Vascular repair after firearm injury is associated with increased morbidity and mortality

Vascular repair after firearm injury is associated with
increased morbidity and mortality
Jeffrey J. Siracuse, MD,a
Thomas W. Cheng, MS,a
Alik Farber, MD,a
Thea James, MD,b
Yi Zuo, MPH,c
Jeffrey A. Kalish, MD,a
Douglas W. Jones, MD,a
and Bindu Kalesan, PhD, MPH,c
Boston, Mass
ABSTRACT
Objective: Firearm injuries have high morbidity and mortality. Presentation of injuries requiring concurrent vascular
repair and its outcomes are unclear. Our study’s objective was to characterize the injury details and to assess the
associated mortality and morbidity after vascular repair.
Methods: The National Inpatient Sample was queried from 1993 to 2014 for all firearm injuries. International Classification
of Diseases, Ninth Revision codes were used to identify firearm injuries and those who also underwent a vascular repair.
Multivariable analysis was used to assess the effect of a concurrent vascular repair on outcomes.
Results: There were 648,662 firearm injuries identified; 63,973 (9.9%) involved a vascular repair. Overall, 88.7% of patients
were male, and Medicaid was the most common insurance (40.2%). Intents were assault or legal intervention (60%),
unintentional (24.2%), and suicide (8.6%). Patients undergoing vascular repair were younger, more often of black race and
male sex, and on Medicaid insurance, with a lower household income and assault/legal intent (P < .005). Patients who
underwent vascular repair had a higher frequency of abdomen/pelvis and extremity injuries as well as an elevated New
Injury Severity Score (P < .005). Patients with vascular repair were more frequently treated at urban, teaching, and large
hospitals (P < .005). Overall mortality rate was 2.2%; patients who underwent vascular repair had a higher mortality
compared with those without (5.51% vs 1.98%; P < .001). Patients with vascular repair had higher rates of acute renal
failure (3.1% vs 0.8%), venous thromboembolic events (0.5% vs 0.3%), pulmonary-related events (0.6% vs 0.28%), cardiac-
related events (0.8% vs 0.2%), sepsis (1.4% vs 0.5%), and any complication (5.7% vs 2%; all P < .0001). Vascular repair was
independently associated with mortality (odds ratio [OR], 2.68; 95% confidence interval [CI], 2.43-2.95; P < .0001). Age
older than 46 years (OR, 2.01; 95% CI, 1.71-2.35; P < .0001), male sex (OR, 1.15; 95% CI, 1.05-1.25; P ¼ .003), self-pay/no
insurance (OR, 1.6; 95% CI, 1.47-1.75; P < .0001), suicide intent (OR, 3.73; 95% CI, 3.36-4.13; P < .0001), unintentional intent
(OR, 1.12; 95% CI, 1.03-1.22; P < .0001), head/neck location (OR, 13.9; 95% CI, 12.5-15.6; P < .0001), Northeast region, and New
Injury Severity Score >4 were independently associated with in-hospital mortality. Vascular repair was also independently
associated with any complication (OR, 2.12; 95% CI, 1.98-2.28; P < .0001).
Conclusions: Firearm injuries with vascular repair were independently associated with higher injury severity score and
mortality. A majority of vascular repairs were performed for injury to the abdomen/pelvis and extremity with assault/legal
intent, whereas head and neck injury and suicide intent were the least frequent. (J Vasc Surg 2019;69:1524-31.)
Keywords: Firearm injury; Gunshot; Trauma; Vascular; Vascular repair; Vascular injury
Firearm injuries are a common source of penetrating
trauma in the United States and a leading cause of death
among the younger population.1
According to the
Centers for Disease Control and Prevention, there were
36,252 firearm deaths in the United States in 2015, and
firearms accounted for 11.1% of age-adjusted deaths.1
Urban populations and populations with lower socioeco-
nomics are disproportionately affected by these
injuries.2-6
However, firearm injuries also affect the gen-
eral population, including affluent and rural areas. The
most frequent intent for fatal firearm injury was suicide,
accounting for 60.7%, followed by assault (35.8%), unin-
tentional (1.3%), and legal intervention (1.3%).1
Recent
high-profile and large-scale firearm assaults have thrust
this issue into the forefront of public health, and it has
become a focus for all physicians involved in trauma
care.7,8
Firearm injuries can affect various organ systems
including the vasculature. Traumatic vascular injury has
been associated with high morbidity and mortality.9-13
This is particularly seen with penetrating trauma.14
However, unlike with blunt trauma, which is increasingly
From the Division of Vascular and Endovascular Surgery,a
and Department of
Emergency Medicine,b
Boston Medical Center, and Center for Clinical Trans-
lational Epidemiology and Comparative Effectiveness Research, Preventive
Medicine and Epidemiology, Department of Medicine,c
Boston University
School of Medicine.
This study was funded by an Evans Foundation grant.
Author conflict of interest: J.J.S. is a speaker for W. L. Gore.
Additional material for this article may be found online at www.jvascsurg.org.
Correspondence: Bindu Kalesan, PhD, MPH, Center for Clinical Translational
Epidemiology and Comparative Effectiveness Research, Preventive Medicine
and Epidemiology, Department of Medicine, Boston University School of
Medicine, 801 Massachusetts Ave, Ste 470, Boston, MA 02118 (e-mail:
kalesan@bu.edu).
The editors and reviewers of this article have no relevant financial relationships to
disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
0741-5214
Copyright Ó 2018 by the Society for Vascular Surgery. Published by Elsevier Inc.
https://doi.org/10.1016/j.jvs.2018.07.081
1524

being treated with endovascular techniques, penetrating
vascular trauma is still often treated with open surgery.15-17
Firearm injuries can be devastating, and there is little
evidence that assesses nationwide injury patterns,
causes, and presentations of firearm-related vascular
injury and associated in-hospital mortality and morbidity.
Our goal was to assess the pattern and incidence of
vascular injuries from firearms in the United States and
associated in-hospital mortality and morbidity. As
trauma surgeons and emergency physicians have taken
an increasingly public role on this issue, there is an
opportunity for vascular surgeons to participate and to
lead as well. We queried the National Inpatient Sample
database as it allows identification of a large sample of
firearm injury patients, details of concomitant vascular
repair, complications, and mortality.
METHODS
The National Inpatient Sample was queried from 1993
to 2014 for all firearm injury presentations. International
Classification of Diseases, Ninth Revision (ICD-9) diag-
nosis codes used to identify firearm injuries by intent
were E9220 to E9229 (unintentional), E9650 to E9654 (as-
sault), E9550 to E9559 (suicide), E970 (legal intervention),
and E9850 to E9856 (undetermined; Supplementary
Table I, online only). Patients who underwent a vascular
repair for those firearm injuries were then identified by
the following ICD-9 procedure codes: 00.45 to 00.48,
38.10, 38.12 to 38.18, 38.32 to 38.39, 38.42 to 38.49, 38.82
to 38.89, 39.22 to 39.26, 39.29, 39.31, 39.32, 39.50, 39.56 to
39.59, and 39.71 to 39.73.
Patients’ demographics, comorbidities, Elixhauser
score, and hospital characteristics were collected. The
New Injury Severity Score (NISS) was calculated as previ-
ously described on the basis of the site and severity of
injury.18
The resulting cohort of patients was categorized
into two groups: those with a vascular repair and those
without a vascular repair. Age groups were determined
to be 0 to 15 years, 16 to 45 years, and 46 years or older
as previously described because type of injury, location,
and severity are different between these age groups; for
example, firearm injuries in younger adults (aged
16-45 years) are more assault related, and injuries in older
adults (aged 46 years or older) are more often self-
inflicted.19
The primary outcome was defined as
in-hospital mortality. Complications including acute
renal failure (ICD-9 codes 584.5-584.9), venous thrombo-
embolism (ICD-9 codes 415.11-415.13, 415.19), pulmonary-
related events (ICD-9 codes 518.52, 518.4, 519.00-519.09),
cardiac-related events (ICD-9 codes 997.1, 410.0-410.9,
998.0), neurologic-related events (ICD-9 codes 997.00-
997.02, 997.09), and sepsis (ICD-9 codes 995.91 and
995.92) were examined.
The Boston University School of Medicine Institutional
Review Board approved this study and informed consent
was waived.
Statistical analysis. Weighted numbers and percent-
ages were used for all statistical analysis. Univariate anal-
ysis performed included c2
test and survey linear
regression model as appropriate.
All patient and hospital covariates were considered for
possible confounders and underwent a variance inflation
factor test to evaluate for multicollinearity. Covariates
with a variance inflation factor >7 were excluded from
the multivariate model. Multivariable survey logistic
regression was used to identify factors that indepen-
dently associated with in-hospital mortality. The software
used for statistical analysis was Stata Statistical Software
release 14 (StataCorp LP, College Station, Tex). Statistical
significance was set at P < .005.
RESULTS
There were 648,662 firearm injuries identified in the data-
base. The majority of these injuries occurred in patients
who were between the ages of 16 and 45 years (82.3%;
Table I). Black race (40.2%) was the most common race,
and 88.7% were male. The majority (40.2%) had Medicaid
insurance, followed by self-pay/none (31.2%). The majority
were in the lowest household income quartile (42.5%).
Overall, intent was divided into assault/legal (60%), unin-
tentional (24.2%), suicide (8.6%), and undetermined
(7.1%; Table II). Injury location was extremity (29.5%),
abdomen/pelvis (23.2%), external without invading a
body cavity (16%), chest (12.1%), head/neck (11.5%), and
face (3.7%). Hospital characteristics were mainly urban
location (90.9%), teaching hospital (71.2%), and large bed
size (70%). Hospital by census regions was South (40.8%),
West (22.9%), Midwest (19.1%), and Northeast (17.2%).
There were 63,973 (9.9%) injuries that involved a
vascular repair (Table I). Vascular repair was seen
more often in patients aged 16 to 45 years (85.8% vs
82%; P < .0001), patients of black race (43.3% vs 39.8%;
P < .0001) and male sex (91.4% vs 88.7%; P < .0001),
patients with Medicaid (43.8% vs 40.3%; P < .0001),
patients with household incomes #$24,999 (46.9% vs
ARTICLE HIGHLIGHTS
d
Type of Research: Retrospective analysis of prospec-
tively collected data from the National Inpatient
Sample
d
Key Findings: In this retrospective analysis of the Na-
tional Inpatient Sample of over 648,000 firearm in-
juries, 9.9% required a vascular repair. The need for
vascular repair predicted higher mortality (5.5% vs
2.0%), sepsis (1.4% vs 0.5%), and any complication
(5.7% vs 2%).
d
Take Home Message: This study suggests that
firearm injuries resulting in vascular injuries requiring
repair are associated with higher rates of mortality
and complications.
Journal of Vascular Surgery Siracuse et al 1525
Volume 69, Number 5

45%; P ¼ .003), and cases of assault/legal intervention
(66.6% vs 59.3%; P < .0001).
The NISS was signiﬁcantly higher in patients with
vascular repair (Table II; Fig). Location of injury was
more likely in the abdomen/pelvis (33.6% vs 23.1%) and
the extremities (40.8% vs 29.5%; P < .0001) for those
with a vascular repair. Patients with vascular repair
were more likely to be treated at urban (97.3% vs
94.9%; P < .0001), teaching (78.9% vs 74.2%; P < .0001),
and large hospitals (74.5% vs 70%; P < .0001). The rates
of vascular repair per year have moderately increased
from 8.49% in 1993 to 10.87% in 2014 (Supplementary
Table II, online only).
The most common primary ICD-9 procedure codes for
those with vascular repair were open repair of blood
vessel with patch (24.4%; ICD-9 codes 39.56-39.58), suture
of artery (14.6%; ICD-9 code 39.31), suture of vein (7.92%;
ICD-9 code 39.32), other repair of vessel (5.14%; ICD-9
code 39.59), primary anastomosis (3.82%; ICD-9 codes
38.32-38.39), vessel bypass (18.9%; ICD-9 codes 38.42-
38.49, 39.22-39.26, 39.29), and vessel ligation (20.3%; ICD-
9 codes 38.82-38.89). Only 1.17% had a documented
endovascular intervention as the primary ICD-9 proced-
ure code. Secondary ICD-9 procedure codes were most
often suture of vein (17.9%; ICD-9 code 39.32), suture of ar-
tery (14.6%; ICD-9 code 39.31), open repair of blood vessel
with patch (14.8%; ICD-9 codes 39.56-39.58), other repair
of vessel (4.62%; ICD-9 code 39.59), primary anastomosis
(1.83%; ICD-9 codes 38.32-38.39), vessel bypass (3.6%;
ICD-9 codes 38.42-38.49, 39.22-39.26, 39.29), vessel ligation
(31.3%; ICD-9 codes 38.82-38.89), and endovascular
interventions (0.7%). Endovascular procedures were per-
formed three times more commonly during the second
half of the study.
Overall mortality rate was 2.2%; patients who under-
went vascular repair had a higher mortality compared
with those who did not require vascular repair (5.51% vs
1.98%; P < .001). Patients with vascular repair had higher
Table I. Characteristics of the patients
Overall
(N ¼ 648,662)
Vascular repair
(n ¼ 63,973)
No vascular repair
(n ¼ 584,689) P value
Year <.0001
1993-1996 152,442 (23.5) 13,646 (21.3) 138,796 (23.7)
1997-2002 167,900 (25.9) 15,955 (24.9) 151,945 (26.0)
2003-2007 144,942 (22.3) 14,522 (22.7) 130,420 (22.3)
2008-2014 183,378 (28.3) 19,851 (31.0) 163,527 (27.9)
Age, years <.0001
0-15 36,031 (5.6) 2571 (4.0) 33,460 (5.7)
16-45 534,140 (82.3) 54,874 (85.8) 479,266 (82)
$46 78,491 (12.1) 6528 (10.2) 71,963 (12.3)
Race/ethnicity <.0001
White 146,805 (22.6) 12,825 (20.1) 133,980 (22.9)
Black 260,478 (40.2) 27,730 (43.3) 232,748 (39.8)
Hispanic 94,519 (14.6) 9902 (15.5) 84,617 (14.5)
Other race 26,378 (4.1) 2817 (4.4) 23,561 (4.0)
Missing 120,480 (18.6) 10,698 (16.7) 109,782 (18.8)
Sex <.0001
Male 575,604 (88.7) 58,399 (91.4) 517,205 (88.7)
Female 71,162 (11) 5531 (8.6) 65,631 (11.3)
Insurance <.0001
Private 178,774 (27.6) 15,871 (25.1) 162,903 (28.2)
Self-pay/none 202,409 (31.2) 19,695 (31.1) 182,714 (31.6)
Medicaid 260,902 (40.2) 27,767 (43.8) 233,135 (40.3)
Household income .003
$1-$24,999 275,760 (42.5) 28,106 (46.9) 247,654 (45.0)
$25,000-$34,999 172,802 (26.6) 16,441 (27.5) 156,361 (28.4)
$35,000-$44,999 104,319 (16.1) 10,055 (16.8) 94,264 (17.1)
$$45,000 56,906 (8.8) 5280 (8.8) 51,626 (9.4)
Elixhauser score, mean 0.62 0.74 0.6 <.0001
Values are reported as number (%).
1526 Siracuse et al Journal of Vascular Surgery
May 2019

rates of acute renal failure (3.1% vs 0.8%; P < .0001),
venous thromboembolic events (0.5% vs 0.3%; P < .0001),
pulmonary-related events (0.6% vs 0.28%; P < .0001),
cardiac-related events (0.8% vs 0.2%; P < .001), sepsis
(1.4% vs 0.5%; P < .0001), and any complication (5.7% vs
2%; P < .0001; Table II).
Table II. Details of ﬁrearm trauma and outcomes
Overall
(N ¼ 648,662)
Vascular repair
(n ¼ 63,973)
No vascular repair
(n ¼ 584,689) P value
Trauma details
Intent <.0001
Assault/legal 389,506 (60) 42,604 (66.6) 34,6902 (59.3)
Unintentional 157,225 (24.2) 13,845 (21.6) 143,380 (24.5)
Suicide 55,601 (8.6) 2880 (4.5) 52,721 (9.0)
Undetermined 46,331 (7.1) 4644 (7.3) 41,687 (7.1)
NISS <.0001
1-3 137,110 (21.1) 2680 (4.2) 134,430 (23.0)
4-9 177,381 (27.3) 9364 (14.6) 168,017 (28.7)
10-18 150,795 (23.2) 20,955 (32.8) 129,840 (22.2)
19-75 172,478 (26.6) 30,886 (48.3) 141,592 (24.2)
Location of injury <.0001
Head/neck 74,491 (11.5) 4249 (6.7) 70,242 (12.5)
Face 24,044 (3.7) 758 (1.2) 23,286 (4.2)
Chest 78,597 (12.1) 6387 (10.1) 73,210 (13.1)
Abdomen/pelvis 150,479 (23.2) 21,183 (33.6) 129,296 (23.1)
Extremity 191,192 (29.5) 25,730 (40.8) 165,462 (29.5)
External without invading
a body cavity
103,773 (16) 4729 (7.5) 99,044 (17.7)
Hospital
Location <.0001
Rural 29,983 (4.6) 1658 (2.7) 28,325 (5.1)
Urban 589,821 (90.9) 59,224 (97.3) 530,597 (94.9)
Teaching status <.0001
Nonteaching 156,808 (24.2) 12,780 (21.1) 144,028 (25.8)
Teaching 461,547 (71.2) 47,988 (78.9) 413,559 (74.2)
Bed size <.0001
Small 32,846 (5.1) 2037 (3.2) 30,809 (5.3)
Medium 157,508 (24.3) 14,206 (22.3) 143,302 (24.7)
Large 454,297 (70) 47,340 (74.5) 406,957 (70.0)
Census region .17
Northeast 111,872 (17.2) 10,177 (15.9) 101,695 (17.4)
Midwest 123,618 (19.1) 12,539 (19.6) 111,079 (19.0)
South 264,578 (40.8) 26,674 (41.7) 237,904 (40.7)
West 148,595 (22.9) 14,584 (22.8) 134,011 (22.9)
Complications
Acute renal failure 6859 (1.1) 1950 (3.1) 4909 (0.8) <.0001
VTE 1921 (0.3) 342 (0.5) 1579 (0.3) <.0001
Pulmonary related 2051 (0.3) 416 (0.6) 1634 (0.28) <.0001
Cardiac related 1675 (0.3) 535 (0.8) 1140 (0.2) <.0001
Neurologic related 439 (0.1) 53 (0.1) 386 (0.1) .49
Sepsis 4071 (0.6) 889 (1.4) 3182 (0.5) <.0001
Any complication 15,123 (2.33) 3621 (5.7) 11,502 (2.0) <.0001
NISS, New Injury Severity Score; VTE, venous thromboembolism.
Values are reported as number (%).
Volume 69, Number 5

Vascular repair was independently associated with
mortality (odds ratio [OR], 2.68; 95% confidence interval
[CI], 2.43-2.95; P < .0001; Table III). Age older than 46 years
(OR, 2.01; 95% CI, 1.71-2.35; P < .0001), male sex (OR, 1.15;
95% CI, 1.05-1.25; P ¼ .003), self-pay/no insurance (OR,
1.6; 95% CI, 1.47-1.75), suicide intent (OR, 3.73; 95% CI,
3.36-4.13; P < .0001), unintentional intent (OR, 1.12; 95%
CI, 1.03-1.22; P < .0001), injury at the head/neck location
(OR, 13.9; 95% CI, 12.5-15.6; P < .001), Northeast region,
and NISS were independently associated with in-
hospital mortality. Vascular repair also predicted any
complication (OR, 2.12; 95% CI, 1.98-2.28; P < .0001;
Table IV). The number of vascular repairs was indepen-
dently associated with mortality (P < .0001) and any
complication (P < .0001; Tables V and VI).
DISCUSSION
Vascular injury requiring repair was associated with
increased in-hospital mortality. This is despite fewer
vascular injuries in the head/neck location and suicide
intent, which are overall associated with high lethality.
The majority of repairs were performed by open surgical
techniques, which is consistent with reports for all types
of penetrating trauma.15-17
Our study identifies the inci-
dence, location, severity, and mortality associated with
vascular injury from a firearm. This evidence allows
vascular surgeons to participate in a meaningful national
dialogue regarding this public health issue.
Blunt and penetrating vascular trauma has been
demonstrated to be associated with poorer outcomes
than trauma without a vascular injury.9-14
In our series,
abdominal injury was more often associated with
vascular repair. Abdominal vascular injuries are historically
highly lethal. Mortality rates for isolated abdominal aorta
and inferior vena cava injuries have been reported as
78% and 70%, respectively. Survival is lower when there
is concomitant injury, with a 93% mortality reported
with combined aorta and inferior vena cava injuries.9
Iliac
vessel injuries have also been shown to be highly lethal.10
The 30-day mortality rates of 16.5% for isolated iliac vein
injury, 19.3% for isolated iliac artery injury, and 48.7% for
combined isolated iliac artery and vein injuries were
reported for both blunt and penetrating trauma. Survival
was also lower for noniliac vessel injuries.10
In our series, vascular injuries were also seen more often
with firearm injury to extremities. Extremity trauma, both
blunt and penetrating, with vascular injury has tradition-
ally been associated with high morbidity and mortality.11
Increased rate of mortality has been reported with pene-
trating compared with blunt lower extremity vascular
trauma.14
Similarly, upper extremity trauma, particularly
involving axillary and subclavian vasculature, has been
associated with significant morbidity and mortality.13
As
demonstrated in lower extremity vascular trauma, pene-
trating upper extremity vascular trauma had high
mortality rates of 33.9% for combined proximal arterial
and venous injury.13
This analysis also identified other factors associated
with mortality aside from vascular repair. The Northeast
region was independently associated with mortality,
although it had the lowest reported firearm injuries.
This relationship could be due to lower volume and inex-
perience compared with other regions. Age and male
sex were independently associated with mortality. These
Fig. Change in computed New Injury Severity Score (NISS) by vascular repair across time. Survey-weighted linear
regression was used to calculate marginal means of NISS across years by vascular repair status. P interaction was
calculated to test the difference in temporal trends of NISS by vascular repair status. CI, Confidence interval.
May 2019

results were expected as they have traditionally been
risks factor for poor outcomes after trauma.20,21
Self-pay/no insurance was also associated with mortality.
Underinsured status has consistently been shown to
have poor health outcomes, even in accounting for
race and socioeconomic status, which was demon-
strated in our analysis.22,23
Head/neck injury was also
associated with mortality as these injuries have been
shown to have high lethality.24
Suicide intent was an
independent risk factor for mortality. Details about these
injuries (ie, exact site of head injury) are beyond the
variables available in the study’s database. Also, there
are relevant variables, such as time until treatment for
injury, that are not documented. The NISS has been
developed and shown to be more accurate than the pre-
vious Abbreviated Injury Scale that was developed in
1971.18
The NISS is the sum of the squares of the Abbrevi-
ated Injury Scale scores of a patient’s three most severe
injuries, regardless of body region. This has been used
as the standard summary measure of trauma severity.
In our series, the NISS was higher in patients undergoing
a vascular repair and independently was associated with
higher in-hospital deaths for patients with and without a
vascular injury.
This study has multiple limitations. It is a retrospective
review of a large administrative database. The sample
size may limit our study as statistical differences are
detected on univariate analysis between those who
undergo vascular repair and those who do not, but
some variables differ in magnitude of twofold or more,
such as the rate of venous thromboembolism. Although
we have details about procedures and injury location, the
details of the injuries are not clear. Only vascular repairs
Table III. Multivariable analysis of mortality
Covariate OR 95% CI P value
Vascular repair 2.68 2.43-2.95 <.0001
NISS <.0001
1-3 Reference
4-9 1.73 1.46-2.04
10-18 2.72 2.19-3.39
19-75 3.74 2.87-4.87
Age, years <.0001
0-15 Reference
16-45 1.00 0.86-1.18
$46 2.01 1.71-2.35
Male sex 1.15 1.05-1.25 .003
Insurance <.0001
Private Reference
Self/other/none 1.60 1.47-1.75
Medicaid 0.88 0.81-0.96
Intent <.0001
Assault/legal Reference
Unintentional 1.12 1.03-1.22
Suicide 3.73 3.36-4.13
Undetermined 1.96 1.65-2.33
Head/neck 13.9 12.5-15.6
Face 0.44 0.33-0.58
Chest 1.39 1.13-1.69
Abdomen or pelvis
contents
1.39 1.17-1.65
Extremities or pelvic
girdle
0.13 0.11-0.16
External without
invading a body
cavity
Reference
Elixhauser score >1 0.51 0.45-0.55 <.0001
Census region <.0001
Northeast Reference
Midwest 0.83 0.77-0.89
South 0.79 0.72-0.86
West 0.89 0.82-0.97
CI, Conﬁdence interval; NISS, New Injury Severity Score; OR, odds ratio.
Table IV. Multivariable analysis of any complication
Vascular repair 2.12 1.98-2.28 <.0001
NISS <.0001
1-3 Reference
4-9 2.58 1.92-3.46
10-18 3.12 2.40-4.04
19-75 3.67 3.13-4.32
Age, years <.0001
0-15 Reference
16-45 1.77 1.32-2.38
$46 2.66 2.08-3.39
Male sex 1.25 1.05-1.47 .008
Insurance .0001
Private Reference
Self-pay/none 0.71 0.60-0.83
Medicaid 0.97 0.86-1.09
Head/neck 1.5 1.16-1.95
Face 1.35 1.02-1.78
Chest 1.86 1.49-2.32
Abdomen and
pelvic contents
2.71 2.21-3.34
Extremities or
pelvic girdle
0.76 0.61-0.95
External without
invading a body cavity
Reference
Volume 69, Number 5

were included, which may underestimate injuries that
were observed or treated at later admission, such as
venous hematomas or arterial pseudoaneurysms.
Primary amputation would also not be captured for a
vascular injury. Our endovascular numbers were very
low, and this may reflect real-world practice, particularly
with trauma surgeons performing the repairs; however,
these interventions may not be captured as well as
open repairs. We are also unable to capture those with
a vascular injury who died without a repairdin the field,
in the trauma bay, or on exploration. Therefore, this will
further underestimate the lethality of firearm-related
vascular injury.
CONCLUSIONS
Firearm injuries with vascular repair were indepen-
dently associated with higher injury severity score and
mortality. A majority of vascular repairs were performed
for injury to the abdomen/pelvis and extremity and
with assault/legal intent, whereas head and neck injury
and suicide intent were the least frequent.
AUTHOR CONTRIBUTIONS
Conception and design: JS, BK
Analysis and interpretation: JS, TC, AF, TJ, YZ, JK, DJ, BK
Data collection: BK
Table V. Multivariable analysis of mortality with number
of vascular repairs
No. of vascular repairs <.0001
0 Reference
1 2.22 2.03-2.43
2-6 4.92 4.23-5.74
NISS <.0001
1-3 Reference
4-9 1.71 1.45-2.01
10-18 2.68 2.16-3.32
19-75 3.62 2.79-4.70
Age, years <.0001
0-15 Reference
16-45 1.00 0.86-1.17
$46 2.01 1.72-2.34
Male sex 1.16 1.08-1.25 <.0001
Insurance <.0001
Private Reference
Self/other/none 1.60 1.47-1.74
Medicaid 0.88 0.81-0.95
Intent <.0001
Assault/legal Reference
Unintentional 1.13 1.04-1.22
Suicide 3.73 3.36-4.14
Undetermined 1.96 1.65-2.33
Head/neck 14.5 12.8-16.2
Face 0.45 0.34-0.61
Chest 1.42 1.16-1.74
Abdomen or pelvis
contents
1.40 1.18-1.67
Extremities or
pelvic girdle
0.13 0.11-0.15
External without
Reference
Census region <.0001
Northeast Reference
Midwest 0.82 0.76-0.88
South 0.79 0.72-0.86
West 0.89 0.82-0.97
Table VI. Multivariable analysis of any complication with
number of vascular repairs
No. of vascular repairs
0 Reference <.0001
1 1.92 1.74-2.12
2-6 2.63 2.26-3.06
NISS <.0001
1-3 Reference
4-9 2.58 1.93-3.46
10-18 3.12 2.41-4.03
19-75 3.65 3.11-4.29
Age, years <.0001
0-15 Reference
16-45 1.78 1.32-2.38
$46 2.67 2.09-3.40
Male sex 1.24 1.06-1.46 .008
Insurance <.0001
Private Reference
Self-pay/none 0.70 0.60-0.83
Medicaid 0.97 0.86-1.09
Head/neck 1.52 1.17-1.96
Face 1.37 1.04-1.81
Chest 1.87 1.50-2.33
Abdomen and pelvic
contents
2.71 2.21-3.33
Extremities or
pelvic girdle
0.76 0.61-0.94
External without
Reference
May 2019

Writing the article: JS, TC, AF, YZ, BK
Critical revision of the article: JS, TC, AF, TJ, YZ, JK, DJ, BK
Final approval of the article: JS, TC, AF, TJ, YZ, JK, DJ, BK
Statistical analysis: JS, YZ, BK
Obtained funding: Not applicable
Overall responsibility: JS
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Volume 69, Number 5

Supplementary Table I (online only). International
Classification of Diseases, Ninth Revision (ICD-9) codes used
ICD-9 codes Description
Diagnosis codes
Intent
E9220-E9229 Unintentional
E9650-E9654 Assault
E9550-E9559 Suicide
E970 Legal intervention
E9850-E9856 Undetermined
Procedure codes
00.45-00.48 Vascular stent(s) placement
38.10 Endarterectomy of an
unspecified site
38.12-38.18 Endarterectomy of extracranial
vessels
38.32-38.39 Resection of vessel with
anastomosis of extracranial
vessels
38.82-38.89 Surgical occlusion of vessels
38.42-38.49, 39.22-39.26,
39.29
Surgical bypass
39.31 Suture of artery
39.32 Suture of vein
39.50 Angioplasty of peripheral
vessels
39.56-39.58 Repair of vessel with patch
39.59 Other repair of vessel
39.71-39.73 Endovascular intervention
Complications
diagnosis codes
584.5-584.9 Acute renal failure
415.11-415.13, 415.19 Venous thromboembolism
518.4, 518.52,
519.00-519.09
Pulmonary related
410.0-410.9, 997.1, 998.0 Cardiac related
997.00-997.02, 997.09 Neurologic related
995.91, 995.92 Sepsis
Supplementary Table II (online only). Rates of vascular
repair per year among firearm injury hospitalizations
Year Vascular repair, %
1993 8.49
1994 9.25
1995 8.49
1996 9.71
1997 8.92
1998 9.48
1999 9.71
2000 9.53
2001 9.29
2002 10.02
2003 9.41
2004 10.23
2005 10.07
2006 9.43
2007 10.88
2008 10.64
2009 10.61
2010 10.58
2011 11.05
2012 10.63
2013 11.49
2014 10.87
1531.e1 Siracuse et al Journal of Vascular Surgery
May 2019

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