Eur J Trauma Emerg Surg (2013) 39:123–129 DOI 10.1007/s00068-012-0228-4
ORIGINAL ARTICLE
Penetrating peripheral vascular injury management in a Sri Lankan military hospital A. Ratnayake • B. Samarasinghe • K. Halpage M. Bala
•
Received: 1 May 2012 / Accepted: 6 September 2012 / Published online: 25 September 2012 Ó Springer-Verlag 2012
Abstract Purpose Vascular injuries in austere military conflict settings are a challenging problem. The goal of the current study was to analyze the unique features associated with the management and early outcome of penetrating vascular injuries resulting from the conflict in Sri Lanka. Methods All adults with extremity vascular injuries admitted to the Military Base Hospital Anuradhapura in an eight-month period were prospectively recorded in a data sheet and retrospectively analyzed. Mechanism, location, method of repair, and outcomes were analyzed. Result Out of a total of 5,821 combat-related casualties, there were 128 victims with vascular injuries (2.2 %). The overall limb salvage rate was 83 % with an all-cause mortality of 3.1 %. Combined arterial and venous injuries were most common (44 %), predominantly in the popliteal zone. Among the arterial injuries, 70 % were repaired with a vein interposition graft and 7 % were primarily repaired. The majority of the venous injuries (54 %) were ligated. Twenty early major complications were recorded. A temporary intraluminal shunting technique was applied in the 14 most severely injured patients. This patient population was followed up for an average of 35 days institutionally
A. Ratnayake K. Halpage Military Base Hospital, Anuradhapura, Sri Lanka B. Samarasinghe Department of Surgery, University of Peradeniya, Peradeniya, Sri Lanka M. Bala (&) Department of General Surgery and Trauma Unit, Hadassah-Hebrew University Medical Center, Kiriat Hadassah, POB 12000, 91120 Jerusalem, Israel e-mail: [email protected]
before they were referred to rehabilitation (60 %) or transferred to other institutions (26 %). Conclusions Vascular reconstruction using vein, combined with a wound management strategy and early fasciotomy, resulted in a high limb salvage rate and remarkably low infection, delayed amputation, and mortality rates. Management of combat vascular injuries based on clinical guidance is feasible and leads to good outcome in a minimally equipped setting during local military conflicts. Surgeons in military hospitals should be trained in vascular injury repair to save the lives and functional limbs of patients. Keywords Vascular injuries Combat experience Military hospital Limb salvage Early fasciotomy
Introduction Combat vascular injuries often combine massive soft-tissue destruction with osseous and neurological trauma [1, 2]. Further complicating the situation, the surgeon has to serve in a setting that is far from ideal and lacks valuable resources [3]. In current conflicts, surgeons generally attempt limb salvage unless the extremity is so badly mangled that salvage is pointless or orthopedic reconstruction is unavailable, based on the degree of soft-tissue and nerve damage and extent of bony injury [2, 4, 5]. The objective of this study was to provide an account of wartime extremity vascular injury in a local military conflict in Sri Lanka from the unique perspective and setting of a wartime military hospital. An additional objective was to analyze management strategies related to vascular reconstruction and to report early infection, limb salvage, and mortality rates.
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Description of local conflict settings Military Base Hospital (MBH) Anuradhapura is among the field hospitals located in North-Central Province, Sri Lanka, 120–180 km south of the main battleground during humanitarian operations. Surgical care in relation to this battlefield has been organized by dividing it into echelons based on size, capability, and proximity to the front line. The first echelon is the advanced dressing station (ADS), which serves as a triage facility performing limited lifesaving procedures close to the front line, and forwarding the wounded to the main dressing station (MDS) and further to the third echelon, the MBH. The MBH is the closest referral hospital for military personnel with extremity and vascular injuries, and is located 40–45 min (average helicopter flying time) from the MDS. The MBH is equipped with two operating theaters, a three-bed intensive care room, and 80-bed unmonitored wards. Two general surgeons, trained for three months in vascular surgery, take care of all casualties.
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extremities. The contralateral vein was taken preferentially for lower extremity injuries, although the ipsilateral vein was required in few cases. In nearly all cases, vascular repair was attempted within the first hours from the time of admission. Temporary intraluminal shunting (TIS) was indicated for patients with combined arterial, venous, and soft-tissue injuries and concomitant long bone fractures when the decision was made to perform limb salvage. The standard sterile system tubing was used as a shunt. Concomitant venous injuries were repaired selectively. Prophylactic four-compartment fasciotomies were performed in the majority of the injured patients as soon as they were assessed at the MBH. Patients requiring definitive orthopedic care or advanced intensive care were transferred to other centers after blood flow to the injured extremity was established. Early outcomes were determined, including the need for delayed amputation, graft thrombosis, infection with late anastomotic disruption, and death. Short-term follow-up data were reviewed.
Methods Results All adults with extremity vascular injuries admitted to the MBH from November 2008 to June 2009 were prospectively recorded on a data sheet and retrospectively analyzed. Extremity vascular injuries include those in which limb salvage assessment was attempted. Patterns of injury were documented, noting the mechanism of vascular injury, anatomical distribution, and the presence of associated nonvascular trauma. The mechanism of injury was categorized as either gunshot wound or explosive devices with shrapnel. Vascular injuries were characterized by type (arterial, venous, or a combination thereof) and macroscopic description (transection, laceration, or thrombosis of vessels). Antipersonnel mine (APM) injuries were excluded from the study population due to the unavoidability of amputation considering the severity of injury. Basic demographic data collected included patient age, length of hospital stay, and number of operations. Combatants triaged by MDS as having isolated peripheral vascular injuries were evaluated on arrival at the MDH. Hand-held Doppler examination and ankle brachial index (ABI) served as important adjuncts to clinical assessment when no hard signs of vascular injury were presented. An ABI of below 0.9 was considered abnormal. Vascular repairs were classified into four methods of treatment: ligation, primary repair (including patch angioplasty), interposition autologous vein graft, and open vessel exploration with thrombectomy. The great saphenous vein was the conduit of choice in both the upper and lower
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Incidence and distribution of vascular injuries During the period from November 2008 to June 2009 a total of 5,821 combat-related casualties were admitted to the MBH. Out of these, 128 victims (2.2 %) had peripheral vascular injuries and were included in the study group. All were healthy male combatants with a median age of 24 years (range 18–42). The mechanism of penetrating vascular injury was high-velocity gunshot wounds in 65 patients (50 %) and flying particles from explosive devices in 53 patients (42 %). There were 58 (44 %) combined arterial and venous injuries, 53 (42 %) isolated arterial injuries, and 12 (9 %) with isolated venous pathology. In six cases (4.7 %) the explored main vessels were found to be normal and ligation of branches was performed (branches of the popliteal artery in four cases and profunda femoris in two cases). Long bone fractures were associated with vascular injury in 30 % of cases, while neurological trauma was detected in 15 % of patients on admission. Clinical characteristics of the patients Time delay from injury to definitive care was recorded in 96 cases (75 %) and found to be 5.5 h on average (range 2.5–16.3 h). Hemodynamic parameters at presentation were recorded in 71 patients (55 %). Seven patients presented with shock and required resuscitation.
Penetrating peripheral vascular injury management
Fig. 1 Anatomical distribution of 115 arterial injuries
125
Fig. 3 Methods of treatment of arterial injuries in 115 cases. IPVG interposition vein graft
Table 1 Venous injuries and repair modes
Fig. 2 Macroscopic characteristics of 115 peripheral arterial injuries found on exploration
Twenty-six limbs had palpable pulses at presentation to the MBH. In 42 injured extremities only a Doppler signal was presented, while in 34 limbs neither Doppler signals nor pulses were recorded below the injured area on presentation. Data were not recorded for 27 cases (21 %). The anatomic distribution of arterial injuries is shown in Fig. 1, and macroscopic characteristics are shown in Fig. 2. Lower extremity was the most frequent site for arterial vascular injury—83 cases (72 %). Most arterial injuries required an interposition vein graft (IPVG) (Fig. 3). Arterial ligation was undertaken in cases of tibial (n = 2), ulnar (n = 1), and popliteal (n = 14) vascular injury. Four profunda femoris artery injuries were managed by ligation. Out of 22 primary ligations, 13 limbs were amputated during the same procedure, while one limb was amputated 24 h later. Concomitant arterial and venous injuries were present in 58 lower and four upper extremity cases, while isolated venous injury was found in 12 cases. Either interposition vein graft or lateral venorrhaphy were used to repair 25 (36 %) of these venous injuries (Table 1). Only six popliteal veins were repaired in 21 revascularized limbs, given
Anatomy (N)
Ligation
Lateral repair
Vein patch
IPVG
Amputation
External iliac vein (1)
–
01
–
–
–
SFV-Ft (11)
03
04
01
03
–
SFV-AC (22) Popliteal vein (30)
11 15
08 06
– –
01 –
02 09
Posterior tibial vein (2)
02
–
–
–
–
PF (4)
04
Total (70)
38
20
01
04
– 11
N number of cases, IPVG interposition vein graft, SFV-Ft superficial femoral vein in femoral triangle, SFV-AC superficial femoral vein in adductor canal, PF profunda femoris vein
the extent of soft-tissue loss and the technical challenge of working in this anatomic location. Temporary intraluminal shunting Fourteen TIS procedures were performed during the study period. Patients who required TIS as a primary revascularization strategy had definitive repair done during the same operation following wound debridement, fracture stabilization, and vein graft harvesting. TIS was established in 12 cases to minimize the time required when the ischemic time had already been exceeded (and thus limb viability was questionable), and on two occasions it allowed a single surgeon to treat two patients simultaneously. All 14 injuries were at the level of popliteal (n = 8) or superficial femoral (n = 6), with both arterial and venous injuries. The median mangled extremity severity score (MESS) in this cohort was 8 (range 5–11). In two cases a temporary shunt resulted in heavy bleeding from fractured bone and hemodynamic instability necessitating primary amputation. In another case, nonviable distal muscle
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Fig. 4 Outcome of temporary intraluminal shunts in 14 cases
compartments necessitated amputation during the same procedure. In this subgroup of TIS, two deaths and two delayed amputations were documented, while seven limbs were viable at discharge from the hospital (Fig. 4).
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thrombectomy was performed during the revision of anastomosis. Delayed amputation was performed in one case, and three patients developed symptomatic limb ischemia (and were transferred to the specialized vascular center). Five arterial anastomotic disruptions were detected during the study period following extensive soft-tissue injury and local infection. Disruptions occurred after an average of 14 days (7–29 days). In four cases the bleeding vessel was ligated without any major sequela. Amputation was required in one case (Table 2). Extensive soft-tissue injury was noticed in all cases. Follow-up was performed in a hospital outpatient clinic for patients who required wound care for an average of 35 days. Following complete care, 76 patients (61 %, 76 of 124 survivors) were referred to the Ragama Rehabilitation Center. Thirty-three patients (26 %) were transferred to other institutions for orthopedic or intensive care early in the postoperative period. Data were not available in 15 cases.
Complications and outcome The mortality in the 128 patients with extremity injuries was 3.1 % (n = 4). Two deaths were due to multiple organ dysfunction syndrome, which developed at days 1 and 3 after revascularization of the lower limbs. The MESS was 9 in both cases, and an initial temporary shunt was established. Both occurred after vascular reconstruction and attempts at limb salvage had been made, and in both instances the degree of injury to the bones and soft tissue was such that attempts at salvage may have contributed to the deaths. Two deaths were directly attributed to the hemodynamic instability after revascularization. There were 17 primary amputations in the series, while proximal vascular repair was performed before the distal amputation in four cases. Primary ligation was performed in the remaining 13 limbs. There were two forearm amputations, and all the rest were in the lower limb (12 above the knee, two through the knee, and one below knee). Twelve victims (70 %) had associated long bone fractures, while fractures were found at two levels in three cases. Nonviable distal muscle compartments (n = 15, 88 %) were found to be an indication for primary amputation; while amputation was performed due to severe softtissue injury in two cases. There were a total of 20 postvascular repair complications (5.5 %), which included ten graft thromboses; five anastomotic disruptions resulted in five delayed amputations. Ten suspected thromboses of arterial repairs were detected due to either the disappearance of pulses immediately postprocedure or routine debridement in 24–48 h. One case was detected immediately following reconstruction and corrected at the same time. In another four cases
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Discussion In contemporary combat theaters, the amputation rate has, impressively, fallen below 10 %. The factors that may have contributed to this are (among others) rapid evacuation of injured soldiers from the battlefield in helicopters, advances in echelon care, damage control resuscitation, and the use of new techniques: TIS and early fasciotomies [4–7]. The low rate of extremity vascular injuries (2.2 %) in this series in comparison to other contemporary wars in Iraq and Afghanistan (12 %) [8] may have been a result of more soldiers with extremity vascular injuries dying on the way to the third echelon, as the average time taken was 5.5 h (as compared to 2 h in Iraq) [5]. The higher number of popliteal injuries (34 % in our series) in comparison with other papers (17–22 %) [4–6] could be explained by the war tactics employed in the Sri Lankan war theater. During the last years of the humanitarian operation, gunfire from underground bunkers at ground level made the knee and lower thigh the most vulnerable sites. In the Sri Lankan war theater, the recorded number of noncritical arterial injuries (below the brachial and popliteal arteries) was less due to the fact that they were managed by direct ligation without proper recording in situations with a high casualty load at a low level of care by military medical units. Some never reached specialized care. Tourniquets were not used enough by the Sri Lankan army. All injured limbs were presented to the MBH (definitive care facility) either packed or following exploration, and often ligation had been done at the second echelon of care (20 cases recorded).
Penetrating peripheral vascular injury management
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Table 2 Characteristics of patients with anastomotic disruptions and early outcome Case no.
Injury mode
Anatomical site
Injury morphology
Associated injury
MESS
Time to repair (h)
Time to rupture (days)
Type of repair
Outcome
1
ED
PTf-AT
Transection
ST???
6
[24
14
Ligation
Limb saved
6
\6
29
IPVG
Limb saved
7
Not recorded
7
IPVG
AKA
7
\6
9
Lateral Repair
Limb saved
6
\6
14
IPVG
Limb saved
V? NB2
GS
SFA-FT
Transection
ST???? VNB-
3
GS
SGPA
Transection
ST???? V? N? B-
4
GS
AC-SFA
Thrombosis
ST???? VNB?
5
GS
PT
Transection
ST???? V? N? B-
ED explosion device, GS gunshot injury, PTf-AT popliteal trifurcation, anterior tibial, SFA-FT superficial femoral artery, femoral triangle, SGPA supragenicular popliteal artery, SFA-AC superficial femoral artery, adductor canal, PT posterior tibial artery, ST soft tissue loss, V vein injury, N injury to the nerve, B long bone, MESS mangled extremity severity score, IPVG interposition vein graft, AKA above-knee amputation
No other studies have reported this number of vascular trauma victims within this timeframe (six months). The average number of casualties per day was around 40. The dilemma faced by surgeons when confronted with extremity vascular injuries in the combat setting is to choose between revascularization with attempted limb salvage and immediate amputation. During decision making, an ischemic time of 6 h does not predict good results per se. Neither an absence of angiography nor a shortage of experienced vascular surgery staff were reasons for primary amputation. In cases where multiple casualties arrived, the preference was for temporary shunting in order to gain time for definitive repair. Despite the average 5.5 h delay that occurred in our patient population, a reasonably good limb salvage percentage (83 %) was achieved. The wide range of times taken to arrive were due to delays in evacuation from the battlefield and lower echelons due to insufficient triage and transportation systems. In a recent report on military experience from the United Kingdom, the MESS did not help to decide whether or not an amputation was appropriate. Age, for example, was not relevant [9]. Our primary amputation decision was made based on the presence of nonviable compartments and extensive soft-tissue and bone injuries. Of 17 primary
amputations performed, proximal revascularization allowed distal amputation in four cases, facilitating an option of a better prosthesis. Wide fasciotomy prior to reconstruction also made this decision-making process more accurate. Early prophylactic fasciotomy at echelons 1 and 2 are beneficial in severe cases of extremity vascular trauma. Early fasciotomy became the current practice in the Sri Lankan military setting to allow early assessment of muscle compartments with this unpredictable ground situation. An uncomplicated fasciotomy wound can be primarily closed within 2–3 days without much morbidity, and this was the cost that we had to bear for the viable muscle compartment that resulted in selected cases. We think that the unique experience of early fasciotomy before revascularization could be beneficial in the setting of delayed referral to a higher level of care in cases with peripheral vascular injuries. In this report, 70 % of the extremity arterial injuries were repaired via the autologous vein, and another 7 % by primary means. In current combat theaters, 55–67 % of the arteries are repaired by interposition graft, while an impressive amputation rate of close to a 5 % is achieved [4–7]. The explanation for the higher amputation percentages in our series (17 %, 22 of 129 limbs) comes from the
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fact that the majority of arterial injuries were caused by high-energy gunshot injuries (50 %) with extensive tissue damage. Also, predominant injuries to the popliteal area and delayed patient presentation preclude vascular repair. For primary repair to be successful, it is essential to perform adequate debridement. The independent influence of wartime venous injury on limb loss and morbidity was established by Rich et al. [10]. In many cases venous injuries were not recorded, and were often treated by primary ligation, especially for upper extremity injuries. Not surprisingly, while isolated venous injuries were rare, none resulted in the amputation of an extremity. We have not been aggressive enough at repairing associated femoral and popliteal venous injuries, as in most instances incoming casualties with suspected vascular trauma preclude such an effort. If we consider our overall 36 % repair rate, popliteal and femoral veins were the only veins repaired. In addition, it should be noted that all cases of delayed amputation had associated venous injury. TIS are a great help for surgeons at the front as well as surgeons in the higher echelons. It allows for early transfer from one echelon to another without causing further ischemia to the limb, and allows surgeons in the higher echelons to perform appropriate debridement or orthopedic fixation prior to proceeding with vascular reconstruction [11, 12]. In the theater in Sri Lanka, TIS was used in a desperate attempt to save limbs that were at the edge of viability for rapid restoration of distal limb perfusion (MESS of 8). Among this cohort of 14 limbs there were seven failures. The use of TIS in the underserved, resource-inadequate environment associated with our series allowed a single surgeon to perform two simultaneous vascular reconstructions. Twenty limbs in our series had complications, of which 12 (60 %) were related to wound infections. The most common complication with arterial reconstruction is the development of wound infection, which leads to secondary hemorrhage or thrombosis and poses the greatest threat to vascular reconstruction. Three of five delayed amputations were performed due to uncontrolled infection complicated by hemorrhage or thrombosis. Injuries to the popliteal artery and the superficial femoral artery had the highest rates of associated postoperative complications. All infected grafts required excision and ligation and eventually resulted in one delayed amputation. Our results were consistent with the literature, which has shown that 3–6.6 % of casualties with a vascular repair will proceed to amputation [5, 6, 13]. Study limitations First, detailed data on the injury mechanism, presence of associated injuries, and exact operative technique were not available for some cases in the cohort. The trauma system
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and the registry of trauma patients are not mature enough, meaning that lots of information on ISS, GCS, and MESS are missing or not exist. The often emergent operating mode with multiple admissions and the lack of registrars and uniform data collection prevent important details from being promptly recorded. The second limitation is the lack of long-term follow-up, even though patients were not discharged from the hospital until all wounds were definitively closed. Finally, the strategies described in this series have not been compared with other vascular reconstruction and wound management techniques. Despite these limitations, the overall observations reported herein are significant, and add knowledge that complements reports of previous wartime experiences.
Conclusions This study shows that in a hospital with limited modern diagnostic facilities in a developing country, peripheral vascular trauma can be managed successfully by early recognition, clinical diagnostic skills, and expert surgical repair. In the military settings with long transportation time, early fasciotomy prior to definitive vascular reconstruction result in a better outcome. Autologous saphenous vein graft interposition remains the treatment of choice for the majority of vascular injuries. Popliteal vessels injuries are most challenging and associated with a high amputation rate. TIS are a favorable option in the severely injured and when the ischemic time has exceeded 6 h. TIS also facilitates limb perfusion prior to transfer to a higher level of care. Complications are mainly due to technical errors and infections. Surgeons in military hospitals should be trained in vascular injury repair to save the lives and functional limbs of patients. Conflict of interest
None.
References 1. Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. A profile of combat injury. J Trauma. 2003;54:S13–9. 2. Gawande A. Casualties of war-military care for the wounded from Iraq and Afghanistan. N Engl J Med. 2004;351:2471–5. 3. Starnes BW, Beekley AC, Sebesta JA, Anderson CA, Rush RM Jr. Extremity vascular injuries on the battlefield: tips for surgeons deployed to war. J Trauma. 2006;60:432–42. 4. Fox CJ, Gillespie DL, O’Donnel SD, Rasmussen TE, Goff JM, Johnson CA, Galgon RE, Sarac TP, Rich NM. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41: 638–44. 5. Clouse WD, Rasmussen TE, Peck MA, Eliason JL, Cox MW, Bowser AN, Jenkins DH, Smith DL, Rich NM. In-theater management of vascular injury: 2 years of the Balad vascular registry. J Am Coll Surg. 2007;204:625–32.
Penetrating peripheral vascular injury management 6. Peck MA, Clouse WD, Cox MW, Bowser AN, Eliason JL, Jenkins DH, Smith DL, Rasmussen TE. The complete management of extremity vascular injury in a local population: a wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base. Iraq J Vasc Surg. 2007;45: 1197–205. 7. Fox CJ, Gillespie DL, Cox ED, Mehta SG, Kraqh JF Jr, Salinas J, Holcomb JB. The effectiveness of a damage control resuscitation strategy for vascular injury in a combat support hospital: result of a case control study. J Trauma. 2008;64:S99–107. 8. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackboume LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg. 2011;253:1184–9. 9. Brown KV, Ramasamy A, Tai N, McLeod J, Midwinter M, Clasper JC. Complications of extremity vascular injuries in conflict. J Trauma. 2009;66:S145–9.
129 10. Rich NM, Hughes CW, Baugh JH. Management of venous injuries. Ann Surg. 1970;171:724–30. 11. Chambers LW, Green DJ, Sample K, Gillingham BL, Rhee P, Brown C, Narine N, Uecker JM, Bohman HR. Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during operation Iraqi Freedom: one unit’s experience. J Trauma. 2006;61:824–30. 12. 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;61:8–12. 13. Radonic V, Baric D, Giunio L, Bill B, Kovacevic H, Sapunar D. War injuries of the femoral artery and vein: a report on 67 cases. Cardio vasc Surg. 1997;5:641–7.
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ORIGINAL ARTICLE
Penetrating peripheral vascular injury management in a Sri Lankan military hospital A. Ratnayake • B. Samarasinghe • K. Halpage M. Bala
•
Received: 1 May 2012 / Accepted: 6 September 2012 / Published online: 25 September 2012 Ó Springer-Verlag 2012
Abstract Purpose Vascular injuries in austere military conflict settings are a challenging problem. The goal of the current study was to analyze the unique features associated with the management and early outcome of penetrating vascular injuries resulting from the conflict in Sri Lanka. Methods All adults with extremity vascular injuries admitted to the Military Base Hospital Anuradhapura in an eight-month period were prospectively recorded in a data sheet and retrospectively analyzed. Mechanism, location, method of repair, and outcomes were analyzed. Result Out of a total of 5,821 combat-related casualties, there were 128 victims with vascular injuries (2.2 %). The overall limb salvage rate was 83 % with an all-cause mortality of 3.1 %. Combined arterial and venous injuries were most common (44 %), predominantly in the popliteal zone. Among the arterial injuries, 70 % were repaired with a vein interposition graft and 7 % were primarily repaired. The majority of the venous injuries (54 %) were ligated. Twenty early major complications were recorded. A temporary intraluminal shunting technique was applied in the 14 most severely injured patients. This patient population was followed up for an average of 35 days institutionally
A. Ratnayake K. Halpage Military Base Hospital, Anuradhapura, Sri Lanka B. Samarasinghe Department of Surgery, University of Peradeniya, Peradeniya, Sri Lanka M. Bala (&) Department of General Surgery and Trauma Unit, Hadassah-Hebrew University Medical Center, Kiriat Hadassah, POB 12000, 91120 Jerusalem, Israel e-mail: [email protected]
before they were referred to rehabilitation (60 %) or transferred to other institutions (26 %). Conclusions Vascular reconstruction using vein, combined with a wound management strategy and early fasciotomy, resulted in a high limb salvage rate and remarkably low infection, delayed amputation, and mortality rates. Management of combat vascular injuries based on clinical guidance is feasible and leads to good outcome in a minimally equipped setting during local military conflicts. Surgeons in military hospitals should be trained in vascular injury repair to save the lives and functional limbs of patients. Keywords Vascular injuries Combat experience Military hospital Limb salvage Early fasciotomy
Introduction Combat vascular injuries often combine massive soft-tissue destruction with osseous and neurological trauma [1, 2]. Further complicating the situation, the surgeon has to serve in a setting that is far from ideal and lacks valuable resources [3]. In current conflicts, surgeons generally attempt limb salvage unless the extremity is so badly mangled that salvage is pointless or orthopedic reconstruction is unavailable, based on the degree of soft-tissue and nerve damage and extent of bony injury [2, 4, 5]. The objective of this study was to provide an account of wartime extremity vascular injury in a local military conflict in Sri Lanka from the unique perspective and setting of a wartime military hospital. An additional objective was to analyze management strategies related to vascular reconstruction and to report early infection, limb salvage, and mortality rates.
123
124
Description of local conflict settings Military Base Hospital (MBH) Anuradhapura is among the field hospitals located in North-Central Province, Sri Lanka, 120–180 km south of the main battleground during humanitarian operations. Surgical care in relation to this battlefield has been organized by dividing it into echelons based on size, capability, and proximity to the front line. The first echelon is the advanced dressing station (ADS), which serves as a triage facility performing limited lifesaving procedures close to the front line, and forwarding the wounded to the main dressing station (MDS) and further to the third echelon, the MBH. The MBH is the closest referral hospital for military personnel with extremity and vascular injuries, and is located 40–45 min (average helicopter flying time) from the MDS. The MBH is equipped with two operating theaters, a three-bed intensive care room, and 80-bed unmonitored wards. Two general surgeons, trained for three months in vascular surgery, take care of all casualties.
A. Ratnayake et al.
extremities. The contralateral vein was taken preferentially for lower extremity injuries, although the ipsilateral vein was required in few cases. In nearly all cases, vascular repair was attempted within the first hours from the time of admission. Temporary intraluminal shunting (TIS) was indicated for patients with combined arterial, venous, and soft-tissue injuries and concomitant long bone fractures when the decision was made to perform limb salvage. The standard sterile system tubing was used as a shunt. Concomitant venous injuries were repaired selectively. Prophylactic four-compartment fasciotomies were performed in the majority of the injured patients as soon as they were assessed at the MBH. Patients requiring definitive orthopedic care or advanced intensive care were transferred to other centers after blood flow to the injured extremity was established. Early outcomes were determined, including the need for delayed amputation, graft thrombosis, infection with late anastomotic disruption, and death. Short-term follow-up data were reviewed.
Methods Results All adults with extremity vascular injuries admitted to the MBH from November 2008 to June 2009 were prospectively recorded on a data sheet and retrospectively analyzed. Extremity vascular injuries include those in which limb salvage assessment was attempted. Patterns of injury were documented, noting the mechanism of vascular injury, anatomical distribution, and the presence of associated nonvascular trauma. The mechanism of injury was categorized as either gunshot wound or explosive devices with shrapnel. Vascular injuries were characterized by type (arterial, venous, or a combination thereof) and macroscopic description (transection, laceration, or thrombosis of vessels). Antipersonnel mine (APM) injuries were excluded from the study population due to the unavoidability of amputation considering the severity of injury. Basic demographic data collected included patient age, length of hospital stay, and number of operations. Combatants triaged by MDS as having isolated peripheral vascular injuries were evaluated on arrival at the MDH. Hand-held Doppler examination and ankle brachial index (ABI) served as important adjuncts to clinical assessment when no hard signs of vascular injury were presented. An ABI of below 0.9 was considered abnormal. Vascular repairs were classified into four methods of treatment: ligation, primary repair (including patch angioplasty), interposition autologous vein graft, and open vessel exploration with thrombectomy. The great saphenous vein was the conduit of choice in both the upper and lower
123
Incidence and distribution of vascular injuries During the period from November 2008 to June 2009 a total of 5,821 combat-related casualties were admitted to the MBH. Out of these, 128 victims (2.2 %) had peripheral vascular injuries and were included in the study group. All were healthy male combatants with a median age of 24 years (range 18–42). The mechanism of penetrating vascular injury was high-velocity gunshot wounds in 65 patients (50 %) and flying particles from explosive devices in 53 patients (42 %). There were 58 (44 %) combined arterial and venous injuries, 53 (42 %) isolated arterial injuries, and 12 (9 %) with isolated venous pathology. In six cases (4.7 %) the explored main vessels were found to be normal and ligation of branches was performed (branches of the popliteal artery in four cases and profunda femoris in two cases). Long bone fractures were associated with vascular injury in 30 % of cases, while neurological trauma was detected in 15 % of patients on admission. Clinical characteristics of the patients Time delay from injury to definitive care was recorded in 96 cases (75 %) and found to be 5.5 h on average (range 2.5–16.3 h). Hemodynamic parameters at presentation were recorded in 71 patients (55 %). Seven patients presented with shock and required resuscitation.
Penetrating peripheral vascular injury management
Fig. 1 Anatomical distribution of 115 arterial injuries
125
Fig. 3 Methods of treatment of arterial injuries in 115 cases. IPVG interposition vein graft
Table 1 Venous injuries and repair modes
Fig. 2 Macroscopic characteristics of 115 peripheral arterial injuries found on exploration
Twenty-six limbs had palpable pulses at presentation to the MBH. In 42 injured extremities only a Doppler signal was presented, while in 34 limbs neither Doppler signals nor pulses were recorded below the injured area on presentation. Data were not recorded for 27 cases (21 %). The anatomic distribution of arterial injuries is shown in Fig. 1, and macroscopic characteristics are shown in Fig. 2. Lower extremity was the most frequent site for arterial vascular injury—83 cases (72 %). Most arterial injuries required an interposition vein graft (IPVG) (Fig. 3). Arterial ligation was undertaken in cases of tibial (n = 2), ulnar (n = 1), and popliteal (n = 14) vascular injury. Four profunda femoris artery injuries were managed by ligation. Out of 22 primary ligations, 13 limbs were amputated during the same procedure, while one limb was amputated 24 h later. Concomitant arterial and venous injuries were present in 58 lower and four upper extremity cases, while isolated venous injury was found in 12 cases. Either interposition vein graft or lateral venorrhaphy were used to repair 25 (36 %) of these venous injuries (Table 1). Only six popliteal veins were repaired in 21 revascularized limbs, given
Anatomy (N)
Ligation
Lateral repair
Vein patch
IPVG
Amputation
External iliac vein (1)
–
01
–
–
–
SFV-Ft (11)
03
04
01
03
–
SFV-AC (22) Popliteal vein (30)
11 15
08 06
– –
01 –
02 09
Posterior tibial vein (2)
02
–
–
–
–
PF (4)
04
Total (70)
38
20
01
04
– 11
N number of cases, IPVG interposition vein graft, SFV-Ft superficial femoral vein in femoral triangle, SFV-AC superficial femoral vein in adductor canal, PF profunda femoris vein
the extent of soft-tissue loss and the technical challenge of working in this anatomic location. Temporary intraluminal shunting Fourteen TIS procedures were performed during the study period. Patients who required TIS as a primary revascularization strategy had definitive repair done during the same operation following wound debridement, fracture stabilization, and vein graft harvesting. TIS was established in 12 cases to minimize the time required when the ischemic time had already been exceeded (and thus limb viability was questionable), and on two occasions it allowed a single surgeon to treat two patients simultaneously. All 14 injuries were at the level of popliteal (n = 8) or superficial femoral (n = 6), with both arterial and venous injuries. The median mangled extremity severity score (MESS) in this cohort was 8 (range 5–11). In two cases a temporary shunt resulted in heavy bleeding from fractured bone and hemodynamic instability necessitating primary amputation. In another case, nonviable distal muscle
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Fig. 4 Outcome of temporary intraluminal shunts in 14 cases
compartments necessitated amputation during the same procedure. In this subgroup of TIS, two deaths and two delayed amputations were documented, while seven limbs were viable at discharge from the hospital (Fig. 4).
A. Ratnayake et al.
thrombectomy was performed during the revision of anastomosis. Delayed amputation was performed in one case, and three patients developed symptomatic limb ischemia (and were transferred to the specialized vascular center). Five arterial anastomotic disruptions were detected during the study period following extensive soft-tissue injury and local infection. Disruptions occurred after an average of 14 days (7–29 days). In four cases the bleeding vessel was ligated without any major sequela. Amputation was required in one case (Table 2). Extensive soft-tissue injury was noticed in all cases. Follow-up was performed in a hospital outpatient clinic for patients who required wound care for an average of 35 days. Following complete care, 76 patients (61 %, 76 of 124 survivors) were referred to the Ragama Rehabilitation Center. Thirty-three patients (26 %) were transferred to other institutions for orthopedic or intensive care early in the postoperative period. Data were not available in 15 cases.
Complications and outcome The mortality in the 128 patients with extremity injuries was 3.1 % (n = 4). Two deaths were due to multiple organ dysfunction syndrome, which developed at days 1 and 3 after revascularization of the lower limbs. The MESS was 9 in both cases, and an initial temporary shunt was established. Both occurred after vascular reconstruction and attempts at limb salvage had been made, and in both instances the degree of injury to the bones and soft tissue was such that attempts at salvage may have contributed to the deaths. Two deaths were directly attributed to the hemodynamic instability after revascularization. There were 17 primary amputations in the series, while proximal vascular repair was performed before the distal amputation in four cases. Primary ligation was performed in the remaining 13 limbs. There were two forearm amputations, and all the rest were in the lower limb (12 above the knee, two through the knee, and one below knee). Twelve victims (70 %) had associated long bone fractures, while fractures were found at two levels in three cases. Nonviable distal muscle compartments (n = 15, 88 %) were found to be an indication for primary amputation; while amputation was performed due to severe softtissue injury in two cases. There were a total of 20 postvascular repair complications (5.5 %), which included ten graft thromboses; five anastomotic disruptions resulted in five delayed amputations. Ten suspected thromboses of arterial repairs were detected due to either the disappearance of pulses immediately postprocedure or routine debridement in 24–48 h. One case was detected immediately following reconstruction and corrected at the same time. In another four cases
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Discussion In contemporary combat theaters, the amputation rate has, impressively, fallen below 10 %. The factors that may have contributed to this are (among others) rapid evacuation of injured soldiers from the battlefield in helicopters, advances in echelon care, damage control resuscitation, and the use of new techniques: TIS and early fasciotomies [4–7]. The low rate of extremity vascular injuries (2.2 %) in this series in comparison to other contemporary wars in Iraq and Afghanistan (12 %) [8] may have been a result of more soldiers with extremity vascular injuries dying on the way to the third echelon, as the average time taken was 5.5 h (as compared to 2 h in Iraq) [5]. The higher number of popliteal injuries (34 % in our series) in comparison with other papers (17–22 %) [4–6] could be explained by the war tactics employed in the Sri Lankan war theater. During the last years of the humanitarian operation, gunfire from underground bunkers at ground level made the knee and lower thigh the most vulnerable sites. In the Sri Lankan war theater, the recorded number of noncritical arterial injuries (below the brachial and popliteal arteries) was less due to the fact that they were managed by direct ligation without proper recording in situations with a high casualty load at a low level of care by military medical units. Some never reached specialized care. Tourniquets were not used enough by the Sri Lankan army. All injured limbs were presented to the MBH (definitive care facility) either packed or following exploration, and often ligation had been done at the second echelon of care (20 cases recorded).
Penetrating peripheral vascular injury management
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Table 2 Characteristics of patients with anastomotic disruptions and early outcome Case no.
Injury mode
Anatomical site
Injury morphology
Associated injury
MESS
Time to repair (h)
Time to rupture (days)
Type of repair
Outcome
1
ED
PTf-AT
Transection
ST???
6
[24
14
Ligation
Limb saved
6
\6
29
IPVG
Limb saved
7
Not recorded
7
IPVG
AKA
7
\6
9
Lateral Repair
Limb saved
6
\6
14
IPVG
Limb saved
V? NB2
GS
SFA-FT
Transection
ST???? VNB-
3
GS
SGPA
Transection
ST???? V? N? B-
4
GS
AC-SFA
Thrombosis
ST???? VNB?
5
GS
PT
Transection
ST???? V? N? B-
ED explosion device, GS gunshot injury, PTf-AT popliteal trifurcation, anterior tibial, SFA-FT superficial femoral artery, femoral triangle, SGPA supragenicular popliteal artery, SFA-AC superficial femoral artery, adductor canal, PT posterior tibial artery, ST soft tissue loss, V vein injury, N injury to the nerve, B long bone, MESS mangled extremity severity score, IPVG interposition vein graft, AKA above-knee amputation
No other studies have reported this number of vascular trauma victims within this timeframe (six months). The average number of casualties per day was around 40. The dilemma faced by surgeons when confronted with extremity vascular injuries in the combat setting is to choose between revascularization with attempted limb salvage and immediate amputation. During decision making, an ischemic time of 6 h does not predict good results per se. Neither an absence of angiography nor a shortage of experienced vascular surgery staff were reasons for primary amputation. In cases where multiple casualties arrived, the preference was for temporary shunting in order to gain time for definitive repair. Despite the average 5.5 h delay that occurred in our patient population, a reasonably good limb salvage percentage (83 %) was achieved. The wide range of times taken to arrive were due to delays in evacuation from the battlefield and lower echelons due to insufficient triage and transportation systems. In a recent report on military experience from the United Kingdom, the MESS did not help to decide whether or not an amputation was appropriate. Age, for example, was not relevant [9]. Our primary amputation decision was made based on the presence of nonviable compartments and extensive soft-tissue and bone injuries. Of 17 primary
amputations performed, proximal revascularization allowed distal amputation in four cases, facilitating an option of a better prosthesis. Wide fasciotomy prior to reconstruction also made this decision-making process more accurate. Early prophylactic fasciotomy at echelons 1 and 2 are beneficial in severe cases of extremity vascular trauma. Early fasciotomy became the current practice in the Sri Lankan military setting to allow early assessment of muscle compartments with this unpredictable ground situation. An uncomplicated fasciotomy wound can be primarily closed within 2–3 days without much morbidity, and this was the cost that we had to bear for the viable muscle compartment that resulted in selected cases. We think that the unique experience of early fasciotomy before revascularization could be beneficial in the setting of delayed referral to a higher level of care in cases with peripheral vascular injuries. In this report, 70 % of the extremity arterial injuries were repaired via the autologous vein, and another 7 % by primary means. In current combat theaters, 55–67 % of the arteries are repaired by interposition graft, while an impressive amputation rate of close to a 5 % is achieved [4–7]. The explanation for the higher amputation percentages in our series (17 %, 22 of 129 limbs) comes from the
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fact that the majority of arterial injuries were caused by high-energy gunshot injuries (50 %) with extensive tissue damage. Also, predominant injuries to the popliteal area and delayed patient presentation preclude vascular repair. For primary repair to be successful, it is essential to perform adequate debridement. The independent influence of wartime venous injury on limb loss and morbidity was established by Rich et al. [10]. In many cases venous injuries were not recorded, and were often treated by primary ligation, especially for upper extremity injuries. Not surprisingly, while isolated venous injuries were rare, none resulted in the amputation of an extremity. We have not been aggressive enough at repairing associated femoral and popliteal venous injuries, as in most instances incoming casualties with suspected vascular trauma preclude such an effort. If we consider our overall 36 % repair rate, popliteal and femoral veins were the only veins repaired. In addition, it should be noted that all cases of delayed amputation had associated venous injury. TIS are a great help for surgeons at the front as well as surgeons in the higher echelons. It allows for early transfer from one echelon to another without causing further ischemia to the limb, and allows surgeons in the higher echelons to perform appropriate debridement or orthopedic fixation prior to proceeding with vascular reconstruction [11, 12]. In the theater in Sri Lanka, TIS was used in a desperate attempt to save limbs that were at the edge of viability for rapid restoration of distal limb perfusion (MESS of 8). Among this cohort of 14 limbs there were seven failures. The use of TIS in the underserved, resource-inadequate environment associated with our series allowed a single surgeon to perform two simultaneous vascular reconstructions. Twenty limbs in our series had complications, of which 12 (60 %) were related to wound infections. The most common complication with arterial reconstruction is the development of wound infection, which leads to secondary hemorrhage or thrombosis and poses the greatest threat to vascular reconstruction. Three of five delayed amputations were performed due to uncontrolled infection complicated by hemorrhage or thrombosis. Injuries to the popliteal artery and the superficial femoral artery had the highest rates of associated postoperative complications. All infected grafts required excision and ligation and eventually resulted in one delayed amputation. Our results were consistent with the literature, which has shown that 3–6.6 % of casualties with a vascular repair will proceed to amputation [5, 6, 13]. Study limitations First, detailed data on the injury mechanism, presence of associated injuries, and exact operative technique were not available for some cases in the cohort. The trauma system
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and the registry of trauma patients are not mature enough, meaning that lots of information on ISS, GCS, and MESS are missing or not exist. The often emergent operating mode with multiple admissions and the lack of registrars and uniform data collection prevent important details from being promptly recorded. The second limitation is the lack of long-term follow-up, even though patients were not discharged from the hospital until all wounds were definitively closed. Finally, the strategies described in this series have not been compared with other vascular reconstruction and wound management techniques. Despite these limitations, the overall observations reported herein are significant, and add knowledge that complements reports of previous wartime experiences.
Conclusions This study shows that in a hospital with limited modern diagnostic facilities in a developing country, peripheral vascular trauma can be managed successfully by early recognition, clinical diagnostic skills, and expert surgical repair. In the military settings with long transportation time, early fasciotomy prior to definitive vascular reconstruction result in a better outcome. Autologous saphenous vein graft interposition remains the treatment of choice for the majority of vascular injuries. Popliteal vessels injuries are most challenging and associated with a high amputation rate. TIS are a favorable option in the severely injured and when the ischemic time has exceeded 6 h. TIS also facilitates limb perfusion prior to transfer to a higher level of care. Complications are mainly due to technical errors and infections. Surgeons in military hospitals should be trained in vascular injury repair to save the lives and functional limbs of patients. Conflict of interest
None.
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Penetrating peripheral vascular injury management 6. Peck MA, Clouse WD, Cox MW, Bowser AN, Eliason JL, Jenkins DH, Smith DL, Rasmussen TE. The complete management of extremity vascular injury in a local population: a wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base. Iraq J Vasc Surg. 2007;45: 1197–205. 7. Fox CJ, Gillespie DL, Cox ED, Mehta SG, Kraqh JF Jr, Salinas J, Holcomb JB. The effectiveness of a damage control resuscitation strategy for vascular injury in a combat support hospital: result of a case control study. J Trauma. 2008;64:S99–107. 8. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackboume LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg. 2011;253:1184–9. 9. Brown KV, Ramasamy A, Tai N, McLeod J, Midwinter M, Clasper JC. Complications of extremity vascular injuries in conflict. J Trauma. 2009;66:S145–9.
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