Vascular surgery after gunshot injury linked to increased morbidity and mortality

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Among all hospitalisations that were due to firearm injury, patients who underwent surgical repair of their major blood vessels had the highest injury severity score (predictor of in-hospital death), a Boston University School of Medicine (BUSM) study found.

One out of 10 patients hospitalised with a firearm injury will need to undergo vascular surgery to repair the damage caused by bullet(s) to major blood vessels. Annually, approximately 88,000 Americans survive gunshot injuries and these injuries vary based on which part of the body was injured, the number of bullets, type of gun etc, which also determines the severity of injury.

Using Nationwide Inpatient Sample data from 1993 to 2014, researchers compared those patients who underwent surgical repair of their major blood vessels with those who did not undergo such repair. They then determined the injury severity score in each group and found that the severity was doubly higher in those who underwent repair surgery. In addition, they found the risk of death increased by five times and complications increased by three times when more than one major blood vessel was injured and repaired.

“Our study found that major blood vessel injuries and their repairs occur when the bullet injures abdomen, pelvis area and/or extremities (legs and arms), when the cause or the intent of the shooting was assault, and to head and neck when the injury was self-inflicted. Complications such as kidney failure, venous thrombo-embolism, sepsis, heart and neurologic related problems were also greater in patients who underwent repair of their major blood vessels,” explained corresponding author Dr Bindu Kalesan, assistant professor of medicine at Boston University School of Medicine (BUSM) and assistant professor of community health services at Boston University School of Public Health (BUSPH).

“Vascular injury due to firearms is very morbid and further understanding these injuries will help, both trauma and vascular surgeons on the front-line, better treat these patients and develop systems for improvements,” said first author Dr Jeffrey Siracuse, associate professor of surgery and radiology at BUSM and a vascular surgeon at Boston Medical Centre.

According to the researchers, with vast improvements in trauma care, greater number of patients with more severe injuries will survive. “However, beyond the initial survival, we do not understand or pause to think about the life long impact of the physical and mental health trauma,” added Kalesan.

The researchers hope this study will encourage new collaborative work between surgeons, emergency medicine physicians, psychiatrists and trauma epidemiologists to build a body of evidence on gun violence survivorship to better inform treatment for gun violence survivors.

Abstract
Objective: Firearm injuries have high morbidity and mortality. Presentation of injuries requiring concurrent vascular repair and its outcomes are unclear. Our study’s objective was to characterize the injury details and to assess the associated mortality and morbidity after vascular repair.
Methods: The National Inpatient Sample was queried from 1993 to 2014 for all firearm injuries. International Classification of Diseases, Ninth Revision codes were used to identify firearm injuries and those who also underwent a vascular repair. Multivariable analysis was used to assess the effect of a concurrent vascular repair on outcomes.
Results: There were 648,662 firearm injuries identified; 63,973 (9.9%) involved a vascular repair. Overall, 88.7% of patients were male, and Medicaid was the most common insurance (40.2%). Intents were assault or legal intervention (60%), unintentional (24.2%), and suicide (8.6%). Patients undergoing vascular repair were younger, more often of black race and male sex, and on Medicaid insurance, with a lower household income and assault/legal intent (P < .005). Patients who underwent vascular repair had a higher frequency of abdomen/pelvis and extremity injuries as well as an elevated New Injury Severity Score (P < .005). Patients with vascular repair were more frequently treated at urban, teaching, and large hospitals (P < .005). Overall mortality rate was 2.2%; patients who underwent vascular repair had a higher mortality compared with those without (5.51% vs 1.98%; P < .001). Patients with vascular repair had higher rates of acute renal failure (3.1% vs 0.8%), venous thromboembolic events (0.5% vs 0.3%), pulmonary-related events (0.6% vs 0.28%), cardiac-related events (0.8% vs 0.2%), sepsis (1.4% vs 0.5%), and any complication (5.7% vs 2%; all P < .0001). Vascular repair was independently associated with mortality (odds ratio [OR], 2.68; 95% confidence interval [CI], 2.43-2.95; P < .0001). Age older than 46 years (OR, 2.01; 95% CI, 1.71-2.35; P < .0001), male sex (OR, 1.15; 95% CI, 1.05-1.25; P = .003), self-pay/no insurance (OR, 1.6; 95% CI, 1.47-1.75; P < .0001), suicide intent (OR, 3.73; 95% CI, 3.36-4.13; P < .0001), unintentional intent (OR, 1.12; 95% CI, 1.03-1.22; P < .0001), head/neck location (OR, 13.9; 95% CI, 12.5-15.6; P < .0001), Northeast region, and New Injury Severity Score >4 were independently associated with in-hospital mortality. Vascular repair was also independently associated with any complication (OR, 2.12; 95% CI, 1.98-2.28; P < .0001).
Conclusions: Firearm injuries with vascular repair were independently associated with higher injury severity score and mortality. A majority of vascular repairs were performed for injury to the abdomen/pelvis and extremity with assault/legal intent, whereas head and neck injury and suicide intent were the least frequent.

Authors
Jeffrey J Siracuse, Thomas W Cheng, Alik Farber, Thea James, Yi Zuo, Jeffrey A Kalish, Douglas W Jones, Bindu Kalesan

Boston University School of Medicine material
Journal of Vascular Surgery abstract


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