Outcomes of upper limb vascular injuries at Charlotte Maxeke Johannesburg Academic Hospital South Africa (2021

Abstract

Purpose

This study evaluates upper limb vascular injuries (ULVIs) at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH, South Africa) to describe clinical features, in-hospital outcomes, and factors associated with poor outcomes.

Methods

A retrospective cohort study analyzed 79 suspected ULVI cases from January 1, 2021 to December 31, 2023, of which 74 had confirmed arterial injuries. Data on demographics, mechanism of injury, artery involved, American Association for the Surgery of Trauma (AAST) grades, treatments, and outcomes were collected from medical records. Poor outcomes were defined as postoperative complications (infection, thrombosis, graft failure) or amputations. Adjunct procedures (fasciotomy, nerve repair) were analyzed separately as markers of injury complexity. No ischemia time or shunt use data were recorded.

Results

Of 74 patients (91% male, mean age 33.5 years, SD 9.5), penetrating injuries (91%) included gunshot wounds (GSWs, 50%; 37/74) and stabs (41%; 30/74); nonpenetrating injuries (9%) included various mechanisms (n = 7). Brachial artery injuries predominated (72%), followed by axillary (23%) and subclavian (5%). AAST grade V injuries were most common (58%). Reverse saphenous vein graft (39%) and primary repair (34%) were frequent treatments. Outcomes included successful repairs (82%), postoperative complications (14%), and amputations (4%). GSWs were associated with poor outcomes (p = 0.01 among penetrating cases). Sensitivity analysis confirmed associations with GSWs (p = 0.015), AAST grades IV and V (p < 0.001), and reverse saphenous vein graft (p = 0.005).

Conclusions

CMJAH's ULVI profile, dominated by GSWs and stabs, reflects urban violence in a low- and middle-income country setting. The 4% amputation rate is comparable to high-income country benchmarks, though limited by small sample size, retrospective design, and lack of ischemia time data.

Keywords

Trauma surgery upper limb vascular injury peripheral vascular injury gunshot wound amputation reverse saphenous vein graft low- and middle-income countries

Introduction

Vascular injuries constitute a critical component of trauma operations, often requiring urgent surgical intervention to prevent life-threatening hemorrhage or limb loss.^1,2 These injuries can arise from penetrating mechanisms, such as gunshot wounds (GSWs) and stabs, which cause direct vessel disruption, or non-penetrating mechanisms, such as motor vehicle accidents (MVAs) or falls, which may lead to intimal tears, thrombosis, or vessel compression.^1,3

In low- and middle-income countries (LMICs), managing vascular injuries is particularly challenging due to delays in patient presentation, prolonged prehospital transport times, and limited access to specialized vascular surgery services.^4,5 These factors are exacerbated by underdeveloped prehospital care systems, inadequate trauma triage, and resource constraints, which often result in presentations beyond the traditionally cited 6-h ischemic window,^4,6 though outcomes generally worsen with increasing delays in revascularization (“sooner is better”). Contemporary practices, such as those in European guidelines, emphasize rapid revascularization upon hospital arrival, recognizing that prehospital delays may be influenced by geographical and logistical constraints and should not justify prolonged ischemia times.⁷

Upper limb vascular injuries (ULVIs) pose significant risks of limb loss and long-term morbidity, particularly in high-violence urban settings like Johannesburg, South Africa, where penetrating trauma, predominantly GSWs and stabs, accounts for most cases.^6,8 The high prevalence of interpersonal violence, driven by socioeconomic factors such as poverty, unemployment, and firearm availability, contributes to the unique trauma burden in this region.⁴ This study analyses ULVIs at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), a tertiary trauma center, to describe clinical features, including the specific arteries involved (brachial, axillary, subclavian), in-hospital outcomes (mortality and morbidity), and factors associated with poor outcomes. The brachial artery's superficial anatomical position makes it particularly vulnerable to penetrating trauma, while axillary and subclavian injuries often involve complex repairs due to their proximity to critical structures like the brachial plexus.^9,10 The aim of the study was to characterize the clinical features and in-hospital outcomes of patients presenting with ULVIs from January 1, 2021 to December 31, 2023. The study also sought to identify factors associated with poor outcomes in LMICs, defined as postoperative complications (e.g. infection, thrombosis, graft failure) or amputations, with adjunct procedures (e.g. fasciotomy, nerve repair) analyzed separately as markers of injury complexity. Findings are contextualized against global data from high-income countries (HICs), where advanced trauma systems and endovascular techniques yield lower amputation rates,^2,11 LMICs, where resource limitations mirror South Africa's challenges,^5,12 and war zones, specifically Iraq and Afghanistan, where high-energy penetrating injuries predominate.^9,13,14

Materials and methods

Study design

This retrospective cohort study analyzed patients treated for suspected ULVIs at CMJAH between January 1, 2021 and December 31, 2023. The study followed STROBE guidelines for reporting observational studies. Ethical approval was obtained from the University of the Witwatersrand Human Research Ethics Committee (Protocol M250342).

Patient identification and study population

Patients were identified through operative logbooks and institutional electronic databases (Medibank and REDCap) using procedure codes related to upper limb vascular trauma.¹⁵ Patients aged 15 years or older who underwent surgical exploration for suspected ULVIs and had confirmed traumatic arterial injury involving the brachial, axillary, or subclavian arteries were included.

Patients were excluded if:

no arterial injury was identified at exploration (n = 5)

only isolated distal arterial (radial or ulnar) injuries identified

the injury involved veins only

the condition was non-traumatic

records were incomplete

patients were transferred before definitive treatment

Data collection

The following variables were collected: demographic variables (age, gender, age group: Adolescent (<18 years), Young Adult (18–34 years), Adult (35–49 years), Older Adult (≥50 years)); mechanism of injury (penetrating (GSW, stab), non-penetrating (MVA, blunt trauma, dog bite, intravenous drug user (IVDU), tile injury, fall from height)); clinical variables (artery injured, American Association for the Surgery of Trauma (AAST) injury grades (I–V)¹⁶); treatment variables (primary repair), reverse saphenous vein graft (RSVG), polytetrafluoroethylene graft, ligation, no repair, other/non-vascular procedures were included if arterial injury was confirmed intraoperatively, even if definitive vascular repair was not performed (e.g. due to collateral circulation or ligation); outcome variables (successful repair, postoperative complications, amputation). Postoperative complications included infection, thrombosis, or graft failure. Adjunct procedures (fasciotomy, nerve repair, or venous ligation) were recorded separately as indicators of injury complexity. Ischemia time and temporary shunt use were not recorded in the dataset.

The primary outcome was poor outcome, defined as postoperative complication or amputation. Successful repair was defined as the absence of both complications and amputation.

Statistical analysis

The primary analysis population included 74 patients with confirmed arterial ULVI. Primary analyses focused on penetrating injuries (GSW and stab, n = 67 (91%)), given their predominance. Seven non-penetrating mechanisms (two MVA and one each of blunt direct blow, dog bite, IVDU, tile injury, fall from height) were analyzed descriptively as a separate subgroup due to their distinct pathophysiology and small numbers. Descriptive statistics (frequencies, percentages, means, SDs, medians, interquartile ranges (IQRs) summarized variables. Chi-square tests assessed associations for penetrating injuries, with Fisher's exact test used for analyses with expected cell counts <5. Cross-tabulations were used to explore relationships between variables. Significance was set at p = 0.05. SPSS (Version 28.0, IBM Corp., 2021) was used.

Results

Of 79 suspected ULVI cases, 74 had confirmed arterial injuries and formed the primary analysis cohort; four were excluded as no arterial injury and one as venous injury only. The cohort was 91% male (n = 67), with a mean age of 33.5 years (SD 9.5, median 32, IQR 14). Young adults (18–34 years, 49%) and adults (35–49 years, 39%) predominated. There were 37 GSWs and 30 stab injuries. Left-sided injuries were more common (58%) (Table 1). No ischemia time or shunt use data were recorded in this dataset.

Table 1.

Demographic characteristics of 74 analyzed upper limb vascular injuries stratified as GSW vs. other (stabs + nonpenetrating).

Variable	Frequency (%)	GSW (n = 37)	Other (n = 37)
Gender
Male	67 (91)	35 (95%)	32 (86%)
Female	7 (9)	2 (5%)	5 (14%)
Age group
Adolescent (<18 years)	3 (4)	1 (3%)	2 (5%)
Young adult (18–34 years)	36 (49)	20 (54%)	16 (43%)
Adult (35–49 years)	29 (39)	14 (38%)	15 (41%)
Older adult (≥50 years)	6 (8)	2 (5%)	4 (11%)
Side of injury
Left	43 (58)	21 (57%)	22 (59%)
Right	29 (39)	15 (41%)	14 (38%)
Bilateral	2 (3)	1 (3%)	1 (3%)

GSW: gunshot wound.

Most ULVI cases (53/74 (72%)) involved the brachial artery injuries followed by the axillary (23%, n = 17) and subclavian (5%, n = 4). Of the 37 GSW cases, 27 involved the brachial artery, 8 the axillary, and 2 the subclavian. The procedures performed are given in Table 2 according to mechanism; no shunts were utilized.

Table 2.

Procedures performed according to mechanism.

Procedure type	Frequency (%)	GSW (n = 37)	Non-GSW (n = 37)
RSVG	29 (39)	15 (41%)	14 (38%)
Primary repair	25 (34)	11 (30%)	14 (38%)
Other/nonvascular	9 (12)	6 (16%)	3 (8%)
PTFE graft	5 (7)	3 (8%)	2 (5%)
Amputation	3 (4)	2 (5%)	1 (3%)
No repair	3 (4)	0 (0%)	3 (8%)
Ligation only	2 (3)	0 (0%)	2 (5%)

GSW: gunshot wound; RSVG: reverse saphenous vein graft; PTFE: polytetrafluoroethylene.

Over half of all injuries were AAST grade V injuries (58%, n = 43). Most patients received a good outcome (82%, n = 61), with 10 postoperative complications (14%) and three amputations (4%). Outcomes according to artery involved (Figure 1), and mechanism (Figure 2) are shown and outcomes by variable are listed in Table 3 with GSWs being associated with poor outcomes compared to stab injuries (p = 0.01).

Figure 1.

Outcomes by artery injured (n = 74).

Figure 2.

Outcomes by mechanism of injury (n = 74).

Table 3.

Association of variables and outcomes.

Variable	Amputation (n)	Postoperative complications (n)	Successful repair (n)	p-Value
Penetrating mechanism (n)				0.01
GSW (37)	2	7	28
Stab (30)	1	3	26
AAST Grade (n)				<0.001
Grade II (7)	0	0	7
Grade III (11)	0	1	10
Grade IV (13)	0	3	10
Grade V (43)	3	6	34
Repair type (n)				0.005
Primary repair (25)	0	3	22
RSVG (29)	0	7	22
PTFE graft (5)	0	0	5
Amputation (3)	3	0	0
Ligation only (2)	0	0	2
No repair (3)	0	0	3
Other/nonvascular (9)	0	0	9
Artery involved				0.16
Brachial (53)	2	8	43
Axillary (17)	1	2	14
Subclavian (4)	0	0	4

GSW: gunshot wound; AAST: American Association for the Surgery of Trauma; RSVG: reversed saphenous vein graft; PTFE: polytetrafluoroethylene.

p-values compare successful repair vs. poor outcome for: GSW vs. stab; AAST Grade—grades IV–V vs. II–III; repair type—RSVG vs. other; artery involved—brachial vs. axillary/subclavian.

Due to small numbers no statistical analyses are possible on the non-penetrating injuries but their outcomes were one amputation and one successful repair in the two MVAs, one postoperative complication in the dog bite case, and all others yielded a successful repair.

Discussion

The findings from this retrospective cohort study at CMJAH provide critical insights into the management of ULVIs in a high-violence urban setting, characterized by a predominance of penetrating trauma and brachial artery injuries. The cohort, comprising 74 arterial ULVI cases, aligns with the demographic profile of trauma victims in LMICs.^5,12 Adults between 18 and 49 years old were the most affected, reflecting socioeconomic drivers such as unemployment, gang-related violence, and interpersonal conflicts prevalent in Johannesburg.⁴

The predominance of brachial artery injuries (72%) over axillary (23%) and subclavian (5%) arteries underscores the anatomical vulnerability of the brachial artery due to its superficial position, making it a primary target for penetrating trauma such as GSWs and stabs.¹ Although brachial artery injuries were the most frequent, no statistically significant association with outcomes was observed (p = 0.16).¹⁷ Exploratory analysis of stab injuries (n = 30) showed 60% left-sided, which may be due to right-handed assailants.

The mechanism of injury profile, dominated by GSWs (50%) and stabs (41%), reflects Johannesburg's urban violence epidemic. GSWs were associated with poor outcomes, likely due to high-velocity projectile damage.³ Non-penetrating mechanisms showed varied outcomes, but their small numbers preclude statistical analysis. The high prevalence of AAST grade V injuries (58%) indicates a severe injury burden, likely exacerbated by delayed presentations due to limited prehospital care infrastructure in South Africa⁴; grades IV and V were associated with poor outcomes.

Treatment modalities were tailored to injury severity, with RSVG (39%) and primary repair (34%) being most common. The association between RSVG and poor outcomes is likely confounded by indication, as RSVG was used in complex cases with higher AAST grades and soft-tissue contamination, consistent with previous studies demonstrating that injury severity and mechanism influence outcomes in upper extremity vascular trauma.^17,18 CMJAH's outcomes (4% amputation, 82% successful repair) compare favorably to those from HICs (4–8% amputation, 55–80% successful repair),^2,11 but reflect higher GSW prevalence versus HICs. LMICs report similar GSW rates and higher amputation rates,^5,12 while Iraq and Afghanistan war zones show elevated GSWs and amputations.^9,13,14 Comparisons with Iraq and Afghanistan war-zone data should be interpreted cautiously, as these settings often involve high-resource coalition pathways (e.g. rapid medical evacuation, well-honed damage-control resuscitation, and appropriate tourniquets), unlike the resource-constrained urban violence context at CMJAH.

Prehospital hemorrhage control at CMJAH often uses direct pressure or Foley catheter balloon tamponade, unlike tourniquets in wartime settings, potentially increasing ischemia risk and complications.

The 2025 European Society for Vascular Surgery (ESVS) vascular trauma guidelines emphasize rapid hemorrhage control, reperfusion, autologous vein grafts, selective fasciotomy, selective repair/ligation, and temporary shunts.⁷ At CMJAH, rapid hemorrhage control was achieved via surgical exploration, and RSVG was used in 39% of cases, aligning with ESVS preference for autologous grafts. Selective fasciotomy was performed for compartment syndrome, consistent with ESVS guidance. However, no shunts were used, likely due to resource constraints. These findings highlight the applicability of ESVS principles but underscore the need for enhanced prehospital systems and shunt availability in LMICs.

Limitations

This study has several limitations. First, the retrospective design limits control over data completeness and introduces the potential for information bias. Second, the sample size was relatively small, which limited statistical power and precluded multivariable regression analysis to adjust for confounding variables, and third, important clinical variables such as ischemia time, associated orthopedic injuries, and prehospital interventions were not available in the dataset. The analysis was limited to in-hospital outcomes, and long-term functional outcomes were not assessed. Long-term functional recovery and disability following extremity vascular injuries have been highlighted in previous studies, emphasizing the importance of extended follow-up when evaluating limb salvage and quality-of-life outcomes.¹⁹ Finally, the study was conducted at a single tertiary center, which may limit the generalizability of the findings to other settings.

Future prospective multicenter studies incorporating ischemia time, functional outcomes, and larger patient populations would help clarify factors influencing outcomes in upper limb vascular trauma.

Conclusions

CMJAH's ULVI profile, driven primarily by gunshot and stab injuries, reflects the burden of interpersonal violence in an LMIC urban trauma setting. The 4% amputation rate is comparable to HIC benchmarks, though limited by small sample size, retrospective design, and lack of ischemia time data.

Footnotes

Acknowledgments

The authors thank the staff at the study hospital for their support in facilitating data collection.

ORCID iD

Mozamil Mohamed

Ethical considerations

This study was approved by the University of the Witwatersrand Human Research Ethics Committee (Protocol M250342). The research was conducted in accordance with the Declaration of Helsinki.

Consent to participate

Informed consent was not required for this retrospective study, as it involved anonymized patient data collected as part of routine clinical care, in compliance with institutional ethical guidelines.

Author contributions

MM: conceptualization, data collection, data analysis, and manuscript writing. SM: supervision, data validation, and manuscript review. MSM: supervision, data validation, and manuscript review. All authors approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the University of the Witwatersrand, Johannesburg.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Availability of data and material

Data are not publicly available due to patient confidentiality and institutional restrictions but are available upon reasonable request from the corresponding author, subject to ethical approval.

References

1. Halvorson

Anz

Langfitt

. Vascular injury associated with extremity trauma: initial diagnosis and management. J Am Acad Orthop Surg 2011; 19: 495–504.

2. Branco

DuBose

Inaba

. Trends in the management of vascular trauma. Injury 2014; 45: 1450–1454.

3. Gallo

Gribben

Martin

. Management and outcomes after upper versus lower extremity vascular trauma. Ann Vasc Surg 2021; 76: 152–158.

4. Abdur-Rahman

Taiwo

Nasir

. Challenges in vascular trauma management in sub-Saharan Africa. Ann Afr Med 2019; 18: 140–145.

5. Ali

Ahmed

Khan

. Vascular trauma: 10 years’ experience from a tertiary care hospital. Pak J Med Sci 2018; 34: 1161–1165.

6. Stefanou

Kang

and Kieser

. Update in combined musculoskeletal and vascular injuries of the extremities. World J Orthop 2022; 13: 411–426.

7. Wahlgren

Aylwin

Davenport

, et al. ESVS Guidelines Committee. Editor's choice—European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the management of vascular trauma. Eur J Vasc Endovasc Surg 2025; 69: 179–237.

8. Perkins

De’Ath

Aylwin

, et al. Epidemiology and outcome of vascular trauma at a British major trauma centre. Eur J Vasc Endovasc Surg 2012; 44: 203–209.

9. Vuoncino

Feliciano

Holcomb

. Epidemiology of upper extremity vascular injury in contemporary combat. Ann Vasc Surg 2020; 62: 98–103.

10.

10. Glaser

Kalapatapu

Toursavadkohi

. Endovascular therapy of vascular trauma—current options and review of the literature. Vasc Endovasc Surg 2019; 53: 477–489.

11.

11. Huang

Wang

Zhang

. Outcomes of upper limb vascular trauma: a 10-year retrospective study. Injury 2020; 51: 876–880.

12.

12. Alewi

Jaber

A-H

. Upper limb vascular injury. Univ Thi-Qar J Med 2023; 26: 320–344.

13.

13. Stannard

Scott

Ivatury

. Vascular injuries in combat: a contemporary appraisal. Br J Surg 2008; 95: 583–588.

14.

14. Vertrees

Fox

Quan

. Modern management of complex extremity injuries in the combat environment. J Trauma 2008; 65: 1356–1364.

15.

15. Harris

Taylor

Thielke

, et al. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42: 377–381.

16.

16. Moore

Cogbill

Jurkovich

, et al. Organ injury scaling: revision and update. J Trauma 1990; 30: 1518–1522.

17.

17. Dragas

Davidovic

Kostic

. Upper extremity arterial injuries: factors influencing treatment outcome. Injury 2009; 40: 815–819.

18.

18. Demetriades

Rabinowitz

Sofianos

. Penetrating vascular trauma of the extremities. J Am Coll Surg 1992; 174: 303–306.

19.

19. Stannard

Brown

Benson

. A collaborative research system for functional outcomes following wartime extremity vascular injury. J Trauma Acute Care Surg 2012; 73: S7–12.

Outcomes of upper limb vascular injuries at Charlotte Maxeke Johannesburg Academic Hospital South Africa (2021–2023)

Abstract

Purpose

Methods

Results

Conclusions

Keywords

Introduction

Materials and methods

Study design

Patient identification and study population

Data collection

Statistical analysis

Results

Discussion

Limitations

Conclusions

Footnotes

Acknowledgments

ORCID iD

Ethical considerations

Consent to participate

Author contributions

Funding

Declaration of conflicting interests

Availability of data and material

References