From the Society for Clinical Vascular Surgery

Existing trauma and critical care scoring systems underestimate mortality among vascular trauma patients

Shang A. Loh, MD, Caron B. Rockman, MD, Christine Chung, BS, Thomas S. Maldonado, MD, Mark A. Adelman, MD, Neal S. Cayne, MD, H. Leon Pachter, MD, and Firas F. Mussa, MD, New York, NY

Background: The impact of vascular on patient mortality has not been well evaluated in multi-trauma patients. This study seeks to determine (1) whether the presence of vascular trauma negatively affects outcome compared with nonvascular trauma (NVT) and (2) the utility of existing severity scoring systems in predicting mortality among vascular trauma (VT) patients. Methods: A retrospective review of our trauma database from January 2005 to December 2007 was conducted. Demographics, Severity Scores (ISS), Revised Trauma Scores (RTS), Trauma Score–Injury Severity Scores (TRISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and mortality rates were compared. Control patients were selected from a matching cohort based on ISS. Comparisons were made between groups based on the above scoring systems. Statistical analysis used ␹2 analysis and Student t-tests. Results: Fifty VT and 50 NVT patients were identified with no significant differences in age, gender, mechanism of injury, ISS, RTS, or TRISS. The mean APACHE II score was higher in VT compared with NVT (12.3 vs 8.8, P < .05). Overall VT .(108. ؍ mortality was higher in VT compared with NVT but did not reach statistical significance (24% vs 11.8%, P VT patients with an ISS score >24 had .(007. ؍ patients with RTS score >5 had a higher mortality rate (26% vs 2.2%, P VT patients with an APACHE II score <14 also .(04. ؍ a higher mortality compared with NVT patients (61% vs 28.6%, P Finally, VT patients with a TRISS probability of survival of >80% .(007. ؍ had a higher mortality rate (18.2% vs 0%, P .(05. ؍ had a higher mortality rate (13.9% vs 0%, P Conclusions: In multi-trauma patients, the presence of vascular injury was associated with increased mortality in less severely injured patients based on the RTS, TRISS, and APACHE II scores. These scoring systems underestimated mortality in patients with vascular trauma. Level of care and future trauma algorithms should be adjusted in the presence of vascular trauma. (J Vasc Surg 2011;53:359-66.)

Trauma is the leading cause of mortality in the first four ters to determine injury severity,8-10 have not been vali- decades of life.1 While the epidemiology and outcomes of dated specifically for vascular trauma. The aim of this study nonvascular trauma have been well studied, vascular trauma was to examine mortality in patients with vascular trauma at has not been well characterized outside of the military an urban level I compared with patients with 1, 2 experience. More than 10 years ago, Caps reported that nonvascular trauma and matching Injury Severity Scores the incidence of vascular trauma had significantly increased (ISS). Furthermore, we sought to evaluate the usefulness of over the previous 5 decades, contributing to overall trauma common injury severity scoring systems in predicting mor- morbidity and mortality.2 Furthermore, studies have tality for patients with vascular injuries. shown that abdominal vascular trauma has been associated with higher overall mortality and poorer functional out- METHODS comes than seen in the general trauma population.3-7 Study design. A retrospective analysis of the trauma However, none of these studies matched patients based on database from January 2005 to December 2007 at an urban severity of injury. In addition, current trauma scoring sys- level I trauma center was conducted. Vascular trauma (VT) tems, which utilize either physiologic or anatomic parame- patients were identified based on International Classifica- tion of Disease–9 (ICD-9) diagnoses codes and repre- From the New York University School of Medicine, Department of Surgery, sented all vascular trauma for this time frame. A contempo- Division of Vascular and Endovascular Surgery. Competition of interest: none. rary cohort of multi-trauma patients with nonvascular Presented at the Thirty-eighth Annual Symposium of the Society for Clinical trauma (NVT) and matching ISS was selected as a control Vascular Surgery, April 7-10, 2010, Scottsdale, Ariz. group. The study was approved by the Institutional Review Reprint requests: Firas F. Mussa, MD, Division of Vascular and Endovascu- Board. Parameters collected included: age, sex, vital signs, lar Surgery, New York University Langone Medical Center, 530 First Avenue, Suite 6F, New York, NY 10016 (e-mail: fi[email protected]). Glasgow Coma Scale (GCS), mechanism of injury, location The editors and reviewers of this article have no relevant financial relation- and severity of injury, mode of diagnosis, need for a vascular ships to disclose per the JVS policy that requires reviewers to decline consult, need for vascular intervention, and mortality. Vas- review of any manuscript for which they may have a competition of cular injury severity was graded on a 5-point scale which interest. was a slightly modified version of the original Abbreviated 0741-5214/$36.00 11-13 Copyright © 2011 by the Society for Vascular Surgery. Injury Score (AIS) described by Moore et al. Injury doi:10.1016/j.jvs.2010.08.074 severity ranged from 1 (minor), 2 (moderate), 3 (severe), 4 359 JOURNAL OF VASCULAR SURGERY 360 Loh et al February 2011

(critical), to 5 (unsurvivable).Outcome was also graded on .05 was considered significant. Receiver operator characteris- a 5-point scale from 1 (return to baseline function), 2 (mild tic curves (ROC) were constructed to test the discriminatory functional deficit), 3 (moderate functional deficit), 4 (se- ability of all four trauma scoring systems. The area under the vere functional deficit), to 5 (death). In addition, the curve (AUC) or C-statistic was calculated to determine con- Revised Trauma Score (RTS), Trauma Score–Injury Sever- cordance or discordance. Statistical analysis was performed ity Score (TRISS), and Acute Physiology and Chronic using SPSS statistical software (SPSS, Chicago, Ill). Health Evaluation II (APACHE II) score were calculated based on admission parameters. RESULTS The primary end point was overall mortality. The pre- Patient characteristics. During the study period, a to- dicted mortality based on ISS, RTS, TRISS, and APACHE tal of 2157 patients were evaluated by the trauma service. Fifty II scores was also compared with actual mortality. patients (2.3%) with vascular trauma were identified during Diagnosis of vascular injuries. Upon admission to the study period with an additional 50 ISS-matched, nonvas- the trauma bay, Advanced Trauma Life Support (ATLS) cular trauma patients as controls. Both groups were similar in protocols were observed. All vascular injuries were diag- age and gender. Mechanism of injury was slightly different nosed within the initial hours in the trauma bay or operat- between the two groups but not statistically significant. In the ing room. Clinical suspicion or proximity injuries were VT group, penetrating and pedestrian struck mechanisms evaluated with computed tomography angiogram (CTA). accounted for 38 (75%) of the injuries while the mechanism in Blunt injuries with suspicion of vascular injury were evalu- the NVT group was more evenly distributed (Table I). ated with duplex ultrasonography when anatomically feasi- In the VT group, 13 (26%) had more than one vascular ble during the day and CTA at night. Hard clinical findings injury and 36 (72%) had an injury to a major vascular struc- of vascular injury were evaluated in the operating room ture. Arterial injuries accounted for 42 (82%) of vessels in- (OR) with traditional angiogram or in the interventional volved. Diagnosis was made on clinical grounds in 20 (40%) radiology (IR) suite for pelvic injuries. The APACHE II, and found on angiogram in 23 (46%). The remaining seven RTS, and TRISS trauma scores were calculated from lab (14%) were diagnosed on computed tomography angiogra- values and vital signs upon initial presentation in the trauma phy (CTA) or duplex ultrasound. Thirty-five (70%) patients bay. The ISS system, however, is an anatomic system and had severe to critical injuries posing an imminent danger to the score calculated after injuries was diagnosed. the patient’s life. Patient characteristics are summarized in Calculation of trauma scores. Calculation of the scor- Table I. ing systems has been previously described. Briefly, for the ISS, Vascular surgery consultation. Operative vascular AIS from 1 (minor) to 5 (critical) is assigned to the most intervention was indicated in 28 (56%) patients. Of those, a severe injury in each of six anatomic regions (head and neck, vascular surgeon was involved in 22 (79%). In the remain- face, chest, abdomen, extremity, and external).11-13 If any ing 6 (21%), the injury was repaired primarily by the trauma injury is deemed unsurvivable, it is assigned a value to 6. The service. Injuries repaired by the trauma service involved the top three injuries are squared and summed to calculate the inferior vena cava, portal vein, anterior jugular vein, com- ISS, which can range from 3 (best) to 75 (worst). A score of 6 mon carotid artery, and radial artery. Only two patients in any category automatically gives an ISS of 75.8 (7%) were treated with endovascular techniques precluding The RTS is calculated by assigning a value of 0 (worst) to any meaningful analysis. Both cases were aortic transections 4 (best) to the GCS, systolic blood pressure (SBP), and with placement of a thoracic endograft. Furthermore, the respiratory rate (RR). The score is calculated based on a mortality rate of VT patients requiring operative interven- weighted formula with GCS carrying the most weight fol- tion was 28.6% compared with 18.2% for those VT patients lowed by SBP. The score ranges from 0 (worse) to 7.84 (best) not requiring an operation (P ϭ .512). While the overall and the resultant survival curve is logarithmic.9 Unlike the rate for a vascular surgery consult was 58% (29 patients), other systems, higher RTS scores indicated less severity. that rate increased as injury severity increased. Vascular The APACHE II score was calculated by obtaining 14 surgery consult was obtained in 3/9 (33%) patients with physiologic and laboratory parameters and assigning a value moderate, 8/13 (62%) severe, and 18/22 (82%) with based on deviation from normal. The values are summed to critical injury severities. Those patients with minor or un- achieve the final score. The score ranges from 0 (best) to 75 survivable injuries did not involve a vascular surgeon. (worst) and the resultant survival curve is logarithmic.10 Outcomes and mortality. There was no significant The TRISS score was calculated by utilizing the ISS and difference observed in functional outcome between the two RTS scores in a predetermined equation that takes into groups at the time of discharge (Table I). There was a trend account the age of the patient and whether the injury was toward higher mortality in the VT group compared with the blunt or penetrating. The resultant score is then used to NVT group (24% vs 12%, P ϭ .108, Fig 1). The number of calculate the probability of survival.14 vascular injuries did not appear to impact mortality (single Statistical analysis. Means, standard deviations, and/or 23.08% vs multiple 24.32%, P ϭ .6); however, the vessel standard errors of the mean were calculated. Continuous involved, type, and location of the vascular injuries were not variables were analyzed using Student t test and categorical substratified. variables were analyzed using ␹2 with continuity correction The mortality rates for each of the mechanisms of and Fisher exact tests for smaller samples. A P value less than injuries were also examined to exclude the possibility of JOURNAL OF VASCULAR SURGERY Volume 53, Number 2 Loh et al 361

Table I. Comparison of vascular and nonvascular trauma patients

Vascular trauma Nonvascular trauma P value

Total patients 50 50 Age 37.5 Ϯ 17.7 42.8 Ϯ 17.7 .129 Gender .128 Male 36 (72%) 43 (85%) Female 14 (28%) 7 (14%) Mechanism of injury .420 Gun shot wound 9 (18%) 5 (10%) 11 (22%) 12 (24%) Pedestrian struck 18 (36%) 12 (24%) Motor vehicle crash 2 (4%) 6 (12%) Fall from height 7 (14%) 12 (24%) 3 (6%) 3 (6%) Multiple vascular injuries Yes 13 (26%) n/a No 37 (74%) n/a Injury location Intracranial 3 (6%) n/a Neck 4 (8%) n/a Chest 5 (10%) n/a Abdomen 13 (26%) n/a Pelvis 11 (22%) n/a Upper extremity 6 (12%) n/a Lower extremity 8 (16%) n/a Vessel type Artery 41 (82%) n/a Vein 8 (16%) n/a Both 1 (2%) n/a Type of injury Laceration 21 (42%) n/a Transection 13 (26%) n/a Dissection pseudoaneurysm 5 (10%) n/a Spasm 2 (4%) n/a Thrombosis 2 (4%) n/a Fistula 1 (2%) n/a External hematoma 4 (8%) n/a Compression 2 (4%) n/a Severity of injury Minor 4 (8%) n/a Moderate 9 (18%) n/a Severe 13 (26%) n/a Critical 22 (44%) n/a Unsurvivable 2 (4%) n/a Mode of diagnosis Clinical 20 (40%) n/a Angiogram 23 (46%) n/a CT scan 5 (10%) n/a Duplex 2 (4%) n/a Vascular consult Yes 29 (58%) n/a No 21 (42%) n/a Operation required for vascular injury Yes 28 (56%) n/a No 22 (44%) n/a Outcome .378 Baseline function 11 (22%) 14 (28%) Mild functional deficit 17 (34%) 22 (44%) Moderate functional deficit 7 (14%) 4 (8%) Severe functional deficit 3 (6%) 4 (8%) Death 12 (24%) 6 (12%) .108 increased mortality in the VT trauma as a result of the found more often in NVT patients. However, the pedes- mechanism of injury. In the VT patients, gunshot wounds trian struck and falls from height both carried high mortal- and the pedestrian struck mechanism were more prevalent ity rates (26.32% and 26.67%) while gunshot wounds and while falls from height and motor vehicle accidents were motor vehicle accidents carried low mortality rates (7.14% JOURNAL OF VASCULAR SURGERY 362 Loh et al February 2011

Fig 1. Overall mortality between vascular and nonvascular trauma.

Table II. Trauma scoring systems in vascular and nonvascular trauma patients with predicted mortality

Vascular trauma Predicted Nonvascular trauma Predicted Mean Ϯ SEM mortality Mean Ϯ SEM mortality P value

Injury Severity Score (ISS) 24.22 Ϯ 1.8 14.3% 25.47 Ϯ 1.86 15.6% .630 Revised Trauma Score (RTS) 6.64 Ϯ 0.26 4.0% 7.06 Ϯ 0.21 3.0% .209 APACHE II score 12.26 Ϯ 1.28 15.1% 8.75 Ϯ 1.18 9.6% .046 TRISS 0.811 Ϯ 0.082 18.9% 0.842 Ϯ 0.107 15.8% .283

APACHE II, Acute Physiology and Chronic Health Evaluation II; TRISS, Trauma Score–Injury Severity Scores. and 12.5%). The prevalence of mechanisms of injury carry- The predicted mortality was 4% (VT) and 3% (NVT). In the ing high mortality was evenly distributed between VT and subset of patients with greater than 80% predicted survival NVT patients. (RTS Ͼ5), the presence of vascular injuries was associated Trauma scoring systems and mortality. The ISS, with significantly higher mortality (26.2% vs 2.2%, P ϭ .007, RTS, APACHE II, and TRISS scores were calculated to Fig 3). The predicted mortality of 4% was less than the actual determine the predicted mortality in the presence or ab- mortality of 24% in the VT group. The mean RTS for VT sence of VT and to validate their usefulness and accuracy in fatalities was significantly more favorable than in the NVT predicting mortality. group (6.2 Ϯ 0.6 vs 3.8 Ϯ 0.5, P ϭ .01, Fig 4) which is an . By design, the two groups were underestimation of severity of injury in the presence of VT. matched based on ISS; therefore, there was no difference in APACHE II score. The APACHE II scores were the mean ISS between the two groups (24.2 Ϯ 1.8 vs 25.5 Ϯ significantly different between the VT and NVT groups 1.9, P ϭ .63, Table II). Based on these scores, the composite (12.3 Ϯ 1.3 vs 8.8 Ϯ 1.2, P ϭ .05, Table II). This predicted mortality, adjusted for age, was 14.3% (VT) and correlated to a predicted mortality of 15.1% (VT) and 9.6% 15.6% (NVT). However, the actual mortality of 24% in the (NVT). Nevertheless, this was still markedly lower than the VT group was higher than predicted. There appeared to be a actual mortality of 24% in VT. The mean APACHE II score trend toward a lower mean ISS for VT fatalities compared for VT fatalities was significantly lower compared with the with NVT (37.83 Ϯ 4.49 vs 47.33 Ϯ 6.68, P ϭ .13, Fig 2). NVT group (17.0 Ϯ 2.4 vs 25.8 Ϯ 2.2, P ϭ .02, Fig 5), For the less severely injured patients (ISS Ͻ30, Ͼ80% pre- which again underestimates the injury severity in VT pa- dicted survival), the VT group had a higher mortality but this tients. For those patients with less severe injuries and pre- did not reach statistical significance (10.8% vs 3%, P ϭ .17, Fig dicted survival of greater than 80% (APACHE II Ͻ 14), the 3). Interestingly, for those with a predicted mortality greater actual mortality was statistically higher in the VT group than 15%, VT carried a significantly higher mortality than (18.2% vs 0%, P ϭ.02, Fig 3). NVT (61% vs 29%, P ϭ .04). Trauma score–injury severity score. The TRISS Revised trauma score. The RTS was similar between mean calculated probability of survival was similar between the two groups (6.6 Ϯ 0.3 vs 7.0 Ϯ 0.2, P ϭ.21, Table II). the two groups (0.811 Ϯ 0.082 vs 0.842 Ϯ 0.107, P ϭ .28, JOURNAL OF VASCULAR SURGERY Volume 53, Number 2 Loh et al 363

Fig 2. Mean injury severity score of fatalities between vascular trauma and nonvascular trauma.

Fig 3. Mortality in patients with greater than 80% predicted survival.

Table II). The predicted mortality was 18.9% (VT) and systems. The AUC of the ISS was 0.870 with a 95% CI of 15.8% (NVT). In the subset of patients with greater than 0.746-0.993. The APACHE II and TRISS scoring systems 80% predicted survival (TRISS Ͼ 0.800), the presence of had similar AUC of 0.758 (95% CI, 0.626-0.889) and vascular injuries was associated with significantly higher mor- 0.786 (95% CI, 0.641-0.932). The RTS had an AUC of tality (13.9% vs 0%, P ϭ .05, Fig 3). The predicted mortality of 0.618 (95% CI, 0.432-0.805). 18.9% was less than the actual mortality of 24% in the VT group. The mean TRISS for VT fatalities was significantly DISCUSSION more favorable than in the NVT group (0.659 Ϯ 0.096 vs Despite the steady increase in vascular trauma over the 0.240 Ϯ 0.08, P ϭ .002, Fig 6), which is an underestimation past five decades, major vascular injuries still represent a of severity of injury in the presence of VT. small percentage of traumatic injuries1, 2 and little is known ROC analysis. An ROC analysis of all four scoring about the epidemiology of vascular trauma outside of the systems showed that ISS was better than APACHE II and military experience.1,2 Furthermore, vascular injuries lead TRISS in predicting mortality in vascular trauma patients to increased utilization of medical resources.2 In fact, pa- (Table III). The RTS fared poorly compared with the other tients with VT have the highest utilization of medical JOURNAL OF VASCULAR SURGERY 364 Loh et al February 2011

Fig 4. Mean revised trauma score of fatalities between patients with vascular trauma and nonvascular trauma.

Fig 5. Mean APACHE II score of fatalities between patients with vascular trauma and nonvascular trauma. resources among trauma patients.2 A key limitation to vascular operative intervention involved a vascular surgeon. previously published studies is the lack of comparison with Future studies will better assess the emerging role of endo- similarly injured NVT patients. vascular treatments in trauma patients. Since the initial studies, major advances have been Our finding that VT patients have higher mortality rates made in pre-hospital treatment, rapid hospital transport, compared with NVT (24% vs 12%) is consistent with a prior , and .15-17 All of these factors have led to report by Galindo et al who showed a mortality of 20.8% in improved survival of patients with vascular injuries.16 At VT patients compared with 4.5% in NVT patients.18 The our institution a vascular surgeon was involved in 75% of higher mortality of the NVT group in our study is attributable patients with severe to critical injuries. Vascular surgery was to the matching of ISS with the VT group. The ISS of the not involved in those patients with minor or unsurvivable NVT group was 8.4 in the Galindo study compared with 25.5 injuries. Furthermore, almost 80% of patients requiring in this study. Other studies of vascular trauma, such as the JOURNAL OF VASCULAR SURGERY Volume 53, Number 2 Loh et al 365

Fig 6. Mean TRISS score of fatalities between patients with vascular trauma and nonvascular trauma.

Table III. Receiver operator characteristic curves C- vival) almost all of the mortalities were in vascular trauma statistic for trauma scoring systems in vascular trauma patients. This clearly highlights the fallacies of the scoring patients systems causing an underappreciation of severity in VT patients with a lower calculated trauma score. C-statistic 95% confidence The ROC analysis performed on the scoring systems Trauma scoring system (AUC) interval also supported the conclusions that these scoring systems Injury Severity Score (ISS) 0.870 0.746-0.993 were not ideal to predict mortality in VT patients. The ISS Revised Trauma Score (RTS) 0.618 0.432-0.805 was the best of the four systems tested with an AUC of APACHE II score 0.758 0.0626-0.0889 0.870, which makes it an adequate, but not superb, trauma TRISS 0.786 0.641-0.932 scoring system for VT patients. The TRISS and APACHE APACHE II, Acute Physiology and Chronic Health Evaluation II; TRISS, II systems had AUCs of 0.786 and 0.758 indicating that Trauma Score–Injury Severity Scores. these studies are not ideal for use in vascular trauma pa- tients. Finally, the RTS had an AUC of 0.618 making it a completely inadequate scoring system for VT patients. large urban study by Mattox in 1998,16 did not utilize a Closer examination of physiologic scoring systems such control cohort with matched injury severity. as the RTS, APACHE II, and TRISS reveal that GCS The traditional trauma scoring systems such as the ISS, carries more weight in determining the score than any other RTS, and TRISS were designed to predict mortality calcu- factor. In the RTS system GCS carries 30% more weight lated across the entire spectrum of trauma patients.8,9 Sim- than SBP. In the APACHE II system GCS accounts for ilarly, the APACHE II score is even broader as a measure of 16% of the total possible points and combined with age, critically ill patients regardless of mechanism.10 All four both make up almost 30%. The heavy weight of neurologic systems failed to accurately predict mortality in the VT parameters may explain the lack of utility of these systems group (14.3% [ISS], 4% [RTS], 15.1% [APACHE II], and when applied to VT patients. Anatomic scoring systems 18.9% [TRISS] vs 24% [actual]). The TRISS scoring sys- such as the ISS may suffer from an inability to recognize tems was the most accurate in predicting mortality in the injury to vascular structures without advance imaging. In VT patients but still underestimated the actual mortality. addition, grading of injury severity is subjective and may The ISS, APACHE II, and TRISS systems were reasonably vary based on provider. In all cases, initial assessment may accurate in predicting mortality in NVT patients (15.6%, not be accurate and physiologic parameters specific to 9.6%, and 15.8% vs 11.8%). The increased mortality of hemorrhage should be evaluated. An accurate scoring sys- vascular trauma patients is likely diluted by its low incidence tem to compare and predict mortality in vascular trauma in the general trauma population. The RTS dismal ability to patients would need to combine physiologic parameters predict mortality may stem from its design as an immediate specific for hemorrhage with a defined anatomic scoring clinical assessment tool utilizing parameters that may not system based on vessel injured. The TRISS system com- manifest derangement immediately. Interestingly, in less bines anatomic and physiologic parameters and therefore severely injured patients (greater than 80% predicted sur- better predicts mortality in VT patients compared with the JOURNAL OF VASCULAR SURGERY 366 Loh et al February 2011 other systems examined. However, TRISS does not weight Final approval of the article: SL, CR, CC, TM, MA, NS, factors specific for vascular injuries thus still underestimates HP, FM mortality in this patient population. Statistical analysis: SL, CR Endovascular surgery promises the ability to treat Obtained funding: Not applicable vascular injuries with significantly less morbidity and Overall responsibility: FM mortality.19 In fact, the use of endovascular techniques to treat VT has increased 2.5 times in the past decade; REFERENCES however, few trauma surgeons possess an advanced cath- 20 1. MacKenzie EJ, Fowler CJ. Epidemiology. In: Moore EE, Feliciano DV, eter based skill set. Endovascular therapies offer Mattox KL, editors. Trauma. 5th ed. New York, NY: McGraw-Hill; greater versatility and the ability to treat anatomically 2004. p. 28-37. difficult areas (eg, supra-renal aorta, retro-hepatic infe- 2. Caps MT. The epidemiology of vascular trauma. Semin Vasc Surg rior vena cava, high cervical carotid, and vertebral artery 1998;11:227-31. 3. Asensio JA, Chahwan S, Hanpeter D, Demetriades D, Forno W, Gam- injuries). The boundaries of endovascular therapy are baro E, et al. Operative management and outcome of 302 abdominal constantly moving forward and the reduced morbidity vascular injuries. Am J Surg 2000;180:528-533; discussion 533-4. and mortality of endovascular surgery have the potential 4. Lopez-Viego MA, Snyder WH III, Valentine RJ, Clagett GP. Penetrat- to change the overall outcomes and ultimately mortality ing abdominal aortic trauma: a report of 129 cases. J Vasc Surg 1992; of vascular trauma patients. 16:332-5; discussion 335-6. 5. Tyburski JG, Wilson RF, Dente C, Steffes C, Carlin AM. Factors Limitations. There is no scoring system that is univer- affecting mortality rates in patients with abdominal vascular injuries. sally accepted; therefore, our decision to use ISS was based J Trauma 2001;50:1020-6. on its design as an anatomic rather than physiologic system. 6. Feliciano DV. Abdominal vascular trauma. In: Moore EE, Feliciano Functional disability, as a result of trauma, is especially DV, Mattox KL, editors. Trauma. 5th ed. New York, NY: McGraw- Hill; 2004. p. 755-75. important in young active individuals; however, our study 7. Frykberg ER, Schinco MA. Peripheral vascular injury. In: Moore EE, was not powered to examine functional outcome. The Feliciano DV, Mattox KL, editors. Trauma. 5th ed. New York, NY: small sample size also limited our ability for subset analysis. McGraw-Hill; 2004. p. 969-1002. In particular, we recognize that injury to particular ana- 8. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: tomic areas and vessels carries increased severity. Future a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187-96. studies should examine larger patient numbers to make 9. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flana- meaningful conclusions on immediate and long-term out- gan ME. A revision of the Trauma Score. J Trauma 1989;29:623-9. comes in vascular trauma. 10. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818-29. CONCLUSION 11. Moore EE, Cogbill TH, Jurkovich GJ, McAninch JW, Champion HR, Gennarelli TA, et al. Organ injury scaling. III: Chest wall, abdominal We examined mortality in vascular trauma patients com- vascular, ureter, bladder, and urethra. J Trauma 1992;33:337-9. pared with a matched cohort of nonvascular trauma patients. 12. Moore EE, Malangoni MA, Cogbill TH, Peterson NE, Champion HR, In patients with similar injury severity, the presence of VT was Jurkovich GJ, et al. Organ injury scaling VII: cervical vascular, periph- associated with a trend toward increased mortality. Further- eral vascular, adrenal, penis, testis, and scrotum. J Trauma 1996;41: 523-4. more, the ISS, RTS, TRISS, and APACHE II scoring systems 13. Moore EE, Malangoni MA, Cogbill TH, Shackford SR, Champion HR, underestimated mortality when VT was present rendering Jurkovich GJ, et al. Organ injury scaling. IV: thoracic vascular, lung, them inaccurate when examining VT patients. New scoring cardiac, and diaphragm. J Trauma 1994;36:299-300. systems should be developed to allow meaningful evaluation 14. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma 1987; of the current care of vascular trauma patients. These patients 27:370-8. should be critically evaluated expeditiously regardless of cal- 15. Bole PV, Purdy RT, Munda RT, Moallem S, Devanesan J, Clauss RH. culated score. In addition, vascular surgery should be involved Civilian arterial injuries. Ann Surg 1976;183:13-23. early given its expertise in both open surgical and endovascular 16. Mattox KL, Feliciano DV, Burch J, Beall AC Jr, Jordan GL Jr, De Bakey techniques. ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Ann Surg 1989;209: The authors would like to acknowledge Maria McGee 698-705; discussion 706-7. and Sally Jacko, RN for their invaluable contribution in 17. Minowa Y, Schreiber R, Moore EE. Regional trauma systems. J Trauma 1996;40:1054-5. data collection. 18. Galindo RM, Workman CR. Vascular trauma at a military level II trauma center(1). Curr Surg 2000;57:615-8. AUTHOR CONTRIBUTIONS 19. Hershberger RC, Aulivola B, Murphy M, Luchette FA. Endovascular Conception and design: SL, FM, HP grafts for treatment of traumatic injury to the aortic arch and great Analysis and interpretation: SL, CR, FM vessels. J Trauma 2009;67:660-71. 20. Burkhardt GE, Rasmussen TE, Propper BW, Lopez PL, Gifford SM, Data collection: SL, CC Clouse WD. A national survey of evolving management patterns for Writing the article: SL vascular injury. J Surg Educ 2009;66:239-47. Critical revision of the article: SL, CR, TM, MA, NS, HP, FM Submitted Apr 25, 2010; accepted Aug 24, 2010.