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anagement of Civilian andilitary Vascular Trauma: Lessons Learned

ony Nguyen, MD, Jeffrey Kalish, MD, and Jonathan Woodson, MD

Management of vascular trauma has evolved tremendously since the turn of the 20th

century. The lessons from each major military conflict over the past 100 years have refinedour understanding of how to care for soldiers and civilians with vascular injuries. The recentwars in Iraq and Afghanistan have likewise improved our strategy for treating victims ofvascular trauma. Understanding the principles that guide management of vascular injurieswill result in preservation of life and limb.Semin Vasc Surg 23:235-242 © 2011 Elsevier Inc. All rights reserved.

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IPPOCRATES IS CREDITED with saying, “he whowishes to be a surgeon should go to war,” and its truth

s evident in the origins and development of current vascularurgical trauma care. Wars have always produced large num-ers of sick and wounded, which challenged physicians to

mprove the practice of medicine and surgery through devel-pment of new procedures, therapies, systems, and para-igms for care. Boiling oil and cautery of ancient wars gaveay to arterial ligation. Better sanitation and shorter, im-roved evacuation systems allowed the appropriate condi-ions to develop techniques to repair arteries. Ligation ofnjured vessels was still the predominant method of handlingascular trauma through the end of World War II. Arterialepairs and vein bypass grafting, resulting in a decrease inmputation rates (50% to 13%) and greater advances in limbalvage, arrived with the advent of mobile surgical hospitalsnd vascular specialty centers from the Korean and Vietnam

ars. Through the Vietnam Vascular Registry, a large vol-me of data was collected and analyzed, which led to devel-pment of best practices in the management of vascularrauma. The military lessons were disseminated to and fur-her refined in the civilian sector.1,2 Modern-day civilianrauma algorithms are rooted in the lessons learned on theany battlefields across the world.

pidemiologyrauma remains the leading cause of death in the 15- to4-year-old age group in the United States, as a consequence

oston Medical Center, Boston, MA.ddress reprint requests to: Jeffrey A Kalish, Boston Medical Center, 88 East

Newton Street, Collamore 5, D-506, Boston, MA 02118. E-mail:

sjeffrey.kalish@bmc.orgE-mail: jeffrey.kalish@bmc.org

895-7967/$-see front matter © 2011 Elsevier Inc. All rights reserved.oi:10.1053/j.semvascsurg.2010.11.004

f unintentional injury, assault, homicide, and suicide.3 Theistribution of civilian vascular trauma has not changeduch throughout the decades; penetrating trauma is still theredominant etiology (70% to 80%), while blunt traumaonstitutes 5% to 15% of injuries. Of the penetrating injuries,ost (50% to 80%) are sustained from gunshot wounds, and

tab wounds are less prevalent (10% to 30%). In addition,atrogenic vascular injury has been increasing in prevalences the number of invasive procedures increases. In fact, it haseen described as high as 33% of all vascular trauma at aevel I trauma center.4 Overall, arteries are more often injuredhan veins, and extremities are injured more than other anatom-cal regions (similar to reported military experiences).5

athophysiologyuccessful management and treatment of vascular injuriesequires an understanding of the pathophysiology and bio-echanics of vascular trauma. On a simplistic level, vascular

rauma is categorized into two types: blunt or penetrating.owever, the severity of injury is a consequence of multiple

actors: (1) direct injury to vessels from missiles or penetrat-ng objects; (2) the transfer of energy and heat to tissueskinetic energy). This results in cavitation effect (shock wave)f high-velocity moving objects as it penetrates tissues andill cause a zone of injury at a distance from the path of theissile tract; (3) the shearing or compressive forces of rapideceleration in the case of blunt trauma. This can lead toontusion, tearing, thrombosis, intimal flap, and dissectionf blood vessels; and (4), although uncommon, the emboli-ation of foreign objects (fragments, shotgun pellets, or bul-ets), which can potentially cause distal vessel injury, occlu-

ion, or thrombosis.

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236 T. Nguyen, J. Kalish, and J. Woodson

asic Principles of Openanagement of Vascular Trauma

anagement of vascular trauma begins with the initial triage,valuation, and resuscitation of the trauma patient. Appro-riate attention must be paid to the airway, ventilation, andxternal hemorrhage control, and circulating blood volumehould be restored. Immediate hemorrhage control can oftene obtained by direct pressure or application of tourniquetsn extremities. Once hemorrhage is controlled, then resusci-ation is continued through the remaining primary and sec-ndary survey in accordance with Advanced Trauma Lifeupport protocols to identify and prioritize all associatednjuries.

The patient with multiple injuries needs detailed assess-ent before embarking on complex or lengthy vascular re-airs. Unrecognized severe intraabdominal or intracranial in-

uries can lead to disastrous outcomes if not addressed early.ericardial effusions and cardiac contusions can render theatient too unstable to proceed with complex repairs. Vascu-

ar shunts have been used with increasing frequency to per-it temporary reperfusion of extremities while other injuries

re treated.Diagnosing vascular injury without any obvious source of

xternal hemorrhage is more challenging. Signs and symp-oms of arterial injury can be described as “hard” and “soft”Table 1). Hard signs, such as active arterial hemorrhage,xpanding hematoma, loss of distal pulse, signs of ischemia,nd a bruit or thrill are highly suggestive of arterial injury.rofound signs of ischemia include the classic 6 “Ps”: pares-hesia, paralysis, pulselessness, pain, pallor, and poikilother-ia. With such findings, no diagnostic imaging is usually

equired before surgical exploration of extremity vessels. Softigns raise the suspicion of arterial injury and include mod-rate-sized hematoma, history of significant blood loss orypotension at the prehospital scene, proximity of wound toascular structures or bony injuries, diminished distal pulses,nd ipsilateral neurologic deficits. Soft signs can warrant ad-itional diagnostic imaging, duplex studies or observationith repeated interval physical examination.Ankle-brachial index (ABI) is an objective bedside diag-

ostic procedure that is instrumental in the management ofower-extremity trauma patient. An ABI of �0.9 may suggestrterial injury and need for further diagnostic imaging.6 A

able 1 Clinical Signs of Arterial Injury: Hard Signs Warranturgical Exploration and Control, Soft Signs Afford Time forurther Diagnostic Imaging

Hard Soft

rterial bleeding History of prehospital blood lossoss of pulse Diminished pulsexpanding hematoma Moderate hematomaruit or thrill Proximity to large vessel or

bony injuryigns of ischemia (6 Ps*) Ipsilateral neurologic deficit

Paresthesia, paralysis, pulselessness, pain, pallor, and poikilother-

smia.

ood history and examination of the uninjured contralateralimb is important for interpreting ABIs. Older patients witheripheral vascular disease may present with reduced ABIs,onfusing the issue.

Once the decision for operative repair has been made, theasic principles for management of vascular trauma apply

rrespective of types and location of injury. Before exploringhe injured vessel, proximal and distal control must be ob-ained. This is especially important in injuries that haveeased bleeding due to an adherent clot or if the offendingenetrating object is still in place. Vascular control some-imes entails gaining exposure that is relatively distant fromhe site of injury due to a large surrounding hematoma. Ves-el occlusion can then be achieved by various methods orevices, such as vascular tapes or loops, vascular clamps,irect pressure with a sponge stick or finger, or balloon oc-lusive devices.

Although anticoagulation is routinely used in elective vas-ular procedures before obtaining vascular control, its use inhe trauma setting is limited. It is typically contraindicated, asrauma patients usually present with multiorgan injuries withncreased intracerebral or solid organ bleeding risks. In theituation where there is an isolated vascular injury, then an-icoagulation can have a role. But this decision should beatient- or injury-specific, as combined vascular injuries areommon and total control of venous bleeding might be dif-cult.Debridement of the injured segment of vessel is the initial

tep in vascular repair. Leaving damaged intima increasesignificantly the chance of post-repair thrombosis with all thettendant consequences. Remembering the pathophysiologyescribed here about kinetic energy and cavitation effect,esection and debridement of the vessel might need to bextended beyond the site of obvious injury to include theotal zone of damaged artery. External examination of thertery alone might not permit proper assessment of the extentf injury.For simple laceration of large vessels, lateral suture arteri-

rrhaphy can suffice if the vessel is large enough and theaceration is �50% of the circumference. Smaller vessels orarger lacerations may require a patch angioplasty to preventtenoses. Autogenous vein is the preferred patch material. Aegmental resection with an end-to-end anastomosis can beerformed for more complex injuries spanning a distance of1 cm. The ends should be spatulated to avoid anastomotic

tricture, especially with small vessels. The key point, as inny vascular repair, is to produce a tension-free anastomosis.sually, 3 cm of artery need to be mobilized for every 1 cm

esected. For injuries �1 cm, an interposition graft is usuallyequired. The ideal conduit is the contralateral saphenousein, if available. The ipsilateral saphenous vein should note sacrificed if there is a concomitant ipsilateral venous injuryecause it is an important collateral venous return pathway.hen autogenous vein is unavailable, prosthetic is an alter-

ative and polytetraflouroethylene is most commonly used.owever, wound contamination and soft-tissue injury limit

he use of prosthetic grafts and patency rates are lower. Con-

truction of spiral vein grafts is largely of historical interest.

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Management of civilian and military vascular trauma 237

he time required to make these grafts and the high throm-osis rates do not warrant their use.

pecific Injury Managementxtremity Injurieshe initial triage of extremity vascular injury follows theuidelines outlined here. Patients with hard signs of vascularnjury are explored without any additional diagnostic imag-ng. If there is any concern regarding location, severity ofnjury, or thrombosis of the runoff vessels, then an intraop-rative angiogram can be performed. When patients presentith soft signs, variable strategies have been offered for man-

gement. In awake, mentally competent patients, serial phys-cal examinations may suffice. Duplex scanning is a low-costption to interrogate axial extremity vessels. Computed to-ographic angiography has grown in popularity because of

he availability of rapid thin-slice scanners, accuracy, andbility to evaluate for multisystem trauma.6

Surgical repair of an extremity vascular injury follows therinciples and techniques described here. Anticoagulationhould be given if it is reasonably safe, but significant soft-issue injury or solid-organ injury usually preclude its use.egional infusion of heparinized saline frequently suffices in

ieu of systemic anticoagulation. Before completion of theepair, a Fogarty balloon catheter should be advanced prox-mally and distally to remove any thrombus. If any concernsxist about the integrity of the runoff vessels, intraoperativerteriography should be performed.

Intraluminal shunting can be performed when vascularepair needs to be delayed due to unstable fracture requiringmmediate fixation, resuscitation requirements, or the needo perform other life-saving procedures.6,7 This can be ac-omplished with various manufactured shunts, but any ade-uately sized sterile tubing can be used. Recent reports fromhe Iraq military conflict showed acceptable patency rates ofp to 18 hours without anticoagulation. However, patencyas dependent on location, with decreasing rates from 86%

t proximal arteries to 12% at more distal locations.8 Shuntatency also depends on a number of technical factors.hambers et al identified certain factors that contribute to

hunt failure: insufficient venous outflow, untreated com-artment syndrome, redundancy causing angulation or loop-

ng of the shunts, and inadequate length causing dislodge-ent.9

able 2 Major Vessels of the Cervical Zones

Zone I: Thoracic Outlet toCricoid Zone II: Cricoid to

ommon carotid artery Common, external, annnominate artery (on the right)ubclavian artery and vein Vertebral artery

nternal jugular vein Internal jugular veinortic arch

nnominate vein

In upper-extremity brachial artery injury, severe ischemias uncommon, as there are numerous collaterals. Isolatednjury to either the radial or ulnar artery can be treated withigation, as there should be adequate collateral perfusionrom the other vessel unless the patient has an incompletealmar arch. In cases where both forearm vessels are injured,hen the ulnar should be revascularized because it is com-only the dominant vessel.Concomitant vascular and orthopedic injuries commonly

ose a dilemma as to which repair takes precedence. Typi-ally, vascular repair should be done before orthopedic repairn order to minimize ischemia time if there is not markednstability or shortening of the limb.10 The vascular repair

ust be evaluated for disruption before the final wound clo-ure or undraping after the bony fixation is completed. Whenhe integrity of a vascular repair may be compromised by aomplex fracture fixation, then it may be ideal to temporarilyevascularize with an intraluminal shunt.11,12 The definitiveascular repair is then performed after the orthopedic proce-ure. An alternative is expeditious placement of an externalxator before the definitive vascular repair. Despite all ofhese theoretical concerns, studies have shown that the sur-ical sequence does not affect the rate of amputations.13

eck Injurieseck injury poses a significant diagnostic and therapeuticilemma. There are numerous vital structures in the very

imited space extending from thoracic outlet to skull base. Inddition to vascular structures, the aerodigestive tract anderves are all at risk. The neck is divided into three anatom-

cal zones to simplify the approach to cervical vascularrauma management (Table 2). Zone I extends from the tho-acic outlet to the cricoid cartilage; Zone II from cricoid car-ilage to the angle of the mandible; and Zone III from angle ofhe mandible to the base of the skull. Initial management andriage of cervical trauma is dependent of the zone and type ofnjury.

As usual, hemodynamically unstable patients are immedi-tely explored in the operating theater without diagnosticmaging other than cervical plain films. Exposure will dependn the zone of injury. Vascular control for Zone I and III areotoriously difficult due to anatomical constraints. For thateason, in hemodynamically stable patients, diagnostic imag-ng is recommended for the purpose of surgical planning. In

le of MandibleZone III: Angle of Mandible

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rnal carotid artery Internal and external carotid artery

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238 T. Nguyen, J. Kalish, and J. Woodson

ddition, endovascular treatment of Zone I and III injuriesay provide viable options that are less morbid.For Zone I, proximal control is obtained via a median

ternotomy incision with extension of the incision on to theeck as necessary. The innominate and left common carotidrtery can be controlled through this incision. The left prox-mal subclavian artery, on the other hand, usually requires aecond or third left intercostal space anterolateral thoracot-my. A cervical incision along the anterior border of theternocleidomastoid muscle is required for Zone II injury. Ifhe bleeding is then found to be from a more proximalource, then the cervical incision can be extended into aedian sternotomy. In the situation of bilateral cervical vas-

ular injuries, either a transverse Kocher incision or bilateralervical incisions will gain exposure to both carotids. Whenxposure of Zone III is required, subluxation or resection ofhe angle of the mandible and resection of the posterior bellyf the digastric muscle may be necessary (Table 3). Even so,ontrol of the distal internal carotid artery may still be diffi-ult. Other methods to gain distal control are balloon occlu-ive devices through the common carotid artery or site ofnjury. Due to the difficulty in exposure and control of ZoneII injuries, endovascular treatment is the preferred optionhen feasible.Surgical options for the management of carotid injuries

nclude ligation or repair (primary, patch angioplasty, or by-ass). The external carotid artery and internal jugular veinsually can be ligated with impunity. Ligation of the internalarotid artery can be associated with significant morbiditynd is usually performed when no other surgical options arevailable.14,15 If primary internal carotid artery repair is notossible, there are several reconstruction options. The exter-al carotid artery can be used as a conduit by dividing it andransposing the proximal end to the internal carotid artery.therwise, an interposition graft can be constructed with

aphenous vein or rarely with prosthetic graft. Shuntinghould be use if there are concerns regarding collateral per-usion from the Circle of Willis.

Treatment for blunt cervical vascular trauma usually in-olves a nonoperative approach. Blunt cervical vascular inju-ies are less frequent, with an incidence of 0.6% in an un-creened versus up to 25% in a screened blunt traumaopulation.16 Computed tomographic angiography has beenccepted as the screening modality for blunt cervical vascular

able 3 Exposure Incisions for Cervical and Great Vessels In

Zone III Zone II

osteriorly to mastoid process withsubluxation of mandible

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njury, as it compares favorably with conventional angiogra-hy.17 The majority of blunt cervical vascular injuries onlyequires medical treatment with either antiplatelet or antico-gulation therapy for 3 to 6 months, but the optimal agent isnknown because there are no randomized controlled studyomparing the two.18 Recent meta-analyses showed no dif-erence between antiplatelet agents and warfarin.19,20 Indica-ions for invasive therapy include progression of neurologicymptoms, persistence of pseudoaneurysm despite anti-hrombotic treatment, and worsening chronic dissection.he choice of therapy, endovascular or open, is dependentn location of injury, contraindication to antithromboticherapy, and compliance with follow-up. Surgical repair cansually be done primarily or with patch angioplasty.Vertebral artery injury is a rare occurrence, with an inci-

ence of up to 0.77% of all trauma admissions. Medical treat-ent for blunt injuries with antithrombotic agents is identi-

al to treatment for carotid artery injury. In fact, most caseeries describe both carotid and vertebral artery injuries si-ultaneously.20 Exposure of the vertebral artery depends on

he particular segment injured. The most accessible segments the first segment (V1), which begins at the origin and endst C6. Exposure requires dividing the sternocleidomastoidnd anterior scalene muscle from their thoracic outlet attach-ents. The phrenic nerve is at risk in this area. The second

egment (V2) travels through C6 to C2 transverse foramensnd requires resection of the anterior transverse process. Thisissection is hazardous because of the adjacent nerve rootsnd an extensive venous network. In addition, the artery inhis segment is deficient in the external elastic lamina andragile. The third segment (V3) begins at C2 and travels to thekull base. Exposure requires extending the cervical incisionosteriorly to the mastoid process. The sternocleidomastoiduscle is divided with care not to injure the spinal accessoryerve. The lateral process of C1 also needs to be resected toain access to the V3. The fourth segment (V4) is intracranial,s it travels along the brainstem to join the contralateral ver-ebral artery.

Because of these difficult and hazardous exposures, surgi-al treatment of vertebral artery hemorrhage is best treatedith ligation at V1. Continued bleeding from the other seg-ents can be temporarily treated with bone wax packings or

alloon occlusive devices before definitive endoluminal em-olization at the distal end of the vessel.21

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Management of civilian and military vascular trauma 239

xillosubclavian Injuriesnjury to the subclavian vessels has a high morbidity andortality. Demetriades et al documented a 61% prehospital

nd 15.5% perioperative mortality rate in their series of 228enetrating subclavian vessel injuries.22 Surgical dissection

n the thoracic outlet region is highly morbid due to thedjacent brachial plexus, surrounding hematoma, and asso-iated pulmonary and mediastinal injuries of these traumaticnjuries. Therefore, it is usually necessary for hemodynami-ally unstable patients only. In stable patients, it is prudent tobtain imaging before therapy, usually with computed tomo-raphic angiography. This allows evaluation of associatedervical, thoracic, and mediastinal injuries. But the “goldtandard” is conventional angiography because of its poten-ial for diagnosis and therapy. Because of the morbidity con-erns of surgical treatment, endovascular treatment hasvolved into the ideal therapy in the hemodynamically stableatient. Even if surgical repair is indicated, a large compliantcclusion balloon can be placed at the time of angiographyor proximal control. If indicated in an unstable patient, theubclavian artery can be ligated without resulting in severeschemia due to the abundance of collaterals. If limiting clau-ication occurs the artery can be reconstructed electively.23-25

Exposure of the right subclavian artery or innominate ar-ery for proximal control is through a median sternotomy.he proximal left subclavian artery is accessed with a highnterolateral thoracotomy in the second or third intercostalpace. The clavicle can be resected as needed. Distal subcla-ian exposure requires a supraclavicular incision. Isolatedxillary artery injury can be treated with an infraclavicularncision, but proximal control usually requires exposure ofhe subclavian artery (Table 3).

ortic and Caval Injuriesortic injury (predominantly located at the isthmus) is theecond most common cause of death in blunt trauma.26

armley et al advocated urgent surgery in this patient popu-ation as they had a 61% 7-day mortality rate in their series.27

he treatment paradigm has shifted since then to a nonop-rative approach in hemodynamically stable patients, witheveral studies showing no increase in survival with earlyurgery.28-30 Blood pressure control should be the initialreatment goal. Simon and Leslie identified several risk fac-ors for failure of conservative management: increasing me-iastinal hematoma or pleural effusion, extravasation of con-rast, malperfusion complications, and hypotension.31

Surgical repair of the descending thoracic aorta requires aeft thoracotomy. After obtaining proximal and distal control,epair of injury is standard with primary or, more often,nterposition graft repair. Distal aortic perfusion during aor-ic clamping is usually required and can be via a left atrial toistal aorta, right atrium to femoral artery, or femoral arteryo femoral vein bypass. Repair of the great vessels can beerformed with interposition grafts via side-biting vascularlamps without the need for cardiopulmonary bypass. Expo-

ures were described in earlier sections. l

The vascular abdomen is divided into three retroperitonealones. Zone I is the midline and includes the supramesocolicasculature (celiac trunk, superior mesenteric artery, renalrteries, inferior vena cava (IVC) and its branches, suprarenalorta) and the inframesocolic vasculatures (inferior mesen-eric artery, IVC, infrarenal aorta). Zone II is the perinephricegions. Zone III is the pelvic region and includes the iliacessels. Management of abdominal vascular trauma dependsn the type and location of injury.Exposure of the supramesocolic Zone I entails mobiliza-

ion and medial rotation the left colon, spleen, tail of pan-reas, stomach, and possibly left kidney. This will gain expo-ure to the aorta, celiac, superior mesenteric artery, and leftenal artery. Mobilization and medial rotation of the rightolon, duodenum, and head of pancreas will expose the rightenal artery and supramesocolic IVC. The inframesocolicone I is exposed by retracting the mesocolon cephalad andmall bowel to the right and dividing the parietal peritoneumverlying the aorta or IVC. Mobilization and medial rotationf the right colon, duodenum, and head of pancreas or leftolon will also gain access to the right and left Zone II, re-pectively. Medial rotation of the right or left colon will alsollow exposure of Zone III inferiorly.

Surgical treatment of the specific vessel injury follows theasic principles of vascular surgery. Primary repair can beone with lateral arteriorraphy or end-to-end anastomosis, ifossible. If reconstruction is required, then autogenous veinr polytetraflouroethylene are both optional conduits. In theetting of enteric contamination, it is not desirable but per-issible in life-saving situations to use polytetraflouroethyl-

ne, but copious irrigation and vascularized tissue coveragef the anastomosis is imperative.32 Ligation of the celiac trunkor its branches) or the inferior mesenteric artery is usuallyenign. On the other hand, ligation of the superior mesen-eric artery has significant risk of extensive bowel ischemia.

Zone II hematoma in blunt trauma should not be explorednless it is expanding. On the contrary, all penetratingrauma Zone II hematomas should be explored. Treatmentptions include nonoperative, revascularization, or nephrec-omy. Revascularization of occluded renal arteries should note attempted unless ischemia time is less than 6 hours, therere bilateral renal injuries, or there is injury to a solitaryidney.33-35

Zone III hematomas should be explored if due to a pene-rating injury, or to a blunt injury with a resulting expandingematoma or an abnormal femoral pulse. Ligation of com-on or external iliac is not tolerable and should not be done.

n damage-control situations, intraluminal shunting is advis-ble. As with extremity vascular injuries, development ofompartment syndrome is possible and patients should beonitored; and there should be a low threshold for fas-

iotomy.Vena caval injury can usually be repaired primarily with

ateral venorrhaphy, but patch angioplasty and polytetraf-ouroethylene interposition graft may be necessary for largernjuries. The key is to avoid a subsequent stenosis after theepair, which is at risk of developing thrombosis or embo-

ism; a temporary IVC filter may be required in such a case.

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240 T. Nguyen, J. Kalish, and J. Woodson

igation of the infrarenal IVC may be tolerated and necessaryn unstable patients, but all suprarenal IVC injuries must beepaired due to the frequent occurrence of hemodynamicnstability secondary to drop in preload and significant risk ofenal failure with ligation at this level.36 Exposure of theetrohepatic vena cava is very difficult. A retrohepatic hema-oma is the only exception to mandatory exploration of allenetrating trauma hematoma. Perihepatic packing is therst-line treatment, and can be left in place for 24 to 48 hoursefore a second-look operation. If all else fails, then atriocavalhunting, total hepatic vascular isolation, or division of theiver to gain exposure can be attempted for hemorrhage con-rol.

atrogenic Injuryatrogenic vascular injury is an increasing problem, compris-ng up to 33% of the current civilian vascular trauma patientopulation.37,38 The rise of iatrogenic vascular injury resultsrom more frequent catheter-based therapies. Of these, 60%re due to femoral access complications and 27% are intra-perative injuries.4 Aside from percutaneous access compli-ations, these injuries are also associated with orthopedic andpine procedures.39 Wood et al40 systematically reviewed 40rticles that reported the frequency of vascular injury withnterior lumbosacral spine surgery. The overall vascularomplication rate was 5% (range, 0 to 18%), and venousnjury was more common than arterial injury (up to 18% v%). The most common vessels injured were the left com-on iliac vein, IVC, and iliolumbar vein, usually due to re-

raction of the vessels. Procedural risk factors were L4-L5xposure, revision surgery, transperitoneal approach, andaparoscopic technique. The authors recommended having aascular surgeon available when these risk factors wereresent.40

More of these iatrogenic injuries are requiring invasiveherapy to either treat or prevent complications. Guilbert etl41 reported a case series of 13 patients who had either ca-otid or subclavian artery cannulation with �7Fr catheteruring internal jugular vein central line placements. Fiveatients were treated with a “pull and pressure” method ofanual compression. All had subsequent complications of

leeding, stroke, or death. Eight patients, on the other hand,ere treated with either open repair or an endovascular ap-roach of catheter removal, and none had complications.hey performed a meta-analysis comprising 30 patients with

nternal jugular vein line misplacement. Seventeen patientsere treated with the pull/pressure method, and 13 patientsere treated with open or endovascular repair. All eight pa-

ients who developed complications (airway compromiseue to hematoma, pseudoaneurysm, hemothorax, andeath) were from the pull/pressure group.41

ar and Vascular Traumahe first recorded attempts at repair of arterial injuries wereuring World War I by Croatian surgeons, but the tech-iques used remain unknown. Long evacuation times for

asualties, sepsis, and poor instruments also limited interest a

nd feasibility of repairing injured vessels. Debakey andimeone reviewed the results of 2,471 vascular injuries re-ulting from World War II and documented a 50% amputa-ion rate when ligation of injured vessels was performed.42

espite this appalling high rate of amputation, they still con-luded that arterial repair was not warranted in most casesecause of the high complication rates secondary to sepsisnd thrombosis.

The Korean conflict was marked by the US Army Fieldingobile Army Surgical Hospitals (MASH units) and surgical

esearch teams. Casualty evacuation times were improvedith the use of helicopters, and antibiotics were more plen-

iful than in previous wars. These conditions permitted spe-ial surgical teams to explore the potential repair of vascularnjuries and document a decline in extremity amputation raterom the 50% seen in World War II to 13% when vascularnjuries were repaired.

The Vietnam War marked advances in the utilization ofelicopters for transporting troops and wounded soldiers.ombat medics were better trained to control hemorrhagend specialized centers were identified by the US Army toreat and evaluate vascular injuries. Colonel Norman Richstablished the Vietnam Vascular Registry at Walter Reedrmy Hospital. This registry helped define the optimal algo-ithms for managing patients with vascular trauma, such ashe importance of repairing a venous injury occurring con-omitantly with a popliteal artery injury to improve patencyates of the arterial repair.

As previously stated, the advancement in management ofascular trauma has been written in the history of the wars ofhe past century. At the time of the writing of this article,merica has been at war for a decade and old lessons about

he management of vascular trauma have been reinforced andew lessons have been learned. The wars in Afghanistan (Op-ration Enduring Freedom) and Iraq (Operation Iraqi Free-om) have been marked by advances in technology, tacticalnd strategic evacuation (flying intensive care units), andpplication of body armor. The US Army has developed andelded a new advanced combat action tourniquet, resuscita-ion protocols, smaller (20-person) and more mobile traumaesuscitation teams (Forward Surgical Teams), and a Jointheater Trauma Registry that allows rapid improvement inare. In addition, there has been improvement in the trainingf medics, surgeons, and trauma teams.All of these improvements have contributed to the lowest

ase fatality rates in the history of modern warfare. A soldiernjured in battle has a �97% chance of surviving if they maket to a Forward Surgical Team. A standard has been set in theombat zone that all injured soldiers will receive Traumaenter Level care within the first “golden hour” defined byivilian trauma systems.

The signature injury-producing weapon of Operation Iraqireedom and Operation Enduring Freedom is the impro-ised explosive device. Improvement in protective body andehicle armor has contributed to soldier survivability, but theate of extremity trauma is now higher in survivors thanreviously reported in earlier wars. Extremity injury now

ccounts for 40% to 70% of all combat wounds, with 70% of

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Management of civilian and military vascular trauma 241

xtremity injuries occurring on the lower extremities. Vascu-ar injuries occur in 5% to 7% of all those injured on theattlefield. Clouse et al reviewed the current status of vascu-

ar trauma in wartime using the Balad Vascular Registry fromraq.43 They noted that cervical vascular injuries accountedor 16% of vascular trauma, with carotid injuries constitutingearly three-quarters (73%) of this group. They also reportedn increased use of temporary vascular shunts to perfuseimbs, while other priorities were addressed or while patientsere transported to a higher level of care. Eighty-six percentf shunts remained patent during their period of use withoutnticoagulants. Extensive soft-tissue and bony injuries (re-ected in a high Mangled Extremity Severity Score) were therimary reasons for limb loss, rather than inability to revas-ularize the limb. The management strategy of rapid evacu-tion, temporary shunting, and early definitive vascular re-air in the combat zone has resulted in excellent limb-salvageates. The recent wars have produced only a limited experi-nce with endovascular management of vascular trauma. Iso-ated subclavian artery and carotid-jugular fistula repairsith stent grafts have been reported. The long logistical trail,arying endovascular abilities of surgeons, and multiple in-uries of victims have limited the application of endovascularechniques. These issues are now being analyzed. The abilityo rapidly evacuate critically ill soldiers from the combat zonesing Critical Care Air Transport Teams within hours to daysfter wounding increases the possibility of applying endovas-ular therapies at medical centers remote from the battlefield.here have been �30,000 casualties, with only 1,200 ampu-

ations resulting from Operation Iraqi Freedom and Opera-ion Enduring Freedom. Limb salvage revascularization sur-ery, coupled with superb rehabilitation programs, haseturned hundreds of soldiers and civilians injured on theattlefield to productive lives. If war is the dark side of hu-anity, then the advances in medical care resulting from this

xperience represent the hope for humanity.

onclusionshe tenets of management of vascular trauma have evolved

rom the many lessons that can be traced through differentime periods, different wars, and different battlefields acrosshe world. Vascular surgical care will always rely on the basicremise of “stopping the bleeding,” and restoring perfusion.lthough open surgical management has always been theold standard for dealing with vascular trauma, the use ofndovascular techniques is becoming more prominent forelected indications. The benefits and detriments of theseewer technologies will require constant reevaluation to ar-ive at the optimal care algorithms as the future unfolds.

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