Treatment of venous thromboembolic complications and prevention of massive pulmonary embolism during staged surgical interventions in wounded patients with gunshot fractures of the lower extremities
AbstractThe aim of this study was to develop an algorithm for the prevention and treatment of venous thromboembolic complications (VTEC) during staged surgical interventions in wounded patients with gunshot fractures of the lower extremities (LE).
Material and methods. The treatment outcomes for VTEC were retrospectively assessed in 149 wounded patients with gunshot fractures of LE who were treated in a Level 5 military medical facility (MMF). All wounded were male, with an average age of 38.4 ± 8.8 years. Instrumental examination included ultrasound angioscanning of LE and computed tomography (as indicated). By localization, gunshot fractures were: femur in 80 (53.7%) wounded, tibia – in 33 (22.1%), fibula – in 1 (0.7%), femur and tibia – in 7 (4.7%), tibia and fibula – in 26 (17.4%), femur and fibula – in 1 (0.7%), femur, tibia and fibula – in 1 (0.7%). Deep vein thrombosis (DVT) of LE was detected in all the wounded. By the segments of damage, patients with DVT were distributed as follows: the iliofemoral segment was affected in 6 (4%) wounded, the femoropopliteal segment – in 53 (36%), the popliteal-tibial segment – in 67 (45%), and the distal segment – in 23 (15%). Short-term treatment outcomes were assessed based on mortality rates, secondary amputation rates, recurrence and/or progression of venous thromboembolism, and hemorrhagic complications.
Results. Indications for lower musculoskeletal surgery were delayed in most patients (123, 82.5%). The median duration of preoperative anticoagulant therapy (ACT) with low-molecular-weight heparins was 7 days (Q1 – 5, Q3 – 11). A total of 247 (53.2%) interventions were performed with a high risk of hemorrhagic complications, while 217 (46.8%) had a low risk of bleeding. A postoperative break from ACT of up to 24 hours was most often used (353 interventions, 76.1%). A 24–48 hours break in ACT was performed after 97 (20.9%) operations, while a 48–72 hour break was performed only after 14 (3%) operations. Surgical prophylaxis of massive PE was performed in 24 (16.1%) patients, with the most common procedure being superficial femoral vein ligation (21 wounded) performed during the previous stages of medical evacuation. The median hospital stay in a MMF was 8 days (Q1 – 6, Q3 – 15). There were no fatal outcomes. Secondary LE amputations were performed in 12 (8%) wounded. DVT progression was noted in 9 (6%) patients. Development of massive PE and major bleeding were not noted. Performing femoral vein ligation before one or more high-risk interventions in wounded patients with gunshot fractures of LE was not associated with lower complication rates compared with isolated anticoagulant therapy with low-molecular-weight heparins in the perioperative period.
Conclusion. A rational combination of perioperative anticoagulant therapy with short-term withdrawal before and immediately after surgery, as well as its resumption in most patients within 24 hours after surgery, with or without surgical pulmonary embolism prophylaxis, helps prevent both massive venous thromboembolic and hemorrhagic complications.
Keywords: venous thromboembolic complications; deep vein thrombosis; gunshot fractures of the lower extremities; anticoagulant therapy; perioperative patient management
Funding. The study was not sponsored.
Conflict of interest. The authors declare no conflict of interest.
Authors’ contributions. Study concept and design – Gavrilov E.K., Khubulava G.G., Khominets V.V.; data collection and processing – Kudyashev A.L., Akbaev I.A.; statistical data processing – Gavrilov E.K., Kudyashev A.L.; writing of the text – Gavrilov E.K., Kudyashev A.L.; editing – Khubulava G.G., Khominets V.V
For citation: Gavrilov E.K., Khubulava G.G., Khominets V.V., Kudyashev A.L., Akbaev I.A. Treatment of venous thromboembolic complications and prevention of massive pulmonary embolism during staged surgical interventions in wounded patients with gunshot fractures of the lower extremities. Angiology and Vascular Surgery. Journal named after Academician A.V. Pokrovsky. 2026; 32 (1): 46–56. DOI: https://doi.org/10.33029/1027-6661-2026-32-1-46-56
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