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Popliteal Scoring Assessment for Vascular Extremity Injuries in Trauma Score Fulfills the Need for a New Reporting Standard in Lower Extremity Vascular Trauma

      Objective

      Popliteal artery injuries portend the highest risk of limb loss of lower extremity vascular trauma. Numerous studies demonstrated need for a revised scoring system, which is simplified and more objective. Utilization of such a score should be as a reporting standard rather than a preoperative determination of limb salvage. POPliteal Scoring Assessment for Vascular Extremity Injuries in Trauma (POPSAVEIT) is a validated score providing a simple and practical means to stratify patients on initial assessment into low- and high-risk categories for amputation. This study aims to further validate POPSAVEIT score across multiple US institutions to demonstrate its effectiveness and generalizability.

      Methods

      The POPSAVEIT study evaluated 505 patients with popliteal vascular injuries across 14 institutions from 2012 to 2020. Patients analyzed in previous studies were excluded. POPSAVEIT score was applied as previously defined: systolic blood pressure <90 mm Hg = 1 point, associated orthopedic injury = 2 points and lack of preoperative pedal Doppler signals = 2 points (or 1 point for lack of palpable pedal pulses if Doppler unavailable); ≥3 defined high risk for amputation. A receiver operating characteristic curve was generated with an area under the curve of >0.65 considered adequate for validation. For patients who underwent revascularization, significant predictors of amputation (P < .05) on univariate analysis were included in a multivariate regression to determine factors independently associated with amputation.

      Results

      A total of 146 patients were included with an amputation rate of 20%. Thirty-one patients were not revascularized, of whom 9 had primary amputation. Rate of amputation increased stepwise with increasing POPSAVEIT scores with 1 of 38 (3%) patients with a score <2 requiring amputation vs 28 of 108 (26%) with a score ≥3 (P = .002) (Fig 1). The receiver operating characteristic curve generated had an area under the curve of 0.750 meeting validation criteria (Fig 2). Multivariate analysis of 115 patients who underwent revascularization demonstrated that POPSAVEIT score (odds ratio [OR]: 5.1, P = .004) and loss of primary patency (OR: 26.5, P < .001) were independently associated with amputation. Use of temporary intravascular shunts (OR: 4.5, P = .066) and concomitant popliteal vein injury (OR: 3.3, P = .158) did not reach statistical significance but had high odds ratios, which may require further studies to evaluate.

      Conclusions

      POPSAVEIT score provides a simple and practical means to effectively stratify patients preoperatively for major amputation, which may fulfill a need for improved reporting standards in lower extremity vascular trauma. In addition to POPSAVEIT score, loss of primary patency was independently associated with amputation, highlighting that successful revascularization is necessary but not sufficient for limb salvage.
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