Changing Health care  in west (UK, USA), we need better understanding of medical health insurance and future needs ?

We did not  dream that this would be happening to health care industry in United Kingdom three decades back. It seems, Since its establishment in July, 1948, the aim of the NHS has been to offer a comprehensive service to improve health and prevent illness, available to all in England and Wales (and then extended throughout the UK), which is largely free of charge. Health care for all, for free, has been the common ethos and philosophy throughout the NHS. But in 60 years things changed, it has been forced to look for better ways to provide health care even in the countries like United kingdom and few others.The money barrier, of course is crucial in making decisions.Now, GPs will return to the market place and will decide what care they can afford to provide for their patients, and who will be the provider and insuring agent. There is fear that the emphasis will move from clinical need (GPs' forte) back to cost (not what GPs were trained to evaluate). The ethos will become that of the individual providers and insurers, and will differ accordingly throughout England, replacing the philosophy of a genuinely national health service. We in Andhrapradesh India, introduced a system to reach people known as "Aarogyasree" public(Govt) funded health insurance scheme, managed through the web (internet) approval of patient selection and procedures and release of money. I forsee that there is going to be a need for similar systems (with modifications) in the other countries also to reach the needy people. That means the robust medical insurance has come to the lime light in many parts of the world by force. We need to understand more about the Medical insurance and It should be a subject for study during undergraduate studies for Medical graduates.

Can we make the vascular access for hemodialysis through the neck lines (central lines) more safer and long lasting?

Vascular access for hemodialysis is known to frequently thrombose and force us to go for revision or create a new vascular access. Central lines are flushed with heparin to prevent the thrombosis but even then some catheters get blocked due to thrombosis and others develop the infection. Such catheters are treated with rtPA (1mg) to lyse the clots in the catheter. Loss of access can be expensive and one has to go for another one. In a recent study published in NEJM it was observed routine use of rtPA (1mg) once in a week in addition to twice a week Heparin irrigation of the catheter can prevent the thrombosis and bacteremia. Brenda RH ( preCLOT study group) did this study and it is very interesting to findout that elective use of rtPA can increase the patency and prevent the bacteremia in those patients undergoing dialysis through the central neck lines. Soon the 1mg rtPA prefilled syringes may be available in many countries to irrigate the the central lines for better patency. We can congratulate Brenda R H et al for conducting this study which can help the hemodialysis patients.

Economics and venous disease in the developing nations
In the coming years venous disease is going to be diagnosed more often and therapies will be suggested by doctors to the patients. It is due to the availability of the Ultrasound scans (doppler) in every medical centre. This can tremendously increase the demand for the treatments which are day care and minimally invasive. Endovenous ablative therapies are going to be popularised by the hospital based doctors. In India, the cost of varicose veins -ablative therapies will be around Rs 40,000/= in the coming years.

Chronic venous ulcers

Patients develop venous ulcers after sufferring from chronic venous hypertension over a period of time ( 8 to 10 years). The venous ulcers fail to heal and they also recur after healing. Patients also become indifferent to the treatments as they have seen failures more often than success with treatments. This patient had ulcer for more than 10 years. The skin around the ulcer is indurated and there are pale grannualtion tissues in the base of the ulcer.

Pulsatile swelling in the Hypothenar eminence

Traumatic(repeated) injury to the ulnar artery can result in aneurysm formation. The radial artery is patent and the palmar arch is also supplied by the radial artery. This patient is advised repair of the ulnar artery aneurysm under tourniquet.

Femoral artery Pseudo aneurysm (post traumatic) in middle aged man.

This gentleman sustained injury to the thigh (Bamboo stick) while working near the cattle at home 1 month back. He developed profuse bleeding and later swelling of the thigh. He waited for 1 month with local therapies. Then he came to our clinic under the Aarogyasri scheme. We operated on him in emergency after getting the approval from Aarogyasri insurance scheme. A short segment of saphenous vein graft was interposed to repair the damaged artery segment. The sartorius muscle (flap) was used to cover the graft. Usually patients from low socioeconomic status are able to reach the tertiary care hospital after a minimum of 2 to 4 weeks and Aarogysri is helping them to get the vascular surgical therapies in emergency situations.

Intra operative photograph showing the vein graft after excision of aneurysm

Post thrombotic syndrome and its prevention by early clearance of thrombus load from the DVT patients is going to attract the attention of doctors as it is promising to clear the vein load of thrombus. Catheter directed thrombolysis in combination with the percutaneous mechanical thrombectomy seem to be future mode of management  of the ilio-femoral deep vein thrombosis. However the cost of such treatment may not make it best choice of treatment for majority of the people who are living in India who can not afford such expensive therapies. The appropriate cost for such therapies will not be less than Rs 1,50,000/= . We donot know if the 3rd party insurance companies will be approving such expensive therapies for the ilio-femoral DVT!



Intraarterial Administration of Bone Marrow Mononuclear Cells in Patients With Critical Limb Ischemia

Critical limb ischemia due to peripheral arterial occlusive disease is associated with a severely increased morbidity and mortality. There is no effective pharmacological therapy available. Injection of autologous bone marrow-derived mononuclear cells (BM-MNC) is a promising therapeutic option in patients with critical limb ischemia, but double-blind, randomized trials are lacking. A Randomized-Start, Placebo-Controlled Pilot Trial (PROVASA) was published in Circulation - cardiovascular interventions.In this study Limb salvage and amputation-free survival rates did not differ between the control and study groups. However, cell therapy was associated with significantly improved ulcer healing (ulcer area, 3.2±4.7 cm² to 1.89±3.5 cm²P=0.014] versus placebo, 2.92±3.5 cm²² [P=0.5]) and reduced rest pain (5.2±1.8 to 2.2±1.3 [P=0.009] versus placebo, 4.5±2.4 to 3.9±2.6 [P=0.3]) within 3 months. 

We in India, need to be careful in jumping to conclusions without adequate  supportive evidence in favor of the cell therapies to treat the critical limb ischaemia for the present. If the strong evidence becomes available certainly and eagerly we are waiting to bring that in to our clinical practice.

What is optimum anticoagulation with Heparin in peripheral vascular treatments?

             Beyond the heparin dose ( initially up to 60 U/kg) and the ACT level (250 seconds) , in the multivariate analysis it was found that female sex, creatinine clearance <60 mL/min per 1.73m² age >70 years, preprocedural anemia, history of heart failure, hybrid vascular surgery, rest pain, and below-knee interventions were independent predictors of higher postprocedural bleeding risk. These findings are consistent with those from 2 large retrospective databases of patients undergoing PCI and a registry of 24 045 patients with acute coronary syndromes from the Global Registry of Acute Coronary Events (GRACE).Less aggressive anticoagulation, or use of an alternative anticoagulant strategy such as a direct thrombin inhibitor, may decrease the incidence of bleeding complications in these subgroups of high-risk patients.
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References

1. Moscucci M, Fox KA, Cannon CP et al. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE). Eur Heart J. 2003; 24: 1815– 1823
2. Shammas NW,Allie D,Hall P: Predictors of in-hospital and 30-day complications of peripheral vascular interventions using bivalirudin as the primary anticoagulant: results from the APPROVE Registry. J Invasive Cardiol. 2005; 17: 356– 359

Surgical site infections in the Hospital patients - Guidelines can prevent them?
American Journal of Surgery - Volume 201, Issue 1 (January 2011)

Surgical site infections (SSIs) occur in more than 500,000 patients annually and result in increased length of hospital stay, readmissions, costs, and mortality in USA. [1] , [2] Up to 60% of SSIs have been estimated to be preventable, [3] , [4] , [5] largely by using recommended evidence-based guidelines such as timely and appropriate administration of antibiotics for prophylaxis and maintenance of perioperative normothermia. [3] , [6] , [7] , [8] A number of hospitals have reported decreased infection rates by improving utilization of these guidelines. [9] , [10] Furthermore, lack of compliance with these guidelines is associated with a significant increase in mortality.[11] Despite the evidence that these measures improve outcome, compliance with these guidelines is suboptimal in many hospitals, as demonstrated by data from large administrative databases and cohort studies. [9] , [12] , [13] , [14] Bratzler et al evaluated a random sample of 34,133 Medicare patients and found that only 56% of patients received antimicrobial therapy within 1 hour before incision and that only 40% had appropriate discontinuation of prophylactic antibiotics after 24 hours.[13] Based on poor compliance with these guidelines and the high morbidity and mortality of postoperative complications, the Surgical Care Improvement Project (SCIP) was developed as a collaborative effort to prevent infectious, thromboembolic, cardiac, and respiratory complications.[15]



1 Kirkland K.B., Briggs J.P., Trivette S.L., et al: The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 20. 725-730.1999; Abstract


2 Weinstein R.A.: Nosocomial infection update. Emerg Infect Dis 4. 416-420.1998; Abstract

3 Mangram A.J., Horan T.C., Pearson M.L., et al: Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory CommitteeAm J Infect Control 27. 97-132.1999; Full Text

4 Page C.P., Bohnen J.M., Fletcher J.R., et al: Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical careArch Surg 128. 79-88.1993; Abstract

5 Platt R., Munoz A., Stella J., et al: Antibiotic prophylaxis for cardiovascular surgery. Efficacy with coronary artery bypassAnn Intern Med 101. 770-774.1984; Abstract

6 Chodak G.W., Plaut M.E.: Use of systemic antibiotics for prophylaxis in surgery: a critical review. Arch Surg 112. 326-334.1977; Abstract

7 Horan T.C., Gaynes R.P., Martone W.J., et al: CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 13. 606-608.1992; Citation

8 Kurz A., Sessler D.I., Lenhardt R.: Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature GroupN Engl J Med 334. 1209-1215.1996; Abstract

9 Dellinger E.P., Hausmann S.M., Bratzler D.W., et al: Hospitals collaborate to decrease surgical site infections. Am J Surg 190. 9-15.2005; Full Text

10 Hedrick T.L., Heckman J.A., Smith R.L., et al: Efficacy of protocol implementation on incidence of wound infection in colorectal operations. J Am Coll Surg 205. 432-438.2007; Full Text

11 Mahid S.S., Polk , Jr , JrH.C., Lewis J.N., et al: Opportunities for improved performance in surgical specialty practice. Ann Surg 247. 380-388.2008; Abstract

12 Bratzler D.W., Houck P.M.: Antimicrobial prophylaxis for surgery: an advisory statement from the national surgical infection prevention project. Clin Infect Dis 38. 1706-1715.2004; Abstract

13 Bratzler D.W., Houck P.M., Richards C., et al: Use of antimicrobial prophylaxis for major surgery: baseline results from the national surgical infection prevention project. Arch Surg 140. 174-182.2005; Abstract

14 Silver A., Eichorn A., Kral J., et al: Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. The Antibiotic Prophylaxis Study GroupAm J Surg 171. 548-552.1996; Abstract

15 Bratzler D.W., Hunt D.R.: The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 43. 322-330.2006; Abstract

Healing of Venous ulcers and cost of therapy


The treatment of venous leg ulcers (VLU) represents 23% of new patient visits and 36% of all patient visits in vascular surgery practice. Depending on the age of the patient cohort, VLU affects between 0.2% and 1% of the population.1 In first world countries, the treatment of VLU may represent a maximum of 3% of health care expenditures.2 Presently, the standard of care for VLU remains compression therapy, in many cases Unna’s boot, but ideally multilayer wraps.3 With this current treatment, healing rates in patients with normal arterial perfusion is reported to be between 63% at 10 weeks retrospectively and 33% at 12 weeks prospectively.[4] and [5] Overall, annual direct costs for the treatment of VLU are in the range of $30,000 per patient per annum, with only 60-80% of them healing at 6 months. Dr O’Donnell has accurately pointed out that “any treatment modality improving VLU healing time or proportion healed would reduce the burden of VLU care.”6


Others have noted that a maximum of 15% of the limbs affected by VLU observed in large volume vascular practices have an ankle–brachial index (ABI) of <0.8.4 Patients with an ABI of <0.8 were noted to take 19 weeks to heal 50% of their ulcers as compared with 9 weeks taken by the normally perfused group. In another study, which evaluated the closure rate of mixed arterial venous ulcers, the closure rate for the standard of care arm at 16 weeks was 46.2% as compared with the 82.6% in the cohort treated with porcine-derived intestinal submucosa (SIS) (Cook Medical Inc., Bloomington IN).7 A 2004 study conducted in the United Kingdom reported that 13.6% of patients presenting with VLU had an ABI of 0.5-0.85 and 2.2% had an ABI of <0.5.8 M.L. Humphreys, A.H. Stewart and M.S. Gohel et al., Management of mixed arterial and venous leg ulcer, Br J Surg 94 (2007), pp. 1104–1107. View Record in Scopus Cited By in Scopus (9)8 Therefore, to assess the effect of intervening percutaneously on the arterial circulation of patients with mixed arterial venous disease who were dependent on compression therapy. This therefore excluded the few patients who had mixed arterial venous disease with easily correctable, superficial-only venous reflux. The hypothesis was that improving or “normalizing” the lower extremity perfusion, as assessed by ABI and pulse volume recordings (PVRs), would normalize the healing trajectory of this hard-to-close patient subset. Few others have applied this protocol selectively but with a large proportion of patients who underwent arguably more morbid open procedures.8

Second - hand smoking and mortality

Worldwide, 40% of children, 33% of male non-smokers, and 35% of female non-smokers were exposed to second-hand smoke in 2004. This exposure was estimated to have caused 379 000 deaths from ischaemic heart disease, 165 000 from lower respiratory infections, 36 900 from asthma, and 21 400 from lung cancer. 603 000 deaths were attributable to second-hand smoke in 2004, which was about 1·0% of worldwide mortality. 47% of deaths from second-hand smoke occurred in women, 28% in children, and 26% in men. DALYs lost because of exposure to second-hand smoke amounted to 10·9 million, which was about 0·7% of total worldwide burden of diseases in DALYs in 2004. 61% of DALYs were in children. The largest disease burdens were from lower respiratory infections in children younger than 5 years (5 939 000), ischaemic heart disease in adults (2 836 000), and asthma in adults (1 246 000) and children (651 000).

The Lancet, Volume 377, Issue 9760, Pages 139 - 146, 8 January 2011

Post thrombotic syndrome after thrombolytic therapy- Do we have enough support for considering thrombolytic therapy?

Deep venous thrombosis (DVT) of the lower limbs can lead to post-thrombotic syndrome. There is a strong correlation between post-thrombotic syndrome and the extent of the thrombotic process. The progress of distal DVTs is benign with a high rate of recanalization and low rate of venous reflux. Persistence of chronic occlusion and venous reflux is common in extensive DVTs. The proximal DVT (upto 96%) may progress with reflux and/or venous obstruction. Venous segments with evidence of reflux after DVT recanalization were those presenting a spontaneous fibrinolysis up to 7 times longer than the observed in competent segments, suggesting that thrombus removal time is also an important factor in vein valve preservation. The use of locally infused fibrinolytic agents presents the possibility of direct intervention for immediate thrombus removal.Theoretically, this specific feature of thrombolysis should lead to immediate improvement of clinical results in extensive cases of DVT, as well as to preservation of valvular competence and venous wall morphology as has been described by experimental studies. So, we can think in favor of Thrombolytic therapy in extensive proximal DVT cases.

References:

1. Masuda EM, Kessler DM, Kistner RL, Eklof B, Sato DT. The natural history of calf vein thrombosis: lysis of thrombi and development of reflux. J Vasc Surg. 1998;28:67-74. [ Links ]
2. McLafferty RB, Moneta GL, Passman MA, Brant BM, Taylor LM Jr, Porter JM. Late clinical and hemodynamic sequelae of isolated calf vein thrombosis. J Vasc Surg. 1998;27:50-7. [ Links ]
3. O'Shaughnessy AM, FitzGerald DE. The patterns and distribution of residual abnormalities between the individual proximal venous segments after an acute deep vein thrombosis. J Vasc Surg. 2001;33:379-84. [ Links ]
4. Lindner DJ, Edwards JM, Phinney ES, Taylor LM Jr, Porter JM. Long-term hemodynamic and clinical sequelae of lower extremity deep vein thrombosis. J Vasc Surg. 1986;5:436-42. [ Links ]
5. Haenen JH, Janssen MC, van Langen H, van Asten WN, Wollersheim H, Heystraten FM, et al. Duplex ultrasound in the hemodynamic evaluation of the late sequelae of deep venous thrombosis. J Vasc Surg. 1998;3:472-8. [ Links ]
6. Meissner MH, Manzo RA, Bergelin RO, Markel A, Strandness DE Jr. Deep venous insufficiency: The relationship between lysis and subsequent reflux. J Vasc Surg. 1993;18:596-608. [ Links ]
7. Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology. 1999;211:39-49. [ Links ]
8. Emanuelli G, Segramora V, Frigerio C. Selected strategies in venous thromboembolism: local thrombolytic treatment and caval filters. Haematologica. 1995;80 (2 Suppl):84-6. [ Links ]
9. Molina JE, Hunter DW, Yedlicka JW. Thrombolytic therapy for iliofemoral venous thrombosis. Vasc Surg. 1992;26:630-7. [ Links ]
10. Verhaeghe R, Stockx L, Lacroix H, Vermylen J, Baert AL. Catheter directed lysis of iliofemoral vein thrombosis with use of rt-PA. Eur Radiol. 1997;7:996-1001. [ Links ]
11. Palombo D, Porta C, Brustia P, Peinetti F, Udini M, Antico A, et al. La thrombolyse loco-régionale dans la thrombose veineuse profonde. Phlebologie. 1993;46:293-302. [ Links ]
12. Burkart DJ, Borsa JJ, Anthony JP, Thurlo SR. Thrombolysis of occluded peripheral arteries and veins with tenecteplase: a pilot study. J Vasc Interv Radiol. 2002;13:1099-102. [ Links ]
13. Sugimoto K, Hofmann LV, Razavi MK, Kee ST, Sze DY, Dake MD, et al. The safety, efficacy, and pharmacoeconomics of low-dose alteplase compared with urokinase for catheter-directed thrombolysis of arterial and venous occlusions. J Vasc Surg. 2003;37:512-7. [ Links ]
14. Shortell CK, Queiroz R, Johansson M, Waldman D, Illig KA, Ouriel K, et al. Safety and efficacy of limited-dose tissue plasminogen activator in acute vascular occlusion. J Vasc Surg. 2001;34:854-9. [ Links ]
15. Rhodes JM, Cho S-J, Gloviczki P, Mozes G, Rolle R, Miller VM. Thrombolysis for experimental deep venous thrombosis maintains valvular competence and vasoreactivity. J Vasc Surg. 2000;31:1193-205.

High-sensitivity cardiac troponin assay in predicting mortality?

Recent studies have shown that the high-sensitivity cardiac troponin assay can substantially improve early diagnosis of acute myocardial infarction and allow risk stratification of patients with stable congestive heart failure and acute coronary syndromes. An important recent study involving patients with stable coronary artery disease enrolled in the Prevention of Events with Angiotensin Converting Enzyme Inhibition Trial showed that elevated cardiac troponin T levels, measured with a high-sensitivity troponin assay, were significantly associated with the increased incidence of cardiovascular death. However, exclusion criteria consequent on the primary study design on angiotensin-converting enzyme inhibition produced a selected population that, among others, did not include patients who had a recent or planned revascularization procedure.

References:
1. Keller T., Zeller T., Peetz D., et al: Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med 361. 868-877.2009;
2 Reichlin T., Hochholzer W., Bassetti S., et al: Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med 361. 858-867.2009;

Effects of smoking and smoking cessation on lipids and lipoproteins: Outcomes from a randomized clinical trial
American Heart Journal - Volume 161, Issue 1 (January 2011)
In this study, despite weight gain, smoking cessation improved HDL-C, total HDL, and large HDL particles, especially in women. Smoking cessation did not affect LDL or LDL size. Increases in HDL may mediate part of the reduced cardiovascular disease risk observed after smoking cessation.

Each year, smoking contributes to >443,000 smoking-related deaths in the United States and few millions in the rest of the world; and nearly 20% of all coronary heart disease deaths can be attributed to smoking. Although the strong relationship between smoking and cardiovascular disease (CVD) has been well-documented, the mechanisms by which smoking increases CVD risk appear to be multifactorial and incompletely understood. Clinical trials, suggest that cigarette smoking is associated with a more atherogenic lipid profile characterized by higher total cholesterol and triglycerides (TG) with lower levels of high-density lipoprotein cholesterol (HDL-C).

References:
1 Center for Disease Control and Prevention : Smoking-attributable mortality, years of potential life lost, and productivity losses—United States. 2002-2004. [accessed 2009 Apr 8]Morb Mortal Wkly Rep 57. 1226-1228.2008;
2 American Heart Association : Heart disease and stroke statistics—2009 update. American Heart AssociationDallas (Tex)2009.
3 Doll R., Peto R., Boreham J., et al: Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ 328. 1519.2004;
4 Freund K.M., Belanger A.J., D'Agostino R.B., et al: The health risks of smoking. The Framingham Study: 34 years of follow-up. Ann Epidemiol 3. 417-424.1993;
5 Ambrose J.A., Barua R.S.: The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol 43. 1731-1737.2004;
6 Gossett L.K., Johnson H.M., Piper M.E., et al: Smoking intensity and lipoprotein abnormalities in active smokers. J Clin Lipidol 3. 372-378.2009;

Novel and new oral antithrombotic drugs for prevention of VTE

Patients undergoing surgery receive anticoagulation for perioperative thromboprophylaxis or ischemic cardiovascular disease. Because anticoagulants may also potentiate bleeding, clinicians need to understand the implications of anticoagulation in perioperative and postoperative patient management. Many newer anticoagulants that are now available or are in clinical development do not require routine coagulation monitoring, have more predictable dose responses, and have fewer interactions with other drugs and food. The most advanced oral anticoagulants in clinical development are the direct factor Xa inhibitors rivaroxaban and apixaban, and the direct thrombin inhibitor dabigatran etexilate. These agents have been evaluated in the postoperative setting in patients undergoing total hip- or knee-replacement surgery with promising results, and it remains to be seen whether these results will translate into other surgical settings. The impact of the new agents will be influenced by the balance between efficacy and safety, improved convenience, and potential cost-effectiveness benefits.

Injury to the Axillo-Brachial artery in a violent act (Axe)
Vascular injuries are commonly seen in road side accidents. Few cases of vascular injuries are treated at NIMS are due to domestic violence at home with sharp, heavy and blunt objects. Usually axillary artery is well protected and so it is rarely injured. Today we repaired axillary artery in young man after axe-injury. Vein graft was needed to bridge the gap. This patient was initially treated with ligation of the injured axillary artery by the local doctors who later referred him to our center for the definitive repair. There was also injury to the median nerve which required plastic surgical repair. Post operatively doppler signals are normal.

Reference
Aust N Z J Surg. 1995 May;65(5):327-30.
Penetrating injuries of the axillary artery.

Degiannis E, Levy RD, Potokar T, Saadia R.
Department of Surgery, Baragwanath Hospital, University of Witwatersrand Medical School, Johannesburg, Republic of South Africa.
Abstract

This is a retrospective study of 32 patients with penetrating injury of the axillary artery. There was an overall mortality of 6% entirely accounted for by associated injuries. Pre-operative angiography was used in 12 of these patients either to confirm the presence of an injury or to define its location. Twelve patients underwent lateral arteriorrhaphy or an end-to-end anastomosis and 19 patients had an interposition graft. No immediate problems were experienced with polytetrafluoroethylene grafts compared with autogenous vein grafts. There were 14 patients with a concomitant venous injury; 13 were repaired and only transient arm oedema was experienced. Eleven patients had a brachial plexus injury and, of these, nine underwent a secondary nerve repair with a poor outcome. Axillary artery injury has a good prognosis with a morbidity related mainly to associated nerve injury and a mortality accounted for by injuries to other body systems.