 10 h.
Figure 4: Treatment modalities

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  Discussion Top

Vascular injury is not common, representing about 0.67% of all patients.[11] It is estimated to have annual incidence of 0.9–2.3/1,00,000 internationally.[13] However, the exact incidence in our country is unknown because of lack of organised systems of documentation and reportage.

In our study population of 74 cases, there were 58 males (78.4%) and 16 females (21.6%) indicating a male preponderance which is consistent with the finding of other authors [Table 1].[14],[15]

The ages of the patients range from 15 to 78 years with a mean of 32.30 ± 13.75 years which is similar to the findings by Garg et al. with a mean of 32.6 years.[16] These findings have shown clearly that vascular injury is predominantly a common occurrence in young men in their third to fifth decades of life and coincidentally, they constitute the bullet of the productive population.

This was clearly shown in our study where 69% of our cases were in the age bracket 20–50 years and the occurrence of vascular injury in predominantly these young men may be because they constitute the productive sector of the populace who ordinarily are expected to be involved in outdoor activities associated with high-risks including vehicular movements and overseeding, industrial activities and penchant for interpersonal violent acts. Majority of these patients are breadwinners in their families and the economic and health impact on the family life and society in general can be burdensome.

In our study, three mechanisms of trauma were identified; penetrating, blunt and iatrogenic. Penetrating vascular injury accounted for 46% of cases and it is the most common mechanism comprising gunshot (31.1%), stab injury (13.5%) and glass cut (1.4%). This is similar to the UK trauma hospital study which also found that penetrating trauma is the comment mechanism accounting for 56% of patients and this also is consistent with other authors findings.[17],[18]

Gunshot injury remains the most common cause of penetrating vascular trauma in our study amongst the civilian population and this may not be unconnected with the rising social vices, substance abuse, massive unemployment and firearms proliferation in our society due to easy access to illegal firearms ownership and shipment from Libya after the violent overthrow of Mu'ammar Gaddafi in 2011.

Other authors have reported blunt vascular injury as more common than penetrating injury in their series and notably ascribing it to the lower incidence of gunshot and stab injuries in their studies.[19]

Perkins et al.[18] observed that penetrating vascular injury is associated with a higher mortality rate and higher rates of limb amputation; however, Davidovic et al.[20] presented a contrary finding which shows that blunt vascular trauma has a greater likelihood of extensive destruction to both vessels and surrounding structures including the main vessel and collateral blood supply leading to higher amputation rates.[20] These contrasting findings can be explained by the wounding agent because the capacity to inflict damage to the tissue depends on the velocity, mass and surface area of the wounding agent and also the nature of the tissue or organ affected.[21]

Iatrogenic injuries (27%) and road traffic accidents (27%) were the second most common cause of vascular injury in our study. Most of these iatrogenic injuries occurred when non-surgical physicians performed vascular cannulations with catheter insertion for renal dialysis most especially during femoral vein cannulation. Only four cases (5.4%) out of the 20 cases (27%) of iatrogenic vascular injury occurred during dissection to excise retroperitoneal neoplasms causing IVC tear.

Both microscopic and macroscopic injuries can occur during iatrogenic vascular trauma. Through the use of scanning electron microscopy, it has been demonstrated that a macroscopically undamaged vessel may have sustained endothelial injury extensively in its ultrastructure. The normal thromboresistant endothelium can be disrupted by vascular clamp, which could convert it to a thrombogenic surface initiating the cascades of events leading to platelet adherence and formation of thrombus.[22] Stemerman et al.[23] demonstrated that the internal elastic lamella is not replaced following healing of endothelial desquamation from crush injury and arterial atheroma has been demonstrated as an end product of endothelial injury.[24]

The presentation of iatrogenic vascular injury includes intimal damage, haematoma, pseudoaneurysm, bleeding and arteriovenous fistula, and the treatment is determined by the target organ perfusion characteristics of the damaged vessel.[25] The incidence of iatrogenic vascular injury is rising and this has been ascribed to the development of catheter-based cardiac and peripheral vascular interventions to manage cardiovascular, renal and other several other organ diseases.[26] These endoluminal procedures increased by 40% between 1996 and 2003[26] and the associated iatrogenic vascular injury is higher with cardiologist (1.3%) and interventional radiologist (0.9%) than vascular surgeons (0.5%).[27] However, in our study, the iatrogenic injury was predominantly caused by nephrologists who canulate the femoral vein for dialysis. The activities of interventional cardiologists and radiologists are very limited in our centre due to the lack of expertise presently in those specialties.

In our study, transection was the most common vascular injury accounting for 48.6% of cases followed by laceration which occurred in 37.8% of cases. Onakpoya et al. also reported complete transection of 67.5% as the most frequent vascular injury in their study.[28]

Extremity vascular injury was the most common in our study and constituted 82.4% of cases, this may be reflecting only hospital incidence because thoracic and abdominal vascular injuries are potentially highly lethal with about 71% dead before arrival at the hospital.[4]

The femoral artery was the most commonly injured vessel in our study accounting for 43.2% followed distantly by brachial artery which occupied 12.2%.

The predominance of femoral artery injury in our study is also corroborated by Perkins et al.[18] and Mattox et al.[4]

Onakpoya et al. reported a contrary finding in their study with brachial artery injury as the most common (36.5%), followed by femoral artery injury (22.4%).[28] The predominance of femoral artery injury in our study and others[4],[18] is most probably because the femoral vessels are the most commonly used for percutaneous vascular procedures for both diagnosis and therapeutic procedures and iatrogenic injuries in our study occurred mainly in the femoral artery due to the regular attempted cannulation of the femoral vein for the insertion of dialysis catheter by non-surgical physicians with subsequent injury to the artery.

Most of the cases in our study presented with bleeding (63.5%) and ischaemia (27.0%) and this finding was corroborated by Shah et al.[29] where bleeding and ischaemia occurred in 50% and 16.6%, respectively in their study. Bleeding expectedly dominates the clinical presentation of vascular injury; however, the consequences of bleeding, particularly haemorrhagic shock, limb loss or outright mortality mandate urgent intervention. Bleeding, distal ischaemia and other signs constitute the hard signs of vascular injury which indicate a very high probability of vascular injury requiring immediate surgical intervention without pre-operative contrast studies.[30] All the patients that presented with hard signs in our study had immediate exploration without pre-operative imaging except those cases which presented very late and were deemed irreversibly ischaemic and will not benefit from surgical restoration of blood flow.

Patients whose presentations were devoid of hard signs were investigated, and the main imaging technique was CTA (CT angiogram). This is much favoured over ABL index and Doppler studies because of its anatomically detailed visualisation of vessels which aids to localise the site of injury and guide treatment strategies. CTA is currently the first line and preferred assessment of a vascular injury in patients with suspected vascular injury, it provides a rapid, non-invasive and accurate method of detecting vascular trauma.[31] CTA can also be used postoperatively to detect any graft failure in patients with post-operative ischaemic presentation.

The routine use of non-invasive vascular evaluation methods such as Duplex scanning and ABI was jettisoned in our study because of our preference for more precise diagnostic technique like CTA which has high-resolution imaging useful for management planning. We also share the view of Meissner et al. that Doppler USS is operator dependent and may be technically difficult to carry out in patients with open wounds.[32]

The goals of managing vascular trauma are centred on prompt arrest of further haemorrhage, resuscitation and timely restoration of vascular flow. To restore blood flow, a variety of surgical techniques have been used and the repair technique will be determined by the extent of the vascular injury. Open surgical techniques were used in all our cases with vascular repair dominating in 63.5% of cases. Lacerations were repaired laterally, and when more than 50% luminal narrowing occurred after a repair, the affected segment should be resected followed by end-to-end tension-free anastomosis. Autologous venous graft was preferred to PTFE graft, because of its increased resistance to infection most especially in contaminated wounds, its availability and superior patency rates over time.

Endovascular therapy for the treatment of vascular trauma is gaining acceptance gradually and has become an important treatment option in the last few years. Endovascular procedures have been found appropriate for patients who sustain injury in difficult anatomic location where open procedure is very difficult and prone to risk of iatrogenic injuries during surgical exposure.[33] The advantages of endovascular techniques include reduced operating time, minimal estimated blood loss and reduced risk of iatrogenic injury; however, its seemingly very expensive compared to open technique.[34]

Endovascular interventions currently in trauma include balloon occlusion and embolisation for bleeding and deployment of covered stents or coil embolisation for the exclusion of pseudoaneurysm and arteriovenous fistulas.[33] In the present study, endovascular intervention was not performed on any of the patients due to the lack of necessary facilities.

Starnes and Bruce[35] believed that 95% of limb salvage rate can be achieved in contemporary times by early surgical intervention and restoration of flow; however, in our study, our limb salvage rate was 81% which equates to 19% limb loss rate, more than thrice the expected international standard and in assessing amputation risk in our study, the mangled extremity severity score index was used. The reasons accounting for a much higher rate of limb loss include delayed presentation at our centre and logistical delay in surgical intervention and revascularisation due to logistical encumbrances in sourcing for consumables needed for surgery including blood and blood products. These are obviously indices of poor healthcare delivery as obtained in a developing nation like ours.

The mortality rate in our study was 8.1% and unstable cardiovascular haemodynamics at presentation due to massive blood loss most especially due to injuries to truncal blood vessels like IVC internal jugular veins were major risk factors.

Another cause of death in our study was ischaemia-reperfusion injury which accounted for three cases out of the six cases that died. The reperfusion injury culminated in multiple organ failure and subsequent death of the patients. These three cases had restoration of blood flow after more than 10 h of arterial transection and restoration of blood flow after a prolonged period of ischaemia may be detrimental to the patient and constitute a major risk factor for reperfusion injury. Attempts at managing ischaemia-reperfusion injury include ischaemic pre-conditioning, ischaemic post-conditioning and pharmacological treatment which may be effective in attenuation.

The limitations of our study include the fact that a retrospective study in a region with poor documentation and data storage could make it impossible to retrieve all data for cases managed in the period of study, leading to fewer cases in this study. A trauma registry will meet these needs.

  Conclusion Top

Vascular trauma although it is a disease of low incidence, management to reduce limb loss or mortality remains a challenge to the vascular surgeon in developing nations like ours with poor health infrastructure due to late presentation and numerous logistical challenges precluding successful outcome. Every effort should be made to achieve restoration of vascular flow within 6 h of injury either by endovascular technique or open surgery. Iatrogenic vascular injuries most especially by physicians who insert dialysis catheters can be reduced drastically by encouraging proper training programmes for skill acquisition.

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Conflicts of interest

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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