ORIGINAL ARTICLE Combat Related Vascular Trauma

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1 ORIGINAL ARTICLE Combat Related Vascular Trauma Ahmad Hussain Mishwani 1, Abdul Ghaffar 2 and Sarfaraz Janjua 3 ABSTRACT Objective: To determine the frequency and pattern of different types of vascular injuries, their management and surgical complications. Study Design: Case series. Place and Duration of Study: Combined Military Hospital, Peshawar, from August 2008 to August Methodology: All patients of vascular injuries were included. Traumatic amputation, amputation for extensive soft tissue, or nerve injury, death due to reasons other than vascular injuries or Mangled Extremity Severity Score (MESS > 7) were excluded from study. Data included patient profile, time and date of admission, place, site, type and mechanism of injury, associated injuries, vital signs, treatment, type of vascular repair and outcome. Decision to operate was mainly based on clinical diagnosis and hand-held Doppler finding. Results: There were 170 vascular injuries in 96 patients; 76.4% were arterial and 23.5% were venous. Gunshot wounds was main cause (54%) and extremities were the commonest site (85%). Arteries were repaired in 87% and veins in 40% cases. Venous interposition graft was the preferred method of repair. The overall limb salvage rate was 95%. Thrombosis and infection of the graft and repair were the main causes of secondary amputation. Haemorrhage, reperfusion injury and infection were the main causes of death. Conclusion: Every effort should be made to repair an injured artery to preserve a limb and life. Tourniquet, prophylactic fasciotomy and vascular shunts play an important role. Management of life threatening injuries, unstable fracture of long bones and debridement before definitive repair of artery is important. Key words: Vessel graft. Combat vascular injuries. Arterial trauma. INTRODUCTION Major vascular injury is a leading cause of potentially preventable haemorrhagic death in modern combat operations. From the time of Hippocrates, vascular surgery has progressed by lessons learnt from the care of wounded in wars. Care of vascular injuries has advanced as a result of the wars of the 20th century and the work of Debakey, Hughes, Rich, and others. 1-4 From the 73% amputation rate in World War II with routine ligation, formal repair of peripheral artery injuries in Korean War and further refinements in Vietnam War reduced amputation rate for popliteal artery injuries to 13%. 5 Advances in vascular surgery and successful repair even in field hospital in recent past have saved up to 95% limbs. 5,6 Recent improvements in critical care, trauma education, damage-control techniques, such as temporary shunting, commercial tourniquets and armour technology play an important role in the pattern of vascular injury and its outcome. Different types of combat wounds are gunshot wounds (fire arm injuries) and wounds caused by explosive devices. Low-velocity missile wounds damage a vessel Department of Surgical 1 / Neurosurgery 2 / Anaesthesia 3, Combined Military Hospital, Peshawar. Correspondence: Brig. Ahmad Hussain Mishwani, Consultant Surgeon and Head of Surgical Department, CMH, Peshawar. ahmishwani@yahoo.com Received November 23, 2010; accepted February 11, in its path only. High-velocity missile can injure a vessel at a distance by widespread destruction caused by blast effect and fragmentation of the missile or bone. Other causes are blunt trauma of motor vehicle accidents, falls, crush injury and air crash, fractures and dislocations. High energy, high velocity mechanism of injury causing extensive tissue damage, contamination, multiple associated injuries, mass casualties, insecure operating environment and routes, delay between injury and repair and less than ideal conditions for surgery all lead to increased morbidity and mortality posing great challenges to the surgeon and team treating war casualties. As far as possible all arterial injuries should be repaired to save limb and life, but some times ligation of a vessel may be a safer option to save life of a patient at the cost of limb. 7 The objective of this study was to describe the patterns, management and complications of combat vascular injuries sustained during war on terror in Khyber Pakhtunkhawa (KPK) and FATA area, Pakistan. METHODOLOGY Vascular injuries in 96 patients were studied from August August 2010 at CMH, Peshawar, KPK, which is a 600 beds tertiary care hospital for troops from Swat to South Waziristan. Traumatic amputation, amputation for extensive soft tissue, or nerve injury, death due to reasons other than vascular injuries or Mangled Extremity Severity Score (MESS > 7) were excluded Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (4):

2 Ahmad Hussain Mishwani, Abdul Ghaffar and Sarfaraz Janjua from the study. Data included patient profile, time and date of admission, place, site, type and mechanism of injury, associated injuries, vital signs, treatment, type of vascular repair and outcome. Decision to operate was mainly based on clinical diagnosis and hand held Doppler. Explosive devices include improvised explosive device (IED), rocket-propelled grenade (RPG), antipersonnel landmines and high-explosive mortars shell. Hard signs of arterial injury were taken pulsatile external bleeding, enlarging haematoma, absent distal pulses, a thrill/bruit, or ischaemic limb (pain, pallor, pulselessness, poikilothermia, paresthesia, and paralysis). Anklebrachial pressure index (ABPI) of < 0.9 or a difference of > 0.1 in ABPI of two extremities was taken to indicate an arterial injury until proven otherwise. Soft signs of vascular injury were taken to proximity of wound to major vessels, history of haemorrhage/shock, non-expanding haematoma, diminished pulse, and anatomically related nerve injury. Pain on squeezing the calf or limb, nonblanching, coarse mottling, large patches of fixed staining, blistering and liquefaction was taken to indicate infarction and impending irreversible ischaemia and considered contraindication for vascular repair. Primary repair was defined as end-to-end anastomosis of the injured vessel. Lateral repair was defined as transverse or longitudinal repair with or without venous patch. Autologous venous graft was defined as interposition graft of reversed autologous vein. Early limb salvage was defined as the treated limb being viable at hospital discharge or death for reason other than limb vascular injury. Data was analysed in Statistical Package for Social Sciences (SPSS) version 13. Mean and Standard deviation were calculated for categorical variables age, gender, while frequency was calculated for type of injury, mechanism of injury, type of repair, and surgical complications. RESULTS Ninety-six patients, 6% of all casualties, had 170 vascular injuries, 130 arterial and 40 venous which also include the concomitant arterial and venous injuries. Gunshot wounds were found in 54% (n=92) patients, explosive devices caused 40% (n=68) injuries, road side accidents 4% (n=7) and crush injuries 2% (n=3) patients. Anatomically, 54% (n=92) of vascular injuries occurred in lower extremities, 31% (n=53) in upper limb, 12% (n=20) in abdomen and pelvis and 3% (n=5) in head and neck. Detailed distribution of arterial injuries is shown in Table I. The majority 85% (n=144) of injuries involved extremities. Ten patients suffered more than one lower extremity vascular injuries and 4 suffered more than one upper extremity vascular injuries (Figure 1 A-B). Concomitant venous injuries were common in both upper and lower extremities and venous injury without arterial injury occurred in only 10 patients. Detailed distribution of venous injuries is shown in Table II. Figure 1 (A,B): Multiple limb vascular injuries. Figure 2 (A,B,C,D,E,F,G,H,I): A. Blocked Vascular shunt; B. Clot in artery proximal to blocked shunt; C. Vascular shunts in artery and vein; D. Canalised clot proximal to shunt; E. Improvised vascular shunt of NG tube; F. Blocked Field repair; G,H,I. Subclavian artery injury, control and repair. Figure 3 (A,B,C): Popliteal artery injury with extensive soft tissue and bone loss, managed by shortening, DCS by external fixator and vascular shunt in place. Injuries to cervical and truncal vessels were rare in patients who survived during evacuation to the hospital. 214 Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (4):

3 Combat related vascular trauma Table I: Arterial injuries. Anatomic distribution and management of arterial injuries Operative procedure performed Location and artery No (%) AVG Primary repair Lateral repair Ligation Embolectomy/ thrombectomy Lower extremity 70 (41.1) Common femoral A 5 ( 3) 4 (2.3) 1 (0.5) Superficial femoral A 15 (8.8) 10 (5.8) 4 (2.3) 1 (0.5) - - Profunda femoral A 10 (5.8) 4 (2.3) 3 (1.7) 2 (1.1) 1 (0.5) - Popliteal A 15 (8.8) 12 (7) 2 (1.1) 1 (0.5) - - Anterior tibial A 8 (4.7) 2 (1.1) 3 (1.7) - 2 (1.1) 1 (0.5) Posterior tibial A 9 (5.2) 4 (2.3) 3 (1.7) - 1 (0.5) 1 (0.5) Peroneal A 8 (4.7) - 4 (2.3) 2 (1.1) 2 (1.1) - Upper extremity 40 (23.5) Subclavian artery 2 (1.1) 1 (0.5) 1 (0.5) Axillary artery 6 (3.5) 5 (2.9) 1 (0.5) Brachial artery 14 (8.2) 10 (5.8) 3 (1.7) 1 (0.5) - - Radial / ulnar artery 18 (10.5) 8 (4.7) 6 (3.5) - 3 (1.7) 1 (0.5) Abdomen 16 (9) Renal arteries 4 (2.3) - 1 (0.5) 1 (0.5) 2 (1.1) - Mesenteric arteries 6 (3.5) - 2 (1.1) - 4 (2.3) - Common Iliac arteries 1 (0.5) (0.5) - - Internal Iliac Artery 2 (1.1) (1.1) - External Iliac Artery 3 (1.7) - 2 (1.1) 1 (0.5) - - Head and neck 4 (2.3) Common carotid A 2 (1.1) - 1 (0.5) 1 (0.5) - - Internal carotid artery 1 (0.5) - 1 (0.5) External carotid A 1 (0.5) (0.5) - - Table II: Venous injuries. Anatomic distribution of venous injuries Name of vein Injured Treatment Number (%) Repair Ligation Inferior vena cava 2 (1.1) 2 (1.1) - Common Iliac vein 1 (0.5) 1 (0.5) - External Iliac vein 1 (0.5) 1 (0.5) - Common femoral 2 (1.1) 2 (1.1) - Superficial femoral 10 (5.8) 3 (1.7) 7 (4.1) Deep femoral vein 4 (2.3) - 4 (2.3) Popliteal vein 10 (5.8) 4 (2.3) 6 (3.5) Internal jugular vein 2 (1.1) 1 (0.5) 1 (0.5) External jugular vein 3 (1.7) - 3 (1.7) Axillary vein 5 (2.9) 2 (1.1) 3 (1.7) Table III: Complications of vascular repair. Complications No (%) Thrombosis 2 (1.1) Haemorrhage 2 (1.1) Infection 4 (2.3) Graft disruption 1 (0.5) Reperfusion injury 2 (1.1) Compartment syndrome 2 (1.1) Chronic pain syndrome 1 (0.5) Death 3 (1.7) None of the patients who survived evacuation to the facility had thoracic vascular injury. Seventy-seven patients had extensive or segmental loss of vessel requiring venous graft or ligation. Associated injuries were mostly caused by explosive devices and included fracture in 35% (n=59) cases, multiple soft tissue injuries in 40% (n=68), nerve injuries in 5% (n=8), abdominal injuries in 14% (n=24), thoracic injuries in 5% (n=8) and head injury in 4% (n=7) cases. Associated fractures and nerve injuries were also common with Gunshot wounds. Tourniquets were used in 2 patients of traumatic amputations and for proximal control in unstable patients. Four patients were received with vascular shunts as a damage-control measure, 2 of which were occluded by the time they reached CMH but the limbs were viable and survived (Figure 2 A-E). One brachial artery and one popliteal artery were repaired in Forward Treatment Centre (FTC) without proper facilities by inexperienced junior surgeons; both were found occluded on re-exploration and revised by graft (Figure 2 F). Twenty percent patients were received in a state of shock and 5% with hypothermia to Emergency Department, majority of these injuries were caused by explosive devices. Sixty percent of venous injuries were treated with ligation, while 40% (n=16) were primarily repaired. The arterial injuries were treated by venous interposition grafting 46%, (n=60) (Figure 2 G-J), primary end-to-end anastomosis 29%, (n=38), lateral repair with or without venous patch (9%, n=12), ligation 17%, (n=22) and thrombectomy/embolectomy in 3% (n=4). In 4 patients end-to-end anastomosis occluded overnight and was replaced by a reverse venous graft Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (4):

4 Ahmad Hussain Mishwani, Abdul Ghaffar and Sarfaraz Janjua within 12 hours to save the limb. Eighty seven percent of arterial and 40% of the venous injuries were repaired. In 2 of the patients with extensive bone and soft tissue loss, shortening helped us in primary end-to-end anastomosis and soft tissue coverage (Figure 3 A-C). The overall limb salvage rate was 95%, (n=161) with a secondary amputation rate of 5%, (n=9) performed mostly on patients with more than 12 hours interval between injury and repair. One patient of internal carotid artery injury had neurological deficit before repair of the artery which persisted postoperatively. There were no amputations due to isolated venous injuries. The cause of secondary amputation was infection of the graft in 3 patients and thrombosis in 2 cases. Infection was the main complication; other complications are shown in Table III. Three patients died; one due to irreversible haemorrhagic shock on reception, second due to secondary haemorrhage from the disrupted infected femoral artery graft and the third from reperfusion injury leading to acute renal failure, ARDS, coagulopathy and multiple organ failure. Patients with more than 6 hours interval between injury and repair were more vulnerable to reperfusion injury, infection. Shock and delay of more than 12 hours between injury and repair were main contributors to secondary amputation and mortality. DISCUSSION This study provides an insight into management of warrelated vascular injuries. Patients reached the hospital by Helicopter, Ambulance car or private transport within 6 hours of injury. Use of a tourniquet saved many lives as is claimed in other studies. 8 Improvised temporary arterial shunts of feeding tubes, nasogastric tubes and chest drains, (due to non-availability of commercial shunts) were used in 10% patients in this study as compared to more than 70% cases quoted in some Western studies. 9 Gunshot wounds were common in this study opposed to Western reports of blasts and explosive injuries. 6 Extremity injuries in (85%) patients is a figure comparable to other reports. 6 The frequency of abdominal and neck injuries is slightly higher in this report compared to the Western studies due to difference in the use of personal protective garments and body armours and higher number of gunshot injuries by sniper shooters and ambushes in the thickly forested mountainous areas. Paralysis and loss of sensation were due to associated nerve injury in some patients. In some arterial injuries, distal pulses were present due to good collateral circulation. Arterial spasm was not a cause of limb ischaemia after trauma The decision of exploring a vessel was based on characteristic external wounds requiring exploration and debridement, pulse oximetry, hand-held Doppler and ABPI instead of diagnostic arteriography recommended in other studies. 12 Most of the patients required immediate resuscitation and intervention, so time-consuming investigations like CT and MR angiography were not done as reported in some studies. 13 A delay and warm ischaemia time of more than 6 hours led to amputation. The muscle viability was decided on the basis of 4 Cs {color, contraction, circulation, consistency (the best)} by fasciotomy. A viable muscle rebounded to its original shape when grasped by a forceps, while a non-viable muscle retained the mark. 14 Management was based on the principles of ATLS, ABCD and E, by an experienced multidisciplinary team of general, vascular, plastic and orthopaedic surgeon. All life threatening injuries were managed before definitive repair of vessels. A separate team harvesting vein graft reduced our operation time. Residual thrombus was cleared by balloon catheter, followed by flushing with heparinized saline. Intraluminal vascular shunts were used to restore circulation of limb and gain time in case of delay in evacuation, lengthy lifesaving procedures, external fixation of associated fractures before arterial repair, debridement of extensive wounds and careful decision of re-construction and primary amputation as reported by others. 9,15 In case of injuries to both artery and vein, the artery was repaired first. The arteries were repaired by lateral suture for minimal injuries, patch angioplasty, end-to-end oblique anastomosis without tension and interposition autogenous vein. Collateral vessels were preserved and use of prosthetic grafts avoided as far as possible except as a temporary measure as is recommended. 4,16 An arterial graft from the contralateral amputated limb may be used. Embolectomy was used in 4 patients with good result. It was tried to repair all arterial injuries including forearm and crural arteries in stable patients. Although some may be ligated with acceptable complication rate, if distal perfusion and viability of limb is confirmed by hand held Doppler. 12,17 Endovascular stents were not used due to non-availability, although it is a preferred option for some patients. The grafts and anastomosis was covered by healthy muscles and soft tissues. Shortening helped in primary end-to-end anastomosis and soft tissue coverage in patients with extensive bone and soft tissue loss, as reported earlier. 18 Main indications for liberal use of fasciotomy were a delay of 4-6 hours after vessel injury, combined vein and artery injury, arterial ligation, concomitant fracture, crush injury, severe softtissue injury, muscle oedema or tense compartment or doubt about compartment syndrome or observation by surgical/nursing staff. Slight elevation of injured extremity was helpful in improving postoperative oedema. 19 The use of vacuum assisted closure dressing (Vac Pack), for complex soft tissue injuries before skin grafting or rotation flap coverage, expedited and simplified the care of these wounds by eliminating soakage, smell and the need for frequent changes of dressing. 12 The lower mortality and amputation rate compared to other studies is due to above mentioned factors, exclusion criteria and not repairing some doubtful cases 216 Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (4):

5 Combat related vascular trauma where others might have tried. Most of these findings are consistent with reported literature on vascular trauma. The frequency of 6% vascular injuries is consistent with other international studies but exact figure may be higher with the use of arteriography. CONCLUSION Every effort should be made to repair an injured artery to preserve a limb and life. Tourniquet, prophylactic fasciotomy and vascular shunts play an important role. Management of life threatening injuries, unstable fracture of long-bones and debridement before definitive repair of artery is important. REFERENCES 1. DeBakey ME. History, the torch that illuminates: lessons from military medicine. Mil Med 1996; 161: DeBakey ME, Simeone FA. Battle injuries of the arteries in World War II: an analysis of 2,471 cases. Ann Surg 1946; 123: Hughes CW. Arterial repair during the Korean war. Ann Surg 1958; 147: Rich NM, Hughes CW. Vietnam vascular registry: a preliminary report. Surgery 1969; 65: Starnes BW, Bruce JM. Popliteal artery trauma in a forward deployed Mobile Army Surgical Hospital: lessons learned from the war in Kosovo. J Trauma 2000; 48: Vance YS, Zachary MA, Garth SH, Alec CB, James AS. Demographics, treatment, and early outcomes in penetrating vascular combat trauma. Arch Surg 2008; 143: Guraya SY, Gardezi JR, Sai GA, Malik U, Nasim A, Imran A. Peripheral vascular injuries: Jinnah Hospital, Lahore, experience. Pakistan Postgraduate Med J 2000; 11: Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, et al. Pre-hospital tourniquet use in operation Iraqi freedom: effect on haemorrhage control and outcomes. J Trauma 2008; 64:S Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma 2006; 61: Joseph MG, Kenneth LM, David VF, Michael ED. Vascular injuries of the axilla. Ann Surg 1982; 195: Clouse WD, Rasmussen TE, Peck MA, Eliason JL, Cox MW, Bowser AN, et al. In-theatre management of vascular injury: 2 years of the Ballad Vascular Registry. J Am Coll Surg 2007; 204: Fox CJ, Gillespie DL, O'Donnell SD, Rasmussen TE, Goff JM, Johnson CA, et al. Contemporary management of wartime vascular trauma. J Vasc Surg 2005; 41: Bynoe RP, Miles WS, Bell RM, Greenwold DR, Sessions G, Haynes JL, et al. Non-invasive diagnosis of vascular trauma by duplex ultrasonography. J Vasc Surg 1991; 14: Callum K, Bradbury A. Acute limb ischaemia. In: Donnelly R, London NJ, editors. ABC of arterial and venous disease. New York: Wiley Blackwell; p Chambers LW, Green DJ, Sample K, Gillingham BL, Rhee P, Brown C, et al. Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during operation Iraqi freedom: one unit's experience. J Trauma 2006; 61: Vertrees A, Fox CJ, Quan RW, Cox MW, Adams ED, Gillespie DL. The use of prosthetic grafts in complex military vascular trauma: a limb salvage strategy for patients with severely limited autologous conduit. J Trauma 2009; 66: Aftabuddin M, Islam N, Jafar MA, Haque E, Alimuzzaman M. Management of isolated radial or ulnar arteries at the forearm. J Trauma 1995; 38: Hsu JR, Beltran MJ. Skeletal trauma research consortium: shortening and angulation for soft-tissue reconstruction of extremity wounds in a combat support hospital. Mil Med 2009; 174: Tai N, Raj JP, Walsh M. Vascular trauma. Surgery 2007; 25: l l l l lol l l l l Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (4):