Rich’s Vascular Trauma

Rich’s Vascular Trauma

3R D EDITION

Todd E. Rasmussen, MD, FACS

Colonel USAF MC
Director, U.S. Combat Casualty Care Research Program
Fort Detrick, Maryland;
Harris B Shumacker, Jr. Professor of Surgery
The Norman M. Rich Department of Surgery
Uniformed Services University of the Health Sciences
Bethesda, Maryland;
Attending Vascular & Trauma Surgeon
Veterans Administration Medical Center & University of Maryland
Shock Trauma Center
Baltimore, Maryland

Nigel R.M. Tai, QHS, MS, FRCS(Gen)

Colonel, L/RAMC
Clinical Director, Trauma Services
Royal London Hospital
Barts Health NHS Trust
London, United Kingdom;
Senior Lecturer
Academic Department of Military Surgery and Trauma
Royal Centre for Defence Medicine
Birmingham, United Kingdom;
Consultant Surgeon
16 Medical Regiment
Colchester, Essex, United Kingdom
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

RICH’S VASCULAR TRAUMA, THIRD EIDTION ISBN: 978-1-4557-1261-8

Copyright © 2016 by Elsevier, Inc. All rights reserved.

The content of this text does not represent official viewpoints of the U.S. Department of Defense or the U.K.
Ministry of Defense.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration,
and contraindications. It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Previous editions copyright © 2004 and 1978.

Library of Congress Cataloging-in-Publication Data

Rich’s vascular trauma / [edited by] Todd E. Rasmussen, Nigel R.M. Tai.—Third edition.
    p. ; cm.
  Vascular trauma
  Preceded by: Vascular trauma / [edited by] Norman M. Rich, Kenneth L. Mattox, Asher Hirshberg. 2nd ed.
c2004.
  Includes bibliographical references and index.
  ISBN 978-1-4557-1261-8 (hardcover : alk. paper)
  I.  Rasmussen, Todd E., editor.  II.  Tai, Nigel R. M., editor.  III.  Rich, Norman M. Vascular trauma.
Preceded by (work):  IV.  Title: Vascular trauma.
  [DNLM:  1.  Blood Vessels—injuries.  2.  Vascular Surgical Procedures.  WG 170]
  RD598.5
  617.4′13044—dc23
2014045541

Acquisitions Editor: Michael Houston

Developmental Editor: Laura Schmidt
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Rachel E. McMullen
Design Direction: Ashley Miner

Printed in China

Last digit is the print number:  9  8  7  6  5  4  3  2  1

To our families, whose love and sacrifice have made this
and so many other endeavors possible

and to the teachers who prepared us; the friends and

colleagues—close and far—whose efforts have
inspired, enabled, and sustained us; and our
patients who, in times of peace and war,
it is our privilege to know and care for
CONTRIBUTORS

Aaron C. Baker, MS, MD Frank K. Butler, MD

Clinical Fellow Chairman
Vascular and Endovascular Surgery Committee on Tactical Combat Casualty Care Director
Mayo Clinic Prehospital Trauma Care
Rochester, Minnesota U.S. Joint Trauma System
Defense Center of Excellence
Lorne H. Blackbourne, MD U.S. Army Institute of Surgical Research
Attending Trauma Surgeon Joint Base San Antonio
San Antonio Military Medical Center Ft. Sam Houston, Texas
Joint Base San Antonio
Ft. Sam Houston, Texas Jeremy W. Cannon, MD, FACS, SM
Chief, Trauma and Critical Care
Kenneth Boffard, MB, BCh, FRCS, FRCS(Edin), Department of Surgery
FRCPS(Glas), FCS(SA), FACS San Antonio Military Medical Center
Professor Emeritus Joint Base San Antonio
Department of Surgery Ft. Sam Houston, Texas;
University of the Witwatersrand; Associate Professor of Surgery
Trauma Director The Norman M. Rich Department of Surgery
Milpark Hospital Uniformed Services University of the Health Sciences
Johannesburg, South Africa Bethesda, Maryland

Oswaldo Borraez, MD Ian D. Civil, MBChB, FRACS, FACS

Mayo Clinic
Vascular Surgery
Rochester Minnesota
Mark W. Bowyer, MD, FACS
Professor of Surgery
Chief of Trauma and Combat Surgery
Surgical Director of Simulation
The Norman M. Rich Department of Surgery
Uniformed Services University
Bethesda, Maryland
Karim Brohi, FRCA, FRCS
Professor of Trauma Sciences
Queen Mary University of London
Consultant Trauma and Vascular Surgeon
Royal London Hospital
Barts Health NHS Trust
London, United Kingdom
Director of Trauma Services
Trauma Services
Auckland City Hospital
Auckland, New Zealand
Jon Clasper, MBA, DPhil, DM, FRCSEd(Orth)
Defence Professor Trauma and Orthopaedics
Visiting Professor in Bioengineering, Imperial College
London
London, United Kingdom
Marcus Cleanthis, BSc(Hons), MBBS, MD, FRCS
Consultant Vascular Surgeon
Department of Vascular Surgery
Frimley Park Hospital
Surrey, United Kingdom

vii
viii Contributors

W. Darrin Clouse, MD, FACS Charles J. Fox, MD, FACS

Professor of Surgery Chief, Vascular Surgery
The Norman M. Rich Department of Surgery Denver Health Medical Center;
Uniformed Services University of the Health Sciences Associate Professor of Surgery
Bethesda, Maryland; University of Colorado School of Medicine
Associate Visiting Surgeon Denver, Colorado
Division of Vascular and Endovascular Surgery
Massachusetts General Hospital David L. Gillespie, MD, RVT, FACS
Boston, Massachusetts Chief, Department of Vascular and Endovascular Surgery
Cardiovascular Care Center
Lazar B. Davidovic, MD, PhD, FETCS Southcoast Health System
Head of the Clinic Fall River, Massachusetts
Clinic for Vascular and Endovascular Surgery
Clinical Center of Serbia Gabriel Herscu, MD
Full Professor of Vascular Surgery Fellow, Vascular Surgery
Faculty of Medicine Division of Vascular Surgery and Endovascular Therapy
University of Belgrade Keck Medical Center
Belgrade, Serbia University of Southern California
Los Angeles, California
David L. Dawson, MD, FACS, RVT, RPVI
Professor of Surgery Shehan Hettiaratchy, MA(Oxon), DM,
University of California, Davis FRCS(Plast)
Sacramento, California; Chief of Service
Special Clinical Consultant, Surgery Plastic, Orthopaedic, ENT, and Major Trauma Services
David Grant Medical Center Imperial College Healthcare NHS Trust
Travis Air Force Base London, United Kingdom;
Fairfield, California Senior Lecturer
Academic Department of Military Surgery and Trauma
Demetrios Demetriades, MD, PhD, FACS Royal Centre for Defence Medicine
Professor of Surgery Birmingham, United Kingdom
University of Southern California;
Director, Acute Care Surgery Timothy Hodgetts, PhD, MMEd, MBA, MBBS,
Los Angeles County and University of Southern California FRCP, FRCSEd, FCEM
Medical Center Honorary Professor of Emergency Medicine
Los Angeles, California University of Birmingham
Birmingham, United Kingdom;
Joseph J. DuBose, MD, FACS Medical Director
Chief Vascular Fellow UK Defence Medical Services
University of Texas Health Science Center—Houston Glouccester, United Kingdom
Associate Professor of Surgery
The Norman M. Rich Department of Surgery Aaron Hoffman, MD
Uniformed Services University of the Health Sciences Director
Houston, Texas Department of Vascular Surgery and Transplantation
Rambam Health Care Campus;
Timothy C. Fabian, MD, FACS Associate Professor
Harwell Wilson Professor and Chairman Rappaport Faculty of Medicine
Surgery Technion
University of Tennessee Health Science Center Haifa, Israel
Memphis, Tennessee
John B. Holcomb, MD, FACS
David V. Feliciano, MD, FACS Center for Translational Injury Research
Battersby Professor and Chief, Division of General Surgery Division of Acute Care Surgery
Chief of Surgery Department of Surgery
Indiana University Hospital University of Texas Health Science Center
Department of Surgery Houston, Texas
Indiana University Medical Center
Indianapolis, Indiana
 Contributors ix

Kenji Inaba, MD, FRCSC, FACS Luis A. Moreno, MD

Associate Professor of Surgery Medical Doctor and Surgeon General
University of Southern California; National University
Division of Acute Care Surgery Vascular Surgeon
Director Surgical Critical Fellowship Bosque University
Los Angeles County and University of Southern California Bogota, Columbia
Medical Center
Los Angeles, California Jonathan J. Morrison, MB ChB, MRCS
Surgical Registrar, West of Scotland Surgical Rotation
Donald H. Jenkins, MD, FACS Research Fellow
Consultant Academic Department of Military Surgery & Trauma,
Associate Professor of Surgery Royal Centre for Defence Medicine,
Division of Trauma, Critical Care and General Surgery Birmingham, United Kingdom
Trauma Center Mayo Clinic
Rochester, Minnesota Rossi Murilo, MD
Professor of Surgery
Michael Jenkins, BSc, MS, FRCS, FEBVS University of Valença
Consultant Vascular Surgeon School of Medicine;
Chief of Service Vascular Surgery & Director of Trauma Director of IECAC (State Institute of Cardiology Aloísio de
Imperial College Healthcare NHS Trust Castro)
St Mary’s Hospital Master’s Degree in Vascular Surgery
London, United Kingdom Federal University of Rio de Janeiro (UFRJ)
Rio de Janeiro, Brazil
Tony Karram, MD
Department of Vascular Surgery and Organ Transplantation Samy Nitecki, MD
Rambam Health Care Campus Director
Haifa, Israel Peripheral Vascular Surgery Unit Vice Chair
Department of Vascular Surgery and Organ Transplantation
Brian S. Knipp, MD Rambam Health Care Campus
Lieutenant Commander Haifa, Israel
Medical Corps, U.S. Navy
NMC Portsmouth David M. Nott, OBE, OStJ, DMCC, BSc, MD, FRCS
Staff Vascular Surgeon Consultant General Surgeon
Portsmouth, Virginia Department of Surgery
Chelsea and Westminster Hospital
Neil G. Kumar, MD Consultant Trauma and Vascular Surgeon
Resident, Vascular Surgery Department of Surgery
Department of Surgery St Mary’s Hospital
Division of Vascular Surgery London, United Kingdom
University of Rochester Medical Center
Rochester, New York Chirag M. Patel, BSc (Hons), MBBS, MRCP, FRCR
Department of Diagnostic and Interventional Radiology
Ari K. Leppäniemi, MD, PhD Barts and the London NHS Trust
Chief of Emergency Surgery London, United Kingdom
Abdominal Surgery
University of Helsinki Predrag Pavić, MD
Meilahti Hospital Vascular Surgery
Helsinki, Finland University Hospital Dubrava
Zagreb, Croatia
Zvonimir Lovrić, PhD, MD
Professor Michael A. Peck, MD
Chief Surgeon of Traumatology Division Peripheral Vascular Associates
Department for Surgery San Antonio, Texas
University Hospital Dubrava
Zagreb, Croatia Rina Porta, MD
Doctorate in Vascular Surgery—FMUSP (Federal University
Mark Midwinter, MB BS, BMedSci(Hons), of São Paulo)
MD, FRCS Vacular Surgery of Emergency Unit of USP
Defence Professor of Surgery São Paulo, Brazil
Academic Department of Military Surgery and Trauma
Royal Centre for Defence Medicine
Birmingham, United Kingdom
x Contributors

Alexander A. Pronchenko, MD, PhD Igor M. Samokhvalov, MD, PhD, Prof.

War Surgery Department Colonel M.C. (Ret)
Kirov Military Medical Academy Chief Surgeon of the Russian Army
Saint-Petersburg, Russia Ministry of Defense of the Russian Federation
Moscow, Russia
Reagan W. Quan, MD Professor and Chair
Chief of Vascular Surgery Department and Clinic of War Surgery
Wellspan Heart and Vascular Center Military Medical Academy named after S.M. Kirov
York, Pennsylvania Saint-Petersburg, Russia

Dinesh G. Ranatunga, MBBS(Hon), FRANZCR Stephanie A. Savage, MD, MS, FACS

Specialist Registrar Associate Professor of Surgery
Department of Diagnostic and Interventional Radiology University of Tennessee Health Science Center
The Royal London Hospital Memphis, Tennessee
Barts Health NHS Trust
London, United Kingdom Hannu Savolainen, MD, PhD
Professor of Vascular Surgery
Todd E. Rasmussen, MD, FACS University of the West Indies
Colonel USAF MC Academic Department of Surgery
Director, U.S. Combat Casualty Care Research Program Queen Elizabeth Hospital
Fort Detrick, Maryland; Bridgetown, Barbados
Harris B Shumacker, Jr. Professor of Surgery
The Norman M. Rich Department of Surgery Daniel J. Scott, MD
Uniformed Services University of the Health Sciences General and Peripheral Vascular Surgery Resident
Bethesda, Maryland; San Antonio Military Medical Center
Attending Vascular & Trauma Surgeon Joint Base San Antonio
Veterans Administration Medical Center & University of Ft. Sam Houston, Texas
Maryland
Shock Trauma Center Sherene Shalhub, MD, MPH
Baltimore, Maryland Assistant Professor
Cardiothoracic and Vascular Surgery
Amila S. Ratnayake, MBBS, MS The University of Texas Medical School
Lieutenant Colonel Houston, Texas
Consultant General & Trauma Surgeon
Army Hospital Abdul H. Sheriffdeen, MBBS(Ceylon), FRCS(Eng)
Colombo 05 Emeritus Professor of Surgery
Sri Lanka University of Colombo
Colombo, Sri Lanka
Ian Renfrew, MRCP, FRCR
Consultant in Interventional Radiology Niten Singh, MD, FACS
Department of Diagnostic and Interventional Radiology Associate Professor of Surgery
The Royal London Hospital Vascular Surgery
Barts Health NHS Trust University of Washington
London, United Kingdom Seattle, Washington;
Associate Professor of Surgery
Viktor A. Reva, MD Uniformed Services of Surgery
Fellow Bethesda, Maryland
Department of War Surgery
Kirov Military Medical Academy Michael J. Sise, MD, FACS
Saint-Petersburg, Russia Clinical Professor
Surgery
Norman M. Rich, MD, FACS, DMCC UCSD Medical Center
Leonard Heaton and David Packard Professor Medical Director
The Norman M. Rich Department of Surgery Division of Trauma
F. Edward Hébert School of Medicine Scripps Mercy Hospital
Uniformed Services University of the Health Sciences San Diego, California
Bethesda, MD

Bandula Samarasinghe, MBBS, MS

Senior Lecturer
University of Peradeniya
Peradeniya, Sri Lanka
 Contributors xi

Benjamin Starnes, MD, FACS Carole Y. Villamaria, MD

Chief, Vascular Surgery Division Surgical Resident
Department of Surgery Department of Surgery
University of Washington University of Texas Health Sciences Center at San Antonio
Seattle, Washington San Antonio, Texas

Nigel R.M. Tai, QHS, MS, FRCS(Gen) Alasdair J. Walker, OBE, QHS, MB ChB, FRCS
Colonel, L/RAMC Medical Director and Consultant Vascular Surgeon
Clinical Director, Trauma Services Joint Medical Command
Royal London Hospital Ministry of Defence
Barts Health NHS Trust Birmingham, United Kingdom
London, United Kingdom;
Senior Lecturer Fred A. Weaver, MD, MMM, FACS
Academic Department of Military Surgery and Trauma Professor and Chief
Royal Centre for Defence Medicine Division of Vascular Surgery and Endovascular Therapy
Birmingham, United Kingdom; Keck School of Medicine, University of Southern California
Consultant Surgeon Los Angeles, California
16 Medical Regiment
Colchester, Essex, United Kingdom Mandika Wijeyaratne, MBBS, MS(Surg),
MD(Leeds UK), FRCS(Eng)
Peep Talving, MD, PhD, FACS Professor of Surgery
Assistant Professor of Surgery Department of Surgery
University of Southern California University of Colombo
Division of Acute Care Surgery Colombo, Sri Lanka
Keck School of Medicine
Los Angeles, California

Jorge H. Ulloa, MD, FACS

Director
Venous Surgery
Clinica de Venas
Associate Professor
Vascular Surgery
Universidad El Bosque
Bogota, Columbia
FOREWORD
The military medical experience of the United States of
America and the United Kingdom during the first decade
of the 21st century has resulted in notable advancements in
the management of vascular trauma.1 Air superiority during
the wars in Afghanistan and Iraq has allowed rapid and, in the
case of the Medical Emergency Response Teams (MERTs)
often advanced, medical evacuation of injured service person-
nel. During the wars, a large number of patients with vascular
trauma have been cared at forward Level II or more definitive
Level III surgical facilities fairly rapidly after the time of injury.
Subsequent transcontinental aeromedical evacuation with
sophisticated Critical Care Air Transport Teams (CCATT) has
permitted wounded troops to be transported half way around
the world in record time while receiving high levels of inten-
sive monitoring and care.
The wars in Afghanistan and Iraq have also witnessed the
broad use of modern body armor and newly designed tour-
niquets by those in harm’s way. The role of temporary vascular
shunts, the optimal types and ratios of fluids for resuscitation,
and the types of conduits for segmental vascular replacement
have been redefined during this decade of war. As the first
prolonged period of combat operations in which specialty
trained vascular and endovascular surgeons have been
deployed, this decade has witnessed the use of endovascular
procedures to manage select patterns of vascular trauma and
a modern reappraisal of endovascular balloon occlusion of the
aorta for the management of hemorrhagic shock. Despite
these and other advances, significant new questions have
arisen including how best to assure adequate training and
readiness of military surgeons to manage the complex injury
pattern that is vascular trauma.2
Making optimal use of Mayo Clinic training and early
assignments at Walter Reed Army Medical Center and the
Uniformed Services University, Air Force Colonel Todd E. Ras-
mussen has been an effective leader, a role model, and a
respected mentor in all aspects of this experience. He has com-
municated successfully with and benefited greatly from highly
skilled allies and friends such as Colonel Nigel R.M. Tai of the
Royal Army Medical Corps. Michael E. DeBakey, whose mili-
tary experience originated in World War II (1941–1945), Carl
W. Hughes in the Korean Conflict (1951–1953), and Norman
M. Rich during the Vietnam War (1965–1972) emphasized the
contributions of Rasmussen and colleagues in 2007. In their
manuscript entitled “Recognition of Air Force Surgeons at
Wilford Hall Medical Center-Supported 332nd Air Force
Theater Hospital, Balad Air Base, Iraq,” DeBakey, Hughes, and
Rich recognized this modern “Band of Brothers” and their
impact on vascular trauma.3
This third edition of Rich’s Vascular Trauma adds a novel
and highly appropriate International Perspectives section to its
already impressive archive of recognized authors and chapters.
Co-editors Rasmussen and Tai have reached out to and have
secured exclusive contributions from military and civilian
leaders in vascular trauma around the globe. This new Inter-
national Perspectives section provides a mix of personal and
regional experiences from surgeons whose partnership in the
management of vascular trauma was and will continue to be
highly valued. As global health, including the management of
injury, becomes a focus of health care professionals around
the world, the third edition of Rich’s Vascular Trauma by the
Society for Vascular Surgery, along with the appointment of
Todd E. Rasmussen as Chief Editor, will provide a current and
comprehensive reference.
Finally, I would like to acknowledge the valuable contribu-
tions of Frank Spencer, Kenneth Mattox, and Asher Hirsch-
berg that helped us establish a firm foundation in the
management of vascular trauma on which surgeons such as
Todd E. Rasmussen, Nigel R.M. Tai, and their colleagues,
trainees, and students can continue to build.
Norman M. Rich, MD
REFERENCES
1. Pruitt BA, Rasmussen TE: Vietnam (1972) to Afghanistan (2014): the state
of military trauma care and research, past to present. J Trauma Acute Care
Surg 77(3 Suppl 2):S57–S65, 2014.
2. Rasmussen TE, Woodson J, Rich NM, et al: Vascular injury at a crossroads.
J Trauma 70(5):1291–1293, 2011.
3. Rich NM, Hughes CW, DeBakey ME: Recognition of Air Force surgeons
at Wilford Hall Medical Center-supported 332nd EMDG/Air Force Theater
Hospital, Balad Air Base, Iraq. J Vasc Surg 46:1312–1313, 2007.
xiii
PREFACE
The third edition of Rich’s Vascular Trauma follows in the
singular lineage of two prior editions from Rich, Mattox, and
Hirshberg, texts that defined the pattern and treatment of
vascular injury and that characterized its global significance.
In keeping with the tone of the original edition, which was
rooted in knowledge gained from the wartime environment,
this edition is similarly founded upon a decade of clinical
experience resulting from the wars in Afghanistan and Iraq.1,2
Modern studies of combat-related injury and, indeed, civilian
trauma studies have redefined and emphasized the impor-
tance of vascular injury in taking the lives of the severely
injured. Epidemiologic study of the burden of injury from a
decade of war has more clearly identified vascular disruption
and subsequent hemorrhage as the leading causes of death in
patients with otherwise survivable injuries.3 Additionally, vas-
cular injury resulting in ischemia has been demonstrated a
leading cause of extremity amputation and disability.
Observations in modern wartime and civilian environ-
ments confirm the beneficial effects of organized trauma
systems in improving survival and decreasing morbidity.4,5 As
such, and to provide a broader perspective, we have set out to
ensure that the third edition explores the clinical implications
of vascular injury throughout all phases of trauma care and
not just in the operating theater. Unlike almost any other
injury pattern, vascular trauma carries direct life- and limb-
threatening implications that extend from the point of injury
and prehospital settings through to the emergency depart-
ment, operating room, and intensive care unit. Any contem-
porary dissertation on vascular trauma that failed to address
the spectrum of patient care would be incomplete. A prime
goal of this edition is to portray vascular trauma with refer-
ence to the trauma-systems approach and, by so doing, offer
information and tools not merely for the surgeon but for
all providers who contribute to the management of this
formidable injury pattern.
To provide this wide-ranging perspective, the third edition
of Rich’s Vascular Trauma draws on civilian and military
authorities from around the world. These experts have come
together to author chapters arranged in the following sections:
Background, Diagnosis and Early Management, Definitive
Management, and Hot Topics in Vascular Injury and Manage-
ment. To allow for a diverse viewpoint the editors have
embraced chapters from those with a range of backgrounds
including prehospital care, emergency medicine, trauma
systems, and intensive care, as well as general, trauma, vascu-
lar, orthopedic, and plastic surgery. It is the editors’ hope that
this edition, as a whole, will not only provide important infor-
mation for those seeking specific solutions but will also prove
compelling reading in areas bordering on the fringes of one’s
traditional practice.
Finally and in recognition of the truly global legacy of
vascular trauma, both the text and the injury pattern, the third
edition concludes with an original International Perspectives
Section. In this section, the editors are privileged to present
individual accounts of vascular trauma from leading surgeons
around the world. The international contributors to this
section hail from nearly every continent on the globe and
represent military and civilian friends and colleagues whose
contributions are fundamental and enduring parts of this text.
This section, more than any other, embodies the heritage that
this new edition draws from its namesake: surgeon, gentle-
man, and ambassador —Norman M. Rich, MD.
Todd E. Rasmussen, MD
Nigel R.M. Tai, QHS, MS, FRCS(Gen)
REFERENCES
1. Stannard A, Brown K, Benson C, et al: Outcome after vascular trauma in
a deployed military trauma system. Br J Surg 98(2):228–234, 2011.
2. White JM, Stannard A, Burkhardt GE, et al: The epidemiology of vascular
injury in the wars in Iraq and Afghanistan. Ann Surg 253(6):1184–1189,
2011.
3. Eastridge BJ, Mabry RL, Seguin P, et al: Death on the battlefield (2001–
2011): implications for the future of combat casualty care. J Trauma Acute
Care Surg 73(6 Suppl 5):S431–S437, 2012.
4. Rasmussen TE, Gross KR, Baer DG: Where do we go from here? J Trauma
Acute Care Surg 75(2 Suppl 2):S105–S106, 2013.
5. Bailey JA, Morrison JJ, Rasmussen TE: Military trauma system in Afghani-
stan: lessons for civil systems? Curr Opin Crit Care 19(6):569–577, 2013.
xv
xvi Preface

This photo shows an image of the 332nd Expeditionary Medical Group, Air Force Theater
Hospital in Balad Iraq (circa 2005). During the war in Iraq from this location, the Balad
Vascular Registry provided information into various aspects of the management of vascular
trauma including reports on the use of temporary vascular shunts, endovascular tech-
niques, and the management of specific anatomic patterns (upper extremity, femoral-
popliteal, and tibial level injuries).1 The clinical and academic efforts of the operative work
force at the Air Force Theater Hospital in Balad were recognized in a commentary by Drs.
Rich, Hughes, and DeBakey in the Journal of Vascular Surgery in 2007.2

This photo shows an image of the United Kingdom’s Role III facility at Camp Bastion,
Afghanistan (circa 2008). The British-led efforts at Camp Bastion, consistently the busiest
surgical hospital in Afghanistan, resulted in reports on not only extremity vascular trauma
but also more complex injury patterns such as noncompressible torso hemorrhage, peri-
traumatic pulmonary thrombosis, junctional vascular injury, and dismounted complex
blast injury.3,4 The term “right turn resuscitation” was also coined at Bastion referring to
the physical space of the hospital in which “turning right” on entry to the emergency
department led one immediately to the operating room. This immediate “right turn”
bypassed the traditional emergency department, affording simultaneous blood and proce-
dural (i.e., operative) resuscitation in the operating theater in the most severely injured of
patients.5

1. Clouse WD, Rasmussen TE, Peck MA, et al: In theater management of
wartime vascular injury: 2 years of the Balad Vascular Registry. J Am Coll
Surg 204(4):625-632, 2007.
2. Rich NM, Hughes CW, Debakey ME: Recognition of Air Force surgeons at
Wilford Hall Medical Center-supported 332nd EMDG/Air Force Theater
Hospital, Balad Air Base, Iraq. J Vasc Surg 46(6):1312–1313, 2007; author
reply 1313.
3. Stannard A1, Brown K, Benson C, et al: Outcome after vascular trauma in
a deployed military trauma system. Br J Surg 98(2):228–234, 2011.
4. Jansen JO, Thomas GO, Adams SA, et al: Early management of proximal
traumatic lower extremity amputation and pelvic injury caused by impro-
vised explosive devices (IEDs). Injury 43(7):976–979, 2012. doi: 10.1016/j.
injury.2011.08.027. Epub 2011 Sep 9.
5. Tai NR1, Russell R: Right turn resuscitation: frequently asked questions.
J R Army Med Corps 157(3 Suppl 1):S310–S314, 2011.
SECTION 1

Background
The Vascular Injury Legacy
NORMAN M. RICH AND ALASDAIR J. WALKER
Although the first crude arteriorrhaphy was performed more
than 250 years ago, it is only within the past 50 years that
vascular surgery has been practiced both widely and consis-
tently with anticipation of good results. Historically, it is of
particular interest that by the turn of the 20th century many
if not most of the techniques of modern vascular surgery had
already been explored through extensive experimental work
and early clinical application. In retrospect it is therefore
almost astonishing that it took nearly another 50 years before
the work of such early pioneers as Murphy, Goyanes, Carrel,
Guthrie, and Lexer was widely accepted and applied in the
treatment of vascular injuries. However, adoption of the
thought processes and practices of these enlightened surgeons
was hampered by the technological limitations of their era and
had to await the dramatic advances in graft materials and
imaging seen during the 1950s and beyond.1,2
Since the days of Ambroise Paré in the mid–16th century,
major advances in the surgery of trauma have occurred during
times of armed conflict when it was necessary to treat large
numbers of severely injured patients, often under far-from-
ideal conditions. This has been especially true with vascular
injuries.
Although German surgeons accomplished arterial repairs
in the early part of World War I, it was not until the Korean
Conflict and the early 1950s that ligation of major arteries was
abandoned as the standard treatment for arterial trauma. The
results of ligation of major arteries following trauma were
clearly recorded in the classic manuscript by DeBakey and
Simeone in 1946, who found only 81 repairs in 2471 arterial
injuries among American troops in Europe in World War II.3
All but three of the arterial repairs were performed by lateral
suture. Ligation was followed by gangrene and amputation in
nearly half of the cases. The pessimistic conclusion reached by
many was expressed by Sir James Learmonth, who said that
there was little place for definitive arterial repair in the combat
wound.
Within a few years, however, in the Korean Conflict, the
possibility of successfully repairing arterial injuries was estab-
lished conclusively, stemming especially from the work of
Hughes, Howard, Jahnke, and Spencer. In 1958 Hughes
emphasized the significance of this contribution in a review
of the Korean experience, finding that the overall amputation
rate was lowered to about 13%, compared to the approxi-
mately 49% amputation rate that followed ligation in World
War II.4
During the Vietnam hostilities, more than 500 young
American surgeons, who represented most of the major surgi-
cal training programs in the United States, treated more than
1 
7500 vascular injuries. In 1969 Rich and Hughes reported the
preliminary statistics from the Vietnam Vascular Registry,
which was established in 1966 at Walter Reed General Hospital
to document and follow all servicemen who sustained vascular
trauma in Vietnam.5 An interim Registry report that encom-
passed 1000 major acute arterial injuries showed little change
from the overall statistics presented in the preliminary report.6
Considering all major extremity arteries, the amputation rate
remained near 13%. Although high-velocity missiles created
more soft-tissue destruction in injuries seen in Vietnam, the
combination of a stable hospital environment and rapid evac-
uation of casualties (similar to that in Korea) made successful
repair possible. Injuries of the popliteal artery, however,
remained an enigma, with an amputation rate remaining
near 30%.
In the past 50 years, civilian experience with vascular
trauma has developed rapidly under conditions much more
favorable than those of warfare. Results are better than those
achieved with military casualties in Korea and Vietnam.
Initial Control of Hemorrhage
Control of hemorrhage following injury has been of prime
concern to man since his beginning. Methods for control have
included various animal and vegetable tissues, hot irons,
boiling pitch, cold instruments, styptics, bandaging, and com-
pression. These methods were described in a historical review
by Schwartz in 1958.7 Celsus was the first to record an accurate
account of the use of ligature for hemostasis in 25 ad. During
the first three centuries, Galen, Heliodorus, Rufus of Ephsus,
and Archigenes advocated ligation or compression of a bleed-
ing vessel to control hemorrhage.
Ancient methods of hemostasis used by Egyptians about
1600 bc are described in the Ebers’ papyrus, discovered by
Ebers at Luxor in 1873.7 Styptics prepared from mineral or
vegetable matter were popular, including lead sulfate, anti-
mony, and copper sulfate. Several hundred years later during
the Middle Ages in Europe, copper sulfate again became
popular and was known as the hemostatic “button.” In ancient
India, compression, cold, elevation, and hot oil were used to
control hemorrhage, while about 1000 bc, the Chinese used
tight bandaging and styptics.
The writings of Celsus provide most of the knowledge of
methods of hemostasis in the first and second centuries ad.7
When amputation was done for gangrene, the prevailing sur-
gical practice was to amputate at the line of demarcation to
prevent hemorrhage. In the first century ad, Archigenes was
apparently the first to advocate amputating above the line of
3
 1  /  The Vascular Injury Legacy 3.e1

ABSTRACT
For more than 2000 years, control of battlefield hemor-
rhage relied on compressive dressings. Added to this were
the use of cautery, styptics, boiling oil, and a variety of
other partially effective adjuncts. In Rome 2000 years ago,
Galen advocated ligature of bleeding vessels. However, this
was lost during the Dark Ages, and it was not until the 16th
century that Ambroise Paré “reinvented” ligature of bleed-
ing vessels when he ran out of boiling oil. Paré was also
one of the first to devise instruments, including the bec de
corbin to grasp bleeding vessels to assist with the ligature.
At the turn of the 20th century, the development of clinical
and experimental concepts related to vascular surgery pro-
gressed, and during the Korean Conflict (1950-1953) suc-
cessful repair of injured arteries and veins was accomplished
consistently in the treatment of battlefield casualties. Over
the past 50 years, additional advances in managing vascu-
lar trauma have been made in both civilian and military
practices. These have included experiences with endovas-
cular procedures, particularly over the past decade, trans-
ferring civilian experience to the management of battlefield
casualties by coalition forces in Afghanistan and Iraq.

Key Words:  vascular trauma,

arterial trauma,
venous trauma,
arterial and venous injuries,
vascular repair,
vascular graft,
endovascular procedures
4 SECTION 1  /  BACKGROUND
demarcation for tumors and gangrene, using ligature of the
artery to control hemorrhage.
Rufus of Ephesus (first century ad) noted that an artery
would continue to bleed when partially severed, but when
completely severed it would contract and stop bleeding within
a short period of time.7 Galen, the leading physician of Rome
in the second century ad, advised placing a finger on the
orifice of a bleeding superficial vessel for a period of time to
initiate the formation of a thrombus and the cessation of
bleeding. He noted, however, that if the vessel were deeper, it
was important to determine whether the bleeding was coming
from an artery or a vein. If coming from a vein, pressure or a
styptic usually sufficed, but ligation with linen was recom-
mended for an arterial injury.
Following the initial contributions of Celsus, Galen, and
their contemporaries, the use of ligature was essentially for-
gotten for almost 1200 years in western medicine. A tension
developed between traditional church teachings and enlight-
ened thought, perhaps holding back any advancement in west-
ern medicine or surgery. Use of the knife was considered
wrong on living tissue; consequently amputation was below
the line of ischemic demarcation. Abu al-Qasim al-Zahrawi,
a prominent Arab physician from Moorish Spain (10th cen-
tury ad), advocated ligation in his great work Kitab Al-Tasrif
almost 600 years before Paré.7
Throughout the Middle Ages, cautery was used almost
exclusively to control hemorrhage. Jerome of Brunswick
(Hieronymus Brunschwig), an Alsatian army surgeon, actually
preceded Paré in describing the use of ligatures as the best way
to stop hemorrhage.7 His recommendations were recorded in
a textbook published in 1497 and provided a detailed account
of the treatment of gunshot wounds. Ambroise Paré, with a
wide experience in the surgery of trauma, especially on the
battlefield, firmly established the use of ligature for control of
hemorrhage from open blood vessels. In 1552 he startled the
surgical world by amputating a leg above the line of demarca-
tion, repeating the demonstration of Archigenes 1400 years
earlier. The vessels were ligated with linen, leaving the ends
long. Paré also developed the bec de corbin, ancestor of the
modern hemostat, to grasp the vessel before ligating it (Fig.
1-1).7 Previously, vessels had been grasped with hooks, tenacu-
lums, or the assistant’s fingers. He designed artificial limbs and
advanced dressing technique. During the siege of Turin (1536),
Paré ran out of oil, which was traditionally used to cauterize.
He mixed egg yolk, rose oil, and turpentine and discovered
this dressing had better outcomes than oil.
FIGURE 1-1  Artist’s concept of the bec de corbin, developed by Paré
and Scultetus in the mid–16th century. It was used to grasp the vessel
before ligating it. (From Schwartz AM: The historical development of
methods of hemostasis. Surgery 44:604, 1958.)
In the 17th century, Harvey’s monumental contribution
describing circulation of blood greatly aided the understand-
ing of vascular injuries.7 Although Rufus of Ephesus appar-
ently discussed arteriovenous communications in the first
century ad, it was not until 1757 that William Hunter first
described the arteriovenous fistula as a pathological entity.8
This was despite the fact that, as early as the second century
ad, Antyllus had described the physical findings, clinical man-
agement (by proximal and distal ligation) and the significance
of collateral circulation.9
The development of the tourniquet was another advance
that played an important role in the control of hemorrhage.
Tight bandages had been applied since antiquity, but subse-
quent development of the tourniquet was slow. Finally, in
1674 a military surgeon named Morel introduced a stick into
the bandage and twisted it until arterial flow stopped.7 The
screw tourniquet came into use shortly thereafter. This method
of temporary control of hemorrhage encouraged more fre-
quent use of the ligature by providing sufficient time for its
application. In 1873 Freidrich von Esmarch, a student of Lan-
genbeck, introduced his elastic tourniquet bandage for first
aid use on the battlefield.10 Previously it was thought that such
compression would injure vessels irreversibly. His discovery
permitted surgeons to operate electively on extremities in a
dry, bloodless field.
Ligation was not without its complications as British
Admiral Horatio Nelson discovered after amputation of his
right arm after the attack at Tenerife, “A nerve had been taken
up in one of the ligatures at the time of the operation,” causing
considerable pain and slowing his recovery.11 Furthermore the
long ligatures meant delayed wound healing. It was Haire, an
assistant surgeon at the Royal Naval Hospital Haslar, who took
the risk of cutting sutures short (rather than leaving them
long) to allow suppuration, necrosis, and granulation before
the suture was pulled away. He observed that “the ligatures
sometimes became troublesome and retarded the cure” and
that cutting them short allowed stumps to heal in the course
10 days.
In addition to the control of hemorrhage at the time of
injury, the second major area of concern for centuries was the
prevention of secondary hemorrhage. Because of its great fre-
quency, styptics, compression, and pressure were used for
several centuries after ligation of injured vessels became pos-
sible. Undoubtedly the high rate of secondary hemorrhage
after ligation was due to infection of the wound often pro-
moted by dressing choices or infection spread by well-meaning
attendants. Although John Hunter demonstrated the value of
proximal ligation for control of a false aneurysm in 1757,
failure to control secondary hemorrhage resulted in the use of
ligature only for secondary bleeding from the amputation
stump.12 Subsequently, Bell (1801) and Guthrie (1815) per-
formed ligation both proximal and distal to the arterial wound
with better results than those previously obtained.13,14
Some of the first clear records of ligation of major arteries
were written in the 19th century and are of particular interest.
The first successful ligation of the common carotid artery for
hemorrhage was performed in 1803 by Fleming, but was not
reported until 14 years later by Coley (1817), because Fleming
died a short time after the operation was performed.15 A
servant aboard the HMS Tonnant attempted suicide by slash-
ing his throat. When Fleming saw the patient, it appeared that
he had exsanguinated. There was no pulse at the wrist and the

pupils were dilated. It was possible to ligate two superior
thyroid arteries and one internal jugular vein. A laceration of
the outer and muscular layers of the carotid artery was noted,
as well as a laceration of the trachea between the thyroid and
cricoid cartilages. This allowed drainage from the wound to
enter the trachea, provoking violent seizures of coughing,
although the patient seemed to be improving. Approximately
1 week following the injury, Fleming recorded: “On the
evening of the 17th, during a violent paroxysm of coughing,
the artery burst, and my poor patient was, in an instant,
deluged with blood!”15
The dilemma of the surgeon is appreciated by the following
statement: “In this dreadful situation I concluded that there
was but one step to take, with any prospect of success; mainly,
to cut down on, and tie the carotid artery below the wound. I
had never heard of such an operation being performed; but
conceived that its effects might be less formidable, in this case,
than in a person not reduced by hemorrhage.”15 The wound
rapidly healed following ligation of the carotid artery and the
patient recovered.
Ellis (1845) reported the astonishing experience of success-
ful ligation of both carotid arteries in a 21-year-old patient
who sustained a gunshot wound of the neck while he was
setting a trap in the woods in 1844, near Grand Rapids, Michi-
gan, when he was unfortunately mistaken for a bear by a
companion.16 Approximately 1 week later, Ellis had to ligate
the patient’s left carotid artery because of hemorrhage. An
appreciation of the surgeon’s problem can be gained by Ellis’
description of the operation: “We placed him on a table, and
with the assistance of Dr. Platt and a student, I ligatured the
left carotid artery, below the omohyoideus muscle; an opera-
tion attended with a good deal of difficulty, owing to the
swollen state of the parts, the necessity of keeping up pressure,
the bad position of the parts owing to the necessity of keeping
the mouth in a certain position to prevent his being strangu-
lated by the blood, and the necessity of operating by candle
light.”16
There was recurrent hemorrhage on the eleventh day after
the accident, and right carotid artery pressure helped control
the blood loss. It was, therefore, necessary also to ligate the
right carotid artery 4 1 2 days after the left carotid artery had
been ligated. Ellis remarked: “For convenience, we had him in
the sitting posture during the operation; when we tightened
the ligature, no disagreeable effects followed; no fainting; no
bad feeling about the head; and all the perceptible change was
a slight paleness, a cessation of pulsation in both temporal
arteries, and of the hemorrhage.”16
The patient recovered rapidly with good wound healing
and returned to normal daily activity. There was no percep-
tible pulsation in either superficial temporal artery.16
The importance of collateral circulation in preserving via-
bility of the limb after ligation was well understood for cen-
turies, as identified by Antyllus nearly 2000 years ago.9 The
fact that time was necessary for establishment of this collateral
circulation was recognized. Halsted (1912) reported cure of
an iliofemoral aneurysm by application of an aluminum band
to the proximal artery without seriously affecting the circula-
tion or function of the lower extremity.17 Asepsis had been
recognized, and the frequency of secondary hemorrhage and
gangrene following ligation promptly decreased as an under-
standing of transmission of infectious disease and its manage-
ment was developed through Pasteur and Lister. Subsequently,
1  /  The Vascular Injury Legacy 5
Halsted (1912) demonstrated the role of collateral circulation
by gradually completely occluding the aorta and other large
arteries in dogs by means of silver or aluminum bands that
were gradually tightened over a period of time.18
Early Vascular Surgery
About 2 centuries after Paré established the use of the ligature,
the first direct repair of an injured artery was accomplished.
This event more than 250 years ago is credited as the first
documented vascular repair. Hallowell, acting on a suggestion
by Lambert in 1759, repaired a wound of the brachial artery
by placing a pin through the arterial walls and holding the
edges in apposition by applying a suture in a figure-of-eight
fashion about the pin (Fig. 1-2).19 This technique (known as
the farrier’s stitch) had been utilized by veterinarians but had
fallen into disrepute following unsuccessful experiments.
Table 1-1 outlines early vascular techniques.
Unfortunately, others could not duplicate Hallowell’s suc-
cessful experience, almost surely because of the multiple prob-
lems of infection and lack of anesthesia. There was one report
by Broca (1762) of a successful suture of a longitudinal inci-
sion in an artery.20 However, according to Shumacker (1969),
an additional 127 years passed following the Hallowell-
Lambert arterial repair before a second instance of arterial
repair of an artery by lateral suture in man was reported by
Postemski in 1886.20
With the combined developments of anesthesia and asepsis,
several reports of attempts to repair arteries appeared in the
latter part of the 19th century. The work of Jassinowsky, who
is credited in 1889 for experimentally proving that arterial
Figure-of-eight suture
Laceration
Pin
Brachial artery
FIGURE 1-2  The first arterial repair performed by Hallowell, acting
on a suggestion by Lambert in 1759. The technique, known as the
farrier’s (veterinarian’s) stitch, was followed in repairing the brachial
artery by placing a pin through the arterial walls and holding the
edges in apposition with a suture in a figure-of-eight fashion about
the pin. (Drawn from the original description by Mr. Lambert, Med Obser
and Inq 2:30–360, 1762.)
Table 1-1 Vascular Repair Before 1900*
Technique Year Surgeon
Pin and thread 1759 Hallowell
Small ivory clamps 1883 Gluck
Fine needles and silk 1889 Jassinowsky
Continuous suture 1890 Burci
Invagination 1896 Murphy
Suture all layers 1899 Dörfler
*Adapted from Guthrie GC: Blood vessel surgery and its applications,
New York, 1912, Longmans, Green and Co.
6 SECTION 1  /  BACKGROUND

wounds could be sutured with preservation of the lumen, was

later judged by Murphy in 1897 as the best experimental work
published at that time.21,22 In 1865 Henry Lee of London
attempted repair of arterial lacerations without suture.23 Glück Femoral artery
in 1883 reported 19 experiments with arterial suture, but all
experiments failed because of bleeding from the holes made Femoral vein Posterior
by the suture needles.24 He also devised aluminum and ivory Anterior
clamps to unite longitudinal incisions in a vessel, and it was
recorded that the ivory clamps succeeded in one experiment
on the femoral artery of a large dog. Von Horoch of Vienna
reported six experiments, including one end-to-end union, all
of which thrombosed.23 In 1889 Bruci sutured six longitudinal Aneurysmal pockets
arteriotomies in dogs; the procedure was successful in four.20 on the anterior and
In 1890 Muscatello successfully sutured a partial transection posterior surface of
of the abdominal aorta in a dog.20 In 1894 Heidenhain closed B the femoral artery
by catgut suture a 1-cm opening in the axillary artery made
accidentally while removing adherent carcinomatous glands.25
The patient recovered without any circulatory disturbance. In
1883 Israel, in a discussion of a paper by Glück, described
closing a laceration in the common iliac artery created during A
an operation for perityphlitic abscess.24,26 The closure was
accomplished by five silk sutures. However, from his personal
observations, Murphy (1897) did not believe it could be pos-
sible to have success in this type of arterial repair.22 In 1896
Sabanyeff successfully closed small openings in the femoral
artery with sutures.20
The classic studies of J.B. Murphy of Chicago (1897) con-
tributed greatly to the development of arterial repair and cul-
minated in the first successful end-to-end anastomosis of an
artery in 1896.22 Previously, Murphy had carefully reviewed
earlier clinical and experimental studies of arterial repair and
had evaluated different techniques extensively in laboratory C
studies. Murphy attempted to determine experimentally how FIGURE 1-3  The first successful clinical end-to-end anastomosis
much artery could be removed and still allow an anastomosis. of an artery was performed in 1896. Sutures were placed in the proxi-
He found that 1 inch of a calf ’s carotid artery could be removed mal artery, including only the few outer coats; three sutures were
and the ends still approximated by invagination suture tech- used to I. (From Murphy JB: Resection of arteries and veins injured in
continuity—end-to-end suture-experimental clinical research. Med Record
nique because of the elasticity of the artery. He concluded that 51:73, 1897.)
arterial repair could be done with safety when no more than
3/4 inch of an artery had been removed, except in certain
locations such as the popliteal fossa or the axillary, space Because of the historical significance, the operation report is
where the limb could be moved to relieve tension on the quoted:
repair. He also concluded that when more than half of the
artery was destroyed, it was better to perform an end-to-end Operation, October 7, 1896. An incision five inches long
anastomosis by invagination rather than to attempt repair of was made from Poupart’s ligament along the course of the
the laceration. This repair was done by introducing sutures femoral artery. The artery was readily exposed about one
into the proximal artery, including only the two outer coats, inch above Poupart’s ligament; it was separated from its
and using three sutures to invaginate the proximal artery into sheath and a provisional ligature thrown about it but not
the distal one, reinforcing the closure with an interrupted tied. A careful dissection was then made down along the
suture (Fig. 1-3).22 In 1896 Murphy was unable to find a wall of the vessel to the pulsating clot. The artery was
similar recorded case involving the suture of an artery after exposed to one inch below the point and a ligature thrown
complete division, and he consequently reported his experi- around it but not tied: a careful dissection was made
ence (1897) and carried out a number of experiments to upward to the point of the clot. The artery was then closed
determine the feasibility of his procedure. Murphy’s patient above and below with gentle compression clamps and was
was a 29-year-old male shot twice with one bullet entering the elevated, at which time there was a profuse hemorrhage
femoral triangle. The patient was admitted to Cook County from an opening in the vein. A cavity, about the size of a
Hospital in Chicago on September 19, 1896, approximately 2 filbert, was found posterior to the artery communicating
hours after wounding. There was no hemorrhage or increased with its caliber, the aneurysmal pocket. A small aneurysmal
pulsation noted at the time. Murphy first saw the patient 15 sac about the same size was found on the anterior surface of
days later, October 4, 1896, and found a large bruit surround- the artery over the point of perforation. The hemorrhage
ing the site of injury. Distal pulses were barely perceptible. from the vein was very profuse and was controlled by digital
When demonstrating this patient to students 2 days later, a compression. It was found that one-eighth of an inch of the
thrill was also detected. An operative repair was decided on. arterial wall on the outer side of the opening remained, and

on the inner side of the perforation only a band of one-
sixteenth of an inch of adventitia was intact. The bullet had
passed through the center of the artery, carried away all of
its wall except the strands described above, and passed
downward and backward making a large hole in the vein in
its posterior and external side just above the junction of the
vena profunda. Great difficulty was experienced in
controlling the hemorrhage from the vein. After dissecting
the vein above and below the point of laceration and
placing a temporary ligature on the vena profunda, the
hemorrhage was controlled so that the vein could be
sutured. At the point of suture the vein was greatly
diminished in size, but when the clamps were removed it
dilated about one-third the normal diameter or one-third
the diameter of the vein above and below. There was no
bleeding from the vein when the clamps were removed. Our
attention was then turned to the artery. Two inches of it
had been exposed and freed from all surroundings. The
opening in the artery was three-eighths of an inch in length;
one-half inch was resected and the proximal was
invaginated into the distal for one-third of an inch with
four double needle threads which penetrated all of the walls
of the artery. The adventitia was peeled off the invaginated
portion for a distance of one-third of an inch: a row of
sutures was placed around the edge of the overlapping distal
end, the sutures penetrating only the media of the proximal
portion; the adventitia was then brought over the end of the
union and sutured. The clamps were removed. Not a drop
of blood escaped at the line of suture. Pulsation was
immediately restored in the artery below the line of
approximation and it could be felt feebly in the posterior
tibial and dorsalis pedis pulses. The sheath and connective
tissue around the artery were then approximated at the
position of the suture with catgut, so as to support the wall
of the artery. The whole cavity was washed out with a five
percent solution of carbolic acid and the edges of the wound
were accurately approximated with silk worm-gut sutures.
No drainage. The time of the operation was approximately
two and one-half hours, most of the time being consumed
in suturing the vein. The artery was easily secured and
sutured, and the hemorrhage from it readily controlled. The
patient was placed in bed with the leg elevated and
wrapped in cotton.22
The anatomic location of the injuries, the gross pathology
involved, and the detailed repair contributed to Murphy’s his-
torically successful arterial anastomosis. Murphy mentioned
that a pulsation could be felt in the dorsalis pedis artery 4 days
following the operation. The patient had no edema and no
disturbance of his circulation during the reported 3 months
of observation.22
Subsequently, Murphy (1897) reviewed the results of liga-
ture of large arteries before the turn of the century.22 He found
that the abdominal aorta had been ligated 10 times with only
1 patient surviving for 10 days. Lidell reported only 16 recov-
eries after ligation of the common iliac artery 68 times, a
mortality of 77%.20 Balance and Edmunds reported a 40%
mortality following ligation of a femoral artery aneurysm in
31 patients. Billroth reported secondary hemorrhage from
50%% of large arteries ligated in continuity. Wyeth collected
106 cases of carotid artery aneurysms treated by proximal
ligation, with a mortality rate of 35%.
1  /  The Vascular Injury Legacy 7
In 1897 Murphy summarized techniques he considered
necessary for arterial suture. They bore a close resemblance to
principles generally followed today:
1. Complete asepsis
2. Exposure of the vessel with as little injury as possible
3. Temporary suppression of the blood current
4. Control of the vessel while applying the suture
5. Accurate approximation of the walls
6. Perfect hemostasis by pressure after the clamps are
taken off
7. Toilet of the wound
Murphy also reported that Billroth, Schede, Braun, Schmidt,
and others had successfully sutured wounds in veins.22 He
personally had used five silk sutures to close an opening 3/8-
inch long in the common jugular vein.
Several significant accomplishments occurred in vascular
surgery within the next few years. In 1903 Matas described his
endoaneurysmorrhaphy technique, which remained the stan-
dard technique for aneurysms for over 40 years.27 In 1906
Carrel and Guthrie performed classic experimental studies
over a period of time with many significant results.28 These
included direct suture repair of arteries, vein transplantation,
and transplantation of blood vessels as well as organs and
limbs. In 1912 Guthrie independently published his continu-
ing work on vascular surgery.14 Following Murphy’s successful
case in 1896, the next successful repair of an arterial defect
came 10 years later when Goyanes used a vein graft to bridge
an arterial defect in 1906.22,29 Working in Madrid, Goyanes
excised a popliteal artery aneurysm and used the accompany-
ing popliteal vein to restore continuity (Fig. 1-4).29 He used
the suture technique developed by Carrel and Guthrie of
Artery
A V
g
FIGURE 1-4  The first successful repair of an arterial defect utilizing
a vein graft. Using the triangulation technique of Carrel with endo-
thelial coaptation, a segment of the adjacent popliteal vein was used
to repair the popliteal artery. A, Artery; V, vein; g, graft. (From Goyanes
DJ: Nuevos trabajos chirugia vascular. El Siglo Med 53:561, 1906.)
8 SECTION 1  /  BACKGROUND
triangulating the arterial orifice with three sutures, followed
by continuous suture between each of the three areas. A year
later in 1907, Lexer in Germany first used the saphenous vein
as an arterial substitute to restore continuity after excision of
an aneurysm of the axillary artery.29 In his 1969 review, Shu-
macker commented that within the first few years of the 20th
century the triangulation stitch of Carrel (1902), the quadran-
gulation method of Frouin (1908), and the Mourin modifica-
tion (1914) had been developed.20
By 1910 Stich had reported more than 100 cases of arterial
reconstruction by lateral suture.30 His review included 46
repairs, either by end-to-end anastomosis or by insertion of a
vein graft.31 With this promising start, it is curious that over
30 years elapsed before vascular surgery was widely employed.
A high failure rate, usually by thrombosis, attended early
attempts at repair; and few surgeons were convinced that
repair of an artery was worthwhile. In 1913 Matas stated that
vascular injuries, particularly arteriovenous aneurysms, had
become conspicuous features of modern military surgery; and
he felt that this class of injury must command the closest
attention of the modern military surgeon: “A most timely and
valuable contribution to the surgery of blood vessels resulted
from wounds in war. Unusual opportunities for the observa-
tion of vascular wounds inflicted with modern military
weapons . . . based on material fresh from the field of action,
and fully confirmed the belief that this last war, waged in close
proximity to well-equipped surgical centers, would also offer
an unusual opportunity for the study of the most advanced
methods of treating injuries of blood vessels.”27
Matas described Soubbotitch’s experience of Serbian mili-
tary surgery during the Serbo-Turkish and Serbo-Bulgarian
Wars at the 1913 London International Congress.27 He
reported that 77 false aneurysms and arteriovenous fistulas
were treated. There were 45 ligations; but 32 vessels were
repaired, including 19 arteriorrhaphies, 13 venorrhaphies, and
15 end-to-end anastomoses (11 arteries and 4 veins). It is
impressive that infection and secondary hemorrhage were
avoided. In 1915 Matas, in discussing Soubbotitch’s report,
emphasized that a notable feature was the suture (circular and
lateral repair) of blood vessels and the fact that it had been
utilized more frequently in the Balkan conflict than in previ-
ous wars.27 He also noted that, judging by Soubbotitch’s sta-
tistics, the success obtained by surgeons in the Serbian Army
Hospital in Belgrade far surpassed those obtained by other
military surgeons in previous wars, with the exception perhaps
of the remarkably favorable results in the Japanese Reserve
Hospitals reported by Kikuzi.
World War I Experience
During the early part of World War I, with the new techniques
of vascular surgery well established, the German surgeons
attempted repair of acutely injured arteries and were success-
ful in more than 100 cases.31 During the first 9 months of
World War I, low-velocity missiles caused arterial trauma of a
limited extent. In 1915, however, the widespread use of high
explosives and high-velocity bullets, combined with mass
casualties and slow evacuation of the wounded, made arterial
repair impractical.
In 1920 Bernheim went to France with the specific intent
of repairing arterial injuries.32 Despite extensive prior experi-
ence and equipment, however, he concluded that attempts at
vascular repair were unwise. He wrote: “Opportunities for
carrying out the more modern procedures for repair or recon-
struction of damaged blood vessels were conspicuous by their
absence during the recent military activities. Not that blood
vessels were immune from injury; not that gaping arteries and
veins and vicariously united vessels did not cry out for relief
by fine suture or anastomosis. They did, most eloquently, and
in great numbers, but he would have been a foolhardy man
who would have essayed sutures of arterial or venous trunks
in the presence of such infections as were the rule in practi-
cally all of the battle wounded.”32
The great frequency of infection with secondary hemor-
rhage virtually precluded arterial repair. In addition, there
were inadequate statistics about the frequency of gangrene
following ligation, and initial reports subsequently proved to
be unduly optimistic. In 1927 Poole, in the Medical Depart-
ment History of World War I, remarked that if gangrene
were a danger following arterial ligation, primary suture
should be performed and the patient should be watched very
carefully.
Despite the discouragement of managing acute arterial
injuries in World War I, fairly frequent repairs of false aneu-
rysms and arteriovenous fistulas were carried out by many
surgeons. These cases were treated after the acute period of
injury, when collateral circulation had developed with the
passage of time and assured viability of extremities. In 1921
Matas recorded that the majority of these repairs consisted of
arteriorrhaphy by lateral or circular suture, with excision of
the sac or endoaneurysmorrhaphy.33
In 1919 Makins, who served in World War I as a British
surgeon, recommended ligating the concomitant vein when it
was necessary to ligate a major artery.34 He thought that this
reduced the frequency of gangrene by retaining within the
limb for a longer period the small amount of blood supplied
by the collateral circulation. This hypothesis was debated for
more than 20 years before it was finally abandoned.
Payr in 1900, Carrel, and the French surgeon Tuffier
described temporary arterial anastomoses with silver and glass
tubes that were inserted with some success by Makins and
other WWI military surgeons, but patency was limited to 4
days merely allowing some collateral development.20,34
World War II Experience
Experiences with vascular surgery in World War II are well
recorded in the review by DeBakey and Simeone in1946, ana-
lyzing 2471 arterial injuries.3 Almost all were treated by liga-
tion, with a subsequent amputation rate near 49%. There were
only 81 repairs attempted—78 by lateral suture and 3 by end-
to-end anastomosis—with an amputation rate of approxi-
mately 35%. The use of vein grafts was even more disappointing;
they were attempted in 40 cases with an amputation rate of
nearly 58%.
The controversial question of ligation of the concomitant
vein remained, though few observers were convinced that the
procedure enhanced circulation. The varying opinions were
summarized by Linton in 1949.35
A refreshing exception to the dismal World War II experi-
ence in regard to ligation and gangrene was the case operated
on by Dr. Allen M. Boyden—an acute arteriovenous fistula
of the femoral vessels repaired shortly after D-Day in
Normandy.

The following comments are taken by Boyden from his
own original field notes (approximately 26 years later in 1970)
and emphasize the value of adequate records, even in military
combat:
“High explosive wound left groin, 14 June 1944, at 2200
hours. Acute arteriovenous aneurysm femoral artery.
Preoperative blood pressure 140-70; pulse 104.
Operation: 16 June 1944, nitrous oxide and oxygen.
Operation: 1910 to 22 hours.
One unit of blood transfused during the opera-tion.
Arteriovenous aneurysms isolated near junction with
profunda femoris artery.
Considerable hemorrhage.
Openings in both artery and vein were sutured with fine
silk.
Postoperative blood pressure 120-68; pulse 118.
Circulation of the extremity remained intact
until evacuation.”
As this case demonstrated Boyden’s interest in vascular
surgery, the Consulting Surgeon for the First Army presented
him with half of the latter’s supply of vascular instruments
and material. This supply consisted of two sets of Blakemore
(Vitallium) tubes, two bulldog forceps, and a 2-mL ampoule
of heparin!
The conclusion that ligation was the treatment of choice
for an injured artery was summarized by DeBakey and
Simeone in 1946: “It is clear that no procedure other than
ligation is applicable to the majority of vascular injuries which
come under the military surgeons’ observation. It is not a
procedure of choice. It is a procedure of stern necessity, for
the basic purpose of controlling hemorrhage, as well as
because of the location, type, size and character of most battle
injuries of the arteries.”3
In retrospect it should be remembered that the average
time lag between wounding and surgical treatment was over
10 hours in World War II, virtually precluding successful arte-
rial repair in most patients. Of historical interest is the non-
suture method of arterial repair used during World War II
(Fig. 1-5).
Experiences During the
Korean Conflict
In pleasant contrast to the experiences of World War II, the
successful repairs of arterial injuries in the Korean Conflict
were due to several factors. There had been substantial prog-
ress in the techniques of vascular surgery, accompanied by
improvements in anesthesia, blood transfusion, and antibi-
otics. Perhaps of greatest importance was the rapid evacua-
tion of wounded men, often by helicopter, which often
allowed their transport from time of wounding to surgical
care within 1-2 hours. In addition, a thorough understand-
ing of the importance of débridement, delayed primary
closure, and antibiotics greatly decreased the hazards of
infection.
Initially in the Korean Conflict, attempts at arterial repair
were disappointing. During one report of experiences at a
surgical hospital for 8 months between September 1951 and
April 1952, only 11 of 40 attempted arterial repairs were
thought to be successful, as reported by Hughes in 1959.36
1  /  The Vascular Injury Legacy 9
1
2
Saline Proximal
Rubber shod
Artery clamp
Vein
Kelly clamp
3 Distal end of
4 vein placed into
proximal end of artery
Distal
5
6 7
FIGURE 1-5  The various steps of a nonsuture method of bridging
arterial defects designed during World War II. (1) The Vitallium tube
with its two ridges (sometimes grooves). (2) The exposed femoral
artery and vein with the vein retracted and clamps placed on a branch.
(3) The removed segment of vein is irrigated with saline solution. (4)
The vein has been pushed through the inside of the Vitallium tube,
and the two ends have been everted over the ends of the tube held
in place with one or two ligatures of fine silk. (5) The distal end of the
segment of the vein is placed into the proximal end of the artery and
held there by two ligatures of fine silk. (6) The snug ligature near the
end of the Vitallium tube is tied to provide apposition of the artery
and the vein. (7) The completed operation, showing the bridging of
a 2-cm gap in the femoral artery. (Modified description of the original
drawings from Blakemore AH, Lord JW, Jr., Stefko PL: The severed primary
artery in war wounded. Surgery 12:488, 1942.)
Only 6 of 29 end-to-end anastomoses were considered initially
successful, and all 6 venous grafts failed. In another report
from a similar period of time, only 4 of 18 attempted repairs
were considered successful. In 1952 Warren emphasized that
an aggressive approach was needed, with the establishment of
a research team headed by a surgeon experienced in vascular
grafting.37 Surgical research teams were established in the
Army, and there was improvement in results of vascular
repairs by 1952. Significant reports were published by Jahnke
and Seeley in 1953; Hughes in 1955 and 1958; and Inui,
Shannon, and Howard in 1955.4,38-40 Similar work in the Navy
was done with the U.S. Marines during 1952 and 1953 by
Spencer and Grewe and reported in 1955.41 These surgeons
worked in specialized research groups under fairly stabilized
conditions, considering that they were in a combat zone. Brig-
adier General Sam Seeley, who was Chief of the Department
of Surgery at Walter Reed Army Hospital in 1950, had the
foresight to establish Walter Reed Army Hospital as a vascular
surgery center; and this made it possible for patients with
vascular injuries to be returned there for later study. In a total
experience with 304 arterial injuries, 269 were repaired and 35
10 SECTION 1  /  BACKGROUND

Table 1-2 Management of Arterial Trauma in Vietnam Casualties Preliminary Report from the
Vietnam Vascular Registry*
End-to-End Prosthetic Throm-
Artery Anastomosis Vein Graft Lateral Suture Graft Bectomy Ligation
Common carotid 2 6 (2) 3 (2) 1
Internal carotid 2 1
Subclavian 1
Axillary 6 (3) 12 (3) 2 (3) (1) (3) (1)
Brachial 57 (8) 32 (10) 2 (1) 1 (9) 1 (2)
Aorta 3 (1)
Renal 1
Iliac 1 1 1 (1) (1) (1)
Common femoral 4 (2) 11 (1) 4 (1) 1 (2) (2) (4)
Superficial femoral 63 (5) 37 (14) 7 (7) (4) 2 (6) (4)
Popliteal 31 (5) 28 (13) 6 (4) (10) 2 (4)
Total 165 (23) 127 (43) 29 (17) 2 (8) 3 (33) 6 (16)

Modified from Rich NM, Hughes CW: Vietnam vascular registry: a preliminary report. Surgery 65(1):218–226, 1969.
*Numbers in parenthesis represent additional procedures performed after the initial repair in Vietnam and repair of major arterial injuries not
initially treated in Vietnam.

ligated, as reported by Hughes in 1958.4 The overall amputa-
tion rate was 13%, a marked contrast to that of about 49% in
World War II. Because amputation rate is only one method of
determining ultimate success or failure in arterial repair, it is
important to emphasize that Jahnke revealed in 1958 that, in
addition to the lowered rate of limb loss, limbs functioned
normally when arterial repair was successful.42
Experience in Vietnam
In Vietnam the time lag between injury and treatment was
reduced even further by the almost routine evacuation by
helicopter, combined with the widespread availability of sur-
geons experienced in vascular surgery. In a 1968 study by Rich,
95% of 750 patients with missile wounds sustained in Vietnam
reached the hospital by helicopter.43 This promptness of evac-
uation, however, created an adverse effect on the overall
results, for patients with severe injuries from high-velocity
missiles survived to reach the hospital but often expired
during initial care. These patients would never have reached
the hospital alive in previous military conflicts.
Between October 1, 1965, and June 30, 1966, there were 177
known vascular injuries in American casualties, excluding
those with traumatic amputation, as reported by Heaton and
colleagues.44 There were 116 operations performed on 106
patients with 108 injuries. These results included the personal
experience of one of us (NMR) at the 2nd Surgical Hospital.
The results reported included a short-term follow-up of
approximately 7-10 days in Vietnam. In Vietnam, amputa-
tions were required for only 9 of the 108 vascular injuries—a
rate of about 8%. Subsequently, following detailed analysis of
the Vietnam Vascular Registry by Rich and colleagues in 1969
and then in 1970, the amputation rate was found to be approx-
imately 13%—identical to that of the Korean Conflict.5,6
Almost all amputations were performed within the first month
after wounding.
The Vietnam Vascular Registry was established at Walter
Reed General Hospital in 1966 to document and analyze all
vascular injuries treated in Army Hospitals in Vietnam. A
preliminary report by Rich and Hughes in 1969 involved the
complete follow-up of 500 patients who sustained 718 vascu-
lar injuries (Table 1-2).5 Although vascular repairs on Viet-
namese and allied military personnel were not included, the
Registry effort was soon expanded to include all American
service personnel, rather than limiting the effort to soldiers.
In 1967 Fisher collected 154 acute arterial injuries in
Vietnam covering the 1965-1966 periods.45 There were 108
arterial injuries with significant information for the initial
review from Army hospitals. In 1967 Chandler and Knapp
reported results in managing acute vascular injuries in the U.S.
Navy hospitals in Vietnam.46 These patients were not included
in the initial Vietnam Vascular Registry report; but, after 1967,
an attempt was made to include all military personnel sustain-
ing vascular trauma in Vietnam. This included active duty
members of the U.S. Armed Forces treated at approximately
25 Army hospitals, 6 Navy hospitals, and 1 Air Force
hospital.
As with any registry, success of the Vietnam Vascular Reg-
istry has depended on the cooperation of hundreds of indi-
viduals within the military and civilian communities. In the
initial report from the Registry, 20 surgeons who had done
more than 5 vascular repairs were identified. As can be seen
by the list of more than 500 surgeons within the front and
back covers of the first edition of this book, many surgeons in
every training program in the United States contributed to the
generally good results obtained in Vietnam.5
In addition to the surgeons already cited, hundreds of
individuals have been directly contacted through the Regis-
try. The cooperative effort that has been obtained has not
only provided long-term follow-up information for the indi-
vidual surgeon, but it has also given the names of additional
patients who have previously been missed, and additional
specific information has been added where needed regarding
individual patients. A major success in the Registry effort
was obtained at the American College of Surgeons’ Clinical
Congress in Chicago in 1970, where 110 surgeons who had
previously performed arterial repairs in Vietnam signed in at
the Vietnam Vascular Registry exhibit. The exhibit attempted
to represent some of the activities and presented some of

the interim results of the combined effort of all of the
surgeons.
The fact that significant problems continue to confront the
surgeon managing combat vascular injuries is emphasized by
the report by Cohen and co-workers in 1969, which evaluated
a 6-month period of experience in Vietnam.47 The following
list represents some of the major remaining problems:
1. Arterial injuries associated with massive damage to soft
tissues
2. Major venous obstruction
3. Repeated vascular operations with a viable limb
4. Associated unstable fractures
5. Inadequate tissue débridement
6. Calf wounds with small vessel injury
Through the Vietnam Vascular Registry, identification
cards have been sent to the majority of the patients whose
names and records are included in the long-term follow-up.1,2,5
The responses from the individual patients through this media
have been extremely encouraging, and the typical response
that is frequently received is that the patients appreciate the
fact that “someone still cares.” Nearly 1500 patients have been
evaluated by one of the authors (NMR) in the Peripheral
Vascular Surgery Clinic and Registry at Walter Reed Army
Medical Center over the past 10 years. Preliminary plans are
presently being made to maintain an extended long-term
follow-up. This will be important in determining the long-
term results of the repairs and in determining the incidence
of such problems as the early development of arteriosclerosis
in the repair sites of these young men. Personal contact has
been made through the Registry with approximately 300 other
surgeons who have performed vascular repairs in Vietnam,
and the support of these surgeons has been solicited in helping
with this long-term follow-up project.
Vietnam via Gulf War 1991 to
Afghanistan and IRAQ
Since Vietnam, there have been many minor conflicts around
the world. In the British Falklands campaign of 1982, despite
excellent surgical outcomes for those who reached field hos-
pitals, there was little vascular experience. The relative paucity
of surgical cases during the multinational Gulf War of 1991
similarly did not influence advances in military vascular
surgery.
The decade of war that followed the events of September
11, 2001, resulted in a significant burden of injury including
vascular trauma. Contemporary studies from Stannard, White,
and others have shown that the recorded rate of this injury
pattern in modern combat is 7% to 12%, which is consider-
ably higher than that reported in previous wars. The reasons
behind the increased rate of vascular trauma are discussed in
Chapter 2. But suffice it to say the recent wartime experience
forms the bases for much of the text that follows.48,49 Providing
details on vascular trauma managed in Afghanistan and Iraq
is beyond the scope of this particular chapter; however, strate-
gies such as topical hemostatic agents, the reemergence of
tourniquets, temporary vascular shunts, smarter transfusion
and resuscitation strategies, and even catheter-based endovas-
cular techniques will be highlighted throughout the text.
Finally, the vexing injury pattern from these wars—that is,
vascular disruption with noncompressible torso hemorrhage—
will be redefined with a call for new management strategies.
1  /  The Vascular Injury Legacy 11
Civilian Experience
The frequency of arterial injuries in civilian life has increased
greatly in the past decade. This is due to more automobile
accidents, the appalling increase of gunshot and stab wounds,
and the increasing use of therapeutic and diagnostic tech-
niques involving the cannulation of major arteries.
As recently as 1950, most general surgeons had little expe-
rience or confidence in techniques of arterial repair. The
experiences in the Korean Conflict, combined with the wide-
spread teaching of techniques of vascular surgery in surgical
residencies, resulted in a great increase in frequency of arte-
rial repair between 1950 and 1960. This is well illustrated in
the report by Ferguson and co-authors in 1961 of experiences
with 200 arterial injuries treated in Atlanta over the 10-year
period beginning in 1950.50 The proportion of patients
treated by arterial repair increased from less than 10% in
1950 to more than 80% in 1959. In the latter part of the study,
ligation was done only for injuries of minor arteries, such as
the radial or ulnar, or certain visceral arteries. The mortality
rate was reduced by one-third and the amputation rate by
half when two consecutive 5-year periods were compared.
The rate of success of arterial repair improved from 36%
to 90%.
In 1964 Patman and associates reported experiences with
271 repairs of arterial injuries in Dallas.51 In the past decade
a series of reports from large urban centers throughout the
United States have appeared, all documenting the effective-
ness of current techniques of arterial repair. Reference will be
made to these reports in specific discussions in the following
chapters. Two large recent series are those of Drapanas and
colleagues in 1970 from New Orleans, which included 226
arterial injuries, and the cumulative report by Perry and asso-
ciates from Dallas in 1971, which included 508 arterial
injuries.52,53
In 1974 Smith and co-workers reported a survey of 268
patients in Detroit with 285 penetrating wounds of the limbs
and neck.54 There were 127 peripheral arterial injuries identi-
fied. In 1975, Cheek and coauthors reviewed 200 operative
cases of major vascular injuries in Memphis that included 155
arterial injuries.55 Kelly and Eiseman in 1975 from Denver
found 116 arterial injuries among 175 injuries to major named
vessels in 143 patients.56 Hardy and associates in 1975 reviewed
360 arterial injuries in 353 patients in Jackson.57 Bole and col-
leagues in 1976 reported 126 arterial injuries in 122 patients
in New York City during 1968-1973.58
During the Troubles in Belfast in the 1970s to 1980s, Baros
D’Sa combined the skills required of civilian and military
vascular surgeons in managing and developed an interna-
tional reputation for the use of shunts in terrorist-induced,
complex vascular trauma.59,60
Conclusion
Advances in the management of vascular trauma have been
driven by the requirements of warfare. This is no less now than
it was in Medieval times. In the last 50 years, concomitant
technological improvements in resuscitation, anesthesia, and
radiology within the civilian sector have contributed further.
The difficult decisions of when to repair, how to repair,
damage-control vascular surgery, and when to amputate will
be covered in the following chapters.
12 SECTION 1  /  BACKGROUND
REFERENCES
1. Rich NM, Spencer FC: Vascular trauma, Philadelphia, 1978, WB
Saunders.
2. Rich NM, Mattox KL, Hirshberg A: Vascular trauma, ed 2, Philadelphia,
2004, W.B. Saunders Company.
3. DeBakey ME, Simeone FA: Battle injuries of the arteries in World War II:
an analysis of 2471 cases. Ann Surg 123:534–579, 1946.
4. Hughes CW: Arterial repair during the Korean War. Ann Surg 147(4):555–
561, 1958.
5. Rich NM, Hughes CW: Vietnam vascular registry: a preliminary report.
Surgery 65(1):218–226, 1969.
6. Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam: 1000
cases. J Trauma 10(5):359–369, 1970.
7. Schwartz AM: The historical development of methods of hemostasis.
Surgery 44(3):604–610, 1958.
8. Hunter W: The history of an aneurysm of the aorta, with some remarks
on aneurysms in general. Med Obs Soc Phys Lond 1:323, 1757.
9. Antyllus: Oribasius 4: 52 (Daemberg Edition). Cited by Olser in Lancet
1:949, 1915.
10. Esmarch F: The surgeon’s handbook of the treatment of the wounded in
war, New York, 1878, LW Schmidt.
11. Owen E: Nelson as a patient. The Lancet 3856:195–197, 1897.
12. Hunter J: Cited in Power, D-Arcy. Hunter’s operation for the cure of
aneurysm. Brit J Surg 17:193–196, 1929.
13. Bell J: Principles of surgery. Discourse 9:4, 1801.
14. Guthrie GJ: On gun shot wounds to the extremities, requiring the differ-
ent operations of amputation with their after treatment, London, 1815,
Longman and Others.
15. Coley RW (Translation for Fleming J): Case of rupture of the carotid
artery and wound of several of its branches successfully treated by
tying off the common trunk of the carotid itself. Med Chir J (Lond)
3:2, 1817.
16. Ellis J: Case of gunshot wound, attended with secondary hemorrhage in
which both carotid arteries were tied at an interval of four and a half days.
NY J Med 5:187, 1845.
17. Halsted WS: The effect of ligation of the common iliac artery on the
circulation and function of the lower extremity. Report of a cure of ilio-
femoral aneurysm by the application of an aluminum band to the vessel.
Bull Johns Hopkins Hosp 23:191–220, 1912.
18. Halsted W: Discussion in Bernheim, BM. Bull Johns Hopkins Hosp 27:93,
1916.
19. Hallowell (1759): Extract of a letter from Mr. Lambert, surgeon at New-
castle upon Tyne, to Dr. Hunter, giving an account of new method of
treating an aneurysm. Med Obser Inq 30:360, 1762.
20. Shumacker HB, Jr, Muhm H: Arterial suture techniques and grafts: past,
present and future. Surgery 66(2):419–433, 1969.
21. Jassinowsky A: Die arteriennhat: eine experimentelle studie. Inaug Diss
Dorpat 1889.
22. Murphy JB: Resection of arteries and veins injured in continuity end-to-
end suture. Exp Clin Res Med Rec 51:73–104, 1897.
23. von Horoch C: Die gefässnaht. Allg Wien Med Ztg 33:263–279, 1888.
24. Glück T: Uber zwei fälle von aortenaneurysmen nebst bemerkungen uber
die naht der blutgefässe. Arch Klin Chir 28:548, 1883.
25. Heidenhain L: Über naht von arterienwunden. Centralbl Chir 22:1113–
1115, 1895.
26. Israel: Cited in Murphy, JB. Resection of arteries and veins injured in
continuity—end-to-end suture–experimental clinical research. Med Rec
51:73, 1897.
27. Matas R: An operation for radical cure of aneurysm based on arteriogra-
phy. Ann Surg 37:161–196, 1903.
28. Carrel A, Guthrie CC: Uniterminal and biterminal venous transplanta-
tions. Surg Gynecol Obstet 2:266–286, 1906.
29. Lexer E: Die ideale operation des arteriellen und des arteriell-venosen
aneurysma. Arch Klin Chir 83:459–477, 1907.
30. Stich R: Ueber gefaess und organ transplantationen mittelst gefaessnaht.
Ergeon Chir Orth 1:1, 1910.
31. Nolan B: Vascular injuries. J Roy Coll Surg 13(2):72–83, 1968.
32. Bernheim BM: Blood vessel surgery in the war. Surg Gynecol Obstet
30:564–567, 1920.
33. Matas R: Military surgery of the vascular system, Philadelphia, 1921, W.B.
Saunders Co.
34. Makins GH: Gunshot injuries to the blood vessels, Bristol, England, 1919,
John Wright and Sons.
35. Linton RR: Injuries to major arteries and their treatment. NY J Med
49:2039, 1949.
36. Hughes CW: Vascular surgery in the armed forces. Milit Med 124(1):30–
46, 1959.
37. Warren R: Report to the surgeon general, Washington, DC, 1952, Depart-
ment of the Army.
38. Jahnke EJ, Jr, Seeley SF: Acute vascular injuries in the Korean War: an
analysis of 77 consecutive cases. Ann Surg 138(2):158–177, 1953.
39. Hughes CW: The primary repair of wounds of major arteries; an analysis
of experience in Korea in 1953. Ann Surg 141(3):297–303, 1955.
40. Inui FK, Shannon J, Howard JM: Arterial injuries in the Korean conflict:
experiences with 111 consecutive injuries. Surgery 37(5):850–857, 1955.
41. Spencer FC, Grewe RV: The management of arterial injuries in battle
casualties. Ann Surg 141(3):304–313, 1955.
42. Jahnke EJ, Jr: Late structural and functional results of arterial injuries
primarily repaired. Surgery 43(2):175–183, 1958.
43. Rich NM: Vietnam missile wounds evaluated in 750 patients. Milit Med
133(1):9–22, 1968.
44. Heaton LD, Hughes CW, Rosegay H, et al: Military surgical practices of
the United States Army in Vietnam. In Current problems in surgery,
Chicago, 1966, Year Book Medical Publishers, Inc.
45. Fisher GW: Acute arterial injuries treated by the United States Army
Medical Service in Vietnam, 1965–1966. J Trauma 7(6):844–855, 1967.
46. Chandler JG, Knapp RW: Early definitive treatment of vascular injuries
in the Vietnam Conflict. JAMA 202(10):960–966, 1967.
47. Cohen A, Baldwin JN, Grant RN: Problems in the management of battle-
field vascular injuries. Am J Surg 118(4):526–530, 1969.
48. Fox CJ, Gillespie DL, O’Donnell SD, et al: Contemporary management of
wartime vascular trauma. J Vasc Surg 41(4):638–644, 2005.
49. Stannard A, Brohi K, Tai N: Vascular injury in the United Kingdom.
Perspect Vasc Surg Endovasc Ther 23(1):27–33, 2011. [Epub 2011 Aug 1].
50. Ferguson IA, Byrd WM, McAfee DK: Experiences in the management of
arterial injuries. Ann Surg 153:980–986, 1961.
51. Patman RD, Poulos E, Shires GT: The management of civilian arterial
injuries. Surg Gynecol Obstet 118:725–738, 1964.
52. Drapanas T, Hewitt RL, Weichert RF, III, et al: Civilian vascular injuries:
a critical appraisal of three decades of management. Ann Surg 172(3):351–
360, 1970.
53. Perry MO, Thal ER, Shires GT: Management of arterial injuries. Ann Surg
173(3):403–408, 1971.
54. Smith RF, Elliot JP, Hageman JH: Acute penetrating arterial injuries of
the neck and limbs. Arch Surg 109(2):198–205, 1974.
55. Cheek RC, Pope JC, Smith HF, et al: Diagnosis and management of major
vascular injuries: a review of 200 operative cases. Am Surg 41(12):755–
760, 1975.
56. Kelly GL, Eiseman B: Civilian vascular injuries. J Trauma 15(6):507–514,
1975.
57. Hardy JD, Raju S, Neely WA, et al: Aortic and other arterial injuries. Ann
Surg 181(5):640–653, 1975.
58. Bole PV, Purdy RT, Munda RT, et al: Civilian arterial injuries. Ann Surg
183(1):13–23, 1976.
59. Barros D’Sa AAB: Management of vascular injuries of civil strife. Injury
14(1):51–57, 1982.
60. Barros D’Sa AAB: The rationale for arterial and venous shunting in the
management of limb vascular injuries, Belfast, Northern Ireland, 1989,
Grune & Stratton Ltd.
Epidemiology of
Vascular Injury
NIGEL R.M. TAI AND TODD E. RASMUSSEN
Introduction
Epidemiology (from the Greek: the study of that which befalls
the people) is defined as the study of the distribution and
determinants of health-related states or events in human
populations, and the application of this study to the preven-
tion and control of health problems.1 The global burden and
impact of trauma as an agent of death and disability is
increasingly well characterized (Table 2-1). However, while
the prevalence and incidence of individual vascular injury
patterns have been well depicted in local situations, the epide-
miological study of vascular trauma is a relatively underex-
ploited field.2 Possible reasons for this include the many
causes of vascular injury, the heterogeneity of the circum-
stances in which vascular injury may be sustained, the protean
direct and indirect consequences of vascular injury to bodily
systems, and the unsuitability of modern trauma scoring
methodologies to capture the specific effects of vascular
injury on patient outcome. Nonetheless, understanding the
historic and contemporary epidemiology of vascular trauma
is important. Box 2-1 lists the generic components of epide-
miological endeavor. With respect to trauma, recognizing the
prevalent populations underpins the alignment and targeting
of hospital resource and provider education, in essence
informing the design of trauma and vascular-care systems.
More widely, better description of mechanisms, case mix and
demography empowers comparison of properly stratified
outcomes from injury, whether used to assess performance
within or between institutions, or to track outcomes with
respect to time. Case mix and other epidemiological data are
used to inform quality-improvement initiatives, to construct
fair reimbursement schedules for treating hospitals, to under-
stand the impact of external socioeconomic realities, to influ-
ence the design and assessment of preventative public health
interventions, and to inform wider health and social policy. In
essence, if vascular and trauma clinicians are to anticipate
injury patterns, to track changes, and to put into place effec-
tive programs to prevent or to mitigate the effects of vascular
trauma, then the study of injury epidemiology is an essential
function of practice.
The aim of this chapter is to outline the general circum-
stances, incidence, and population effects of vascular trauma,
as viewed from the epidemiological perspective, in order to
provide the context to more-detailed illustrations and epide-
miological profiles of specific anatomical injuries given else-
where in the text.
2 
Context and Categorization
of Vascular Trauma
As explained, attempting to directly compare and contrast
vascular injury epidemiology is hampered by the protean
nature of trauma and the multiple and interrelated factors that
determine functional outcome (such as co-injury to critical
soft tissue, as well as bony and neurological structures). This
difficulty is made more acute by the lack of uniformity among
authors as to appropriate injury descriptors, outcome metrics
and follow-up periods. Most studies in both the military and
civilian domains offer descriptions of cohorts comprising spe-
cific vascular regions (extremities) or anatomical areas (e.g.,
crural vessels); this provides detail at the expense of proper
epidemiological perspective. Rates of vascular trauma are con-
flicted by use of different definitions of population-at-risk,
invoking different denominators and inflating or deflating
prevalence accordingly. Outcomes are defined differently and
with varying degrees of accuracy. For instance, mortality rates
may variously be built on definitions such as death while
an inpatient, ignoring those who expire before reaching the
hospital. Epidemiology is dependent on data; countries with
mature trauma systems where accurate data collection is man-
dated offer a more fruitful if narrow perspective on injury
rates and causes. Similarly, while wartime populations often
have higher vascular injury rates than peacetime cohorts, the
presence of detailed injury data (with accurate description of
the denominator populations) is directly related to whether a
trauma systems approach to injury data collection is deployed
by the medical services of the combatant parties. It is fair to
say that countries without a trauma systems approach to
injury management, whether in their military or civilian pop-
ulations, are usually unable to describe the effect of vascular
trauma in populations-at-risk. Because most developing
countries fall into such categories, it is correct to assume that
the global burden of vascular trauma is unknown.
Vascular trauma may be broadly categorized according to
mechanism of injury (iatrogenic, blunt, penetrating, blast,
combination injuries), anatomical site of injury (further sub-
divided into compressible and noncompressible hemorrhage),
and by wider contextual circumstances (military, civilian).
Each of these domains may be further stratified, with military
injury being subdivided by patient status (combatant, non-
combatant) and category of conflict (civil war, counterinsur-
gency warfare, maneuver warfare). Civilian injuries may be
similarly contextualized by local circumstances (e.g., urban
13
 2  /  Epidemiology of Vascular Injury 13.e1

ABSTRACT
While the epidemiology of general trauma is increasingly
well understood, the specific epidemiology of vascular
injury is less well characterized, particularly in the civilian
domain. Factors that mitigate against proper understanding
of the rate and nature of vascular injury among populations
include the absence of national, regional, or institutional
datasets, poorly defined populations-at-risk, and concentra-
tion by researchers on specific injury subtypes at the expense
of a general perspective. The prevalence of vascular injury
in recent military engagements in Iraq and Afghanistan may
be as high as 12%, a fivefold increase from previous cam-
paigns in South East Asia. Various mechanisms may account
for this rise; but improvements in force protection, early
battlefield resuscitation drills, and medivac have almost
certainly increased the number of patients reaching surgery
alive, most of whom have extremity wounds. The preva-
lence of civilian vascular trauma is much lower but is subject
to considerable regional variation. Torso injuries are more
common than in military circumstances, but absence of
large-scale registry data in most countries means that the
burden of vascular trauma remains largely unknown. In
many developed countries, a significant proportion of vas-
cular injuries are iatrogenic in nature, contributing to vas-
cular trauma that is increasing in prevalence as an older
demographic is exposed to an ever-burgeoning suite of
endovascular solutions to chronic diseases.

Key Words:  vascular injury,

trauma,
epidemiology,
military
14 SECTION 1  /  BACKGROUND

Table 2-1 Summary: Deaths (000s) by Cause, in WHO Regions (a), Estimates for 2008
The Eastern Southeast Western
Cause World (b) Africa Americas Mediterranean Europe Asia Pacific
Population (000) 6,737,480 804,865 915,430 580,208 889,170 1,760,486 1,787,321
(000) % total (000) (000) (000) (000) (000) (000)
TOTAL Deaths 56,888 100.0 10,125 6170 4198 9223 14,498 12,674
Injuries 5129 9.0 687 594 445 664 1552 1187
Unintentional injuries 3619 6.4 445 355 293 487 1132 908
Road traffic accidents 1209 2.1 168 148 124 108 309 351
Poisonings 252 0.4 39 35 15 84 31 48
Falls 510 0.9 19 48 24 66 211 142
Fires 195 0.3 39 8 28 20 84 16
Drownings 306 0.5 42 20 22 27 96 98
Other unintentional injuries 1146 2.0 136 96 79 181 401 252
Intentional injuries 1510 2.7 242 239 152 177 420 280
Self-inflicted 782 1.4 51 72 32 126 274 226
Violence 535 0.9 162 157 22 46 102 47
War and civil conflict 182 0.3 29 8 96 5 40 3

From the World Health Organization Global Health Observatory Data Repository (http://apps.who.int/ghodata/?vid=10012), accessed September
2011.

Box 2-1 Core Purposes of Epidemiological
Programs (1)
Identifying risk factors for disease, injury, and death
Describing the natural history of disease
Identifying individuals and populations at greatest risk for disease
Identifying where the public health problem is the greatest
Monitoring diseases and other health-related events over time
Evaluating the efficacy and effectiveness of prevention and
treatment programs
Providing information that is useful in health planning and
decision making for establishing health programs with
appropriate priorities
Assisting in carrying out public health programs
trauma, rural trauma). For the purposes of this chapter, the
context will be considered under two broad conditions con-
cerning the injurious mechanism: vascular injury caused
during military conflict (whether between interstate, intra-
state, or nonstate actors) and vascular injury that occurs in the
context of peacetime circumstances.
Vascular Trauma and
Military Conflict
Vascular injuries that occurred in World War I (WWI), World
War II (WWII), Korea, and Vietnam can be conceived as prod-
ucts of industrial war waged between nation states. Warfare
over the past 2 decades has lost many of the characteristics
that defined previous engagements; the phrase “war among
the people” has gained credibility as the ability of nations to
employ force with utility has declined. This refers to the
modern scenario where “the reality in which the people in the
streets and houses and fields—all the people, anywhere—are
the battlefield. Military engagements can take place anywhere,
with civilians around, against civilians, in defense of civilians.
Civilians are the targets, objectives to be won, as much as an
opposing force”.3 As such, vascular trauma inflicted by high-
energy military ballistic projectiles and purpose-built or
improvised blast weaponry can affect two populations-at-risk:
combatants and noncombatant (civilians).
Vascular Trauma in Combat Troops
Contemporary and recent data confirm that exsanguination
is the major cause of death in fatally wounded soldiers.4-7
Chapter 1 reviews the changing nature of wartime and civilian
vascular trauma over the ages; but the prevalence also seems
to have changed markedly over the past century of conflict.
Estimates from allied surgeons in WWI suggested overall vas-
cular trauma rates of 0.4% to 1.3%.8 DeBakey characterized
the vascular injury burden in WWII as affecting 0.96% of all
patients; but, for the Korean and Vietnam wars, the rate of
vascular injury was judged to be higher at 2% to 3%.9-13
Coalition militaries engaged in combat operations in
Afghanistan (2001-) and Iraq (2003-2011) have invested sub-
stantially in detailed trauma registries in order to capture
injury data. Such databases have been used to characterize
miscellaneous injury patterns so that force protection (body
armor, vehicle design) and treatment protocols can be con-
tinually updated and aligned to contemporary trauma
archetypes. Interestingly, present rates of wartime vascular
trauma confirm a much higher prevalence than in previous
campaigns.14-18
In a comprehensive study summarizing recent U.S. military
experience, White and colleagues analyzed vascular cases
entered in to the United States Joint Theater Trauma Registry
(JTTR) from 2002-2009.14 Defining the denominator as battle-
related injuries sufficiently severe to prevent return to duty
into the combat theater, the specific incidence of vascular
injury (defined as the “total incidence injury”) was found to
be 12% (1570 of 13,076 cases). The incidence of injuries
requiring surgery (defined as the “operative incidence”) was
found to be 9% (1212 of 13,076 cases). The analysis looked
for differences in vascular injury incidence between troops
deployed to Iraq and Afghanistan and found significantly

different rates of 12.5% and 9%, respectively. Peak rates of
injury in either theater differed with combat tempo, account-
ing for 15% of all injuries in 2004 (Iraq) and 11% in 2009
(Afghanistan). Other differences included causative mecha-
nism, with blast accounting for 74% and 67% of injuries in
Iraq and Afghanistan (with an overall contribution of 73%).
There was no difference in the anatomical distribution of the
injuries, nor the died of wounds (DOW) rate (6.4%), between
theaters. Wounds were principally sustained to the extremities
(79%), torso (12%), and cervical regions (8%). In the torso,
the most commonly injured vessels were the iliacs (3.8%),
followed by the aorta (2.9%) and subclavian arteries (2.3%),
and then followed by injuries to the inferior vena cava (1.4%).
In the neck, 109 carotid injuries accounted for 7% of injuries.
It was noted that the vascular injury burden borne by the
extremities was remarkably similar to that noted by DeBakey
in WW2, although the higher contemporary rate of cervical
and aortic injury was attributed to increased survivability and
far-shortened medivac times.
Overall, the authors concluded that the rate of vascular
injury in these wars was 5 times that previously reported from
Vietnam and Korea. Interestingly, this estimation of incidence
also ran substantially higher than that reported from early
analyses—of around 4.4% to 4.8%—published from U.S.
military hospitals in Iraq.15,16 However, it is important to note
that these reports did not include nonoperated cases and were
generally confined to descriptions of vascular cases identified
as “in theaters.” When the analysis includes such cases, the
overall rate of vascular incidence rises. For instance, by deter-
mining rates among patients repatriated back to the continen-
tal United States and screened for additional, unrecognized
vascular injury on reception, Fox and colleagues described a
prevalence of 7%.16
The marked increase in rates of vascular injury recorded
by these contemporary authors, as opposed to that docu-
mented by previous generations, is striking. The reasons for
this finding are unconfirmed. As well as increased wound sur-
vivability, other reasons may include: a) the very high rate of
blast-related injury etiology in these campaigns, b) overesti-
mation of the population-at-risk in earlier reports (thus
deflating the denominator), and c) more accurate capture
of “minor” nonoperated vascular wounds (adding to the
numerator).
In a similar but smaller British study, Stannard and col-
leagues scrutinized the records of 1203 UK servicemen injured
through enemy action between 2003 and 2008.18 Unlike the
U.S. JTTR, the British JTTR dataset also included patients who
were killed in action (KIA)—that is, who died before reaching
a medical treatment facility,19 an aspect of injury burden not
scrutinized in U.S. accounts. Characterization of injury was
made from clinical data and from postmortem examinations
conducted by the UK Coroner system. It was determined that
110 (9.1%) of this cohort sustained injuries to named vessels,
two-thirds of which had extremity vascular injuries. Blast
wounds accounted for 54% and 76% of patients sustaining
torso-cervical and extremity wounds, respectively. Some 66 of
the 110 died before any surgical intervention could be under-
taken, indicating the highly lethal nature of vascular wound-
ing patterns. In particular, no patient with a combination of
vascular injuries affecting more than one body region (torso,
extremity, cervical) survived to surgery. A further defining
difference in wound patterns observed between patients sur-
2  /  Epidemiology of Vascular Injury 15
viving to surgery (versus those who did not) was presence or
absence of a torso vascular injury—with none of those sus-
taining an injury to a named vessel in the abdomen or thorax
undergoing operative intervention. Cervical vascular injuries
also proved highly lethal, with 13 of 17 patients succumbing.
On the other hand, of 76 patients with extremity vascular
injuries, 37 survived to surgery with one postoperative death.
Interventions on 38 limbs included 19 damage-control proce-
dures (15 primary amputations, 4 vessel ligations in a group
characterized by a median mangled extremity score of 9) and
19 definitive limb-revascularization procedures (11 interposi-
tion vein grafts, 8 direct repairs), with a limb salvage (primary
assisted patency) rate of 84%. This UK group concluded that
while favorable limb-salvage rates are achievable in casualties
able to withstand revascularization, torso vascular injury is
not usually amenable to successful surgical intervention.
Vascular Trauma Among Local  
National Populations
Few studies have examined the burden and impact of vascular
trauma in civilians injured in time of war. The registries of
military trauma systems may be biased toward data collection
among their own troops, or in such cases where information
is captured there is usually no data on long term outcomes
due to lack of follow-up in war-afflicted societies. Clouse and
colleagues recorded that 30% and 24% of all vascular casual-
ties treated at a Level III (major trauma center equivalent) U.S.
facility in Iraq were either civilians or local national combat
forces.15 Extremity vascular injuries were significantly more
prevalent in U.S. forces compared with the local population
(81% versus 70%). Vascular injury to the torso was signifi-
cantly less common in U.S. forces (4% versus 13%) but neck
injuries occurred with similar prevalence (14% versus 17%).
The authors hypothesized that the lack of protective body
armor might increase the nonextremity vessel injury rate in
the Iraqi population. Interestingly, vascular injuries were
noted to be overrepresented in the local nationals: although
40% of those admitted to the facility were of Iraqi origin, they
made up to 51% of the vascular injury cohort.
Deployed military hospitals are primarily configured
and resourced for the care of their own nation’s soldiers, so
understanding the additional burden presented with a large
local national population of injured civilians, insurgents, and
military remains important. In a supplementary report from
the Air Force Theater Hospital in Balad, Iraq,20 it was deter-
mined that the incidence of vascular trauma among 4323
locals treated at the facility was 4.4%. The authors focused
on extremity injuries—which affected 70% of vascular
casualties—and observed that the median length of stay from
presentation to definitive wound closure was 11 days. Casual-
ties underwent a median of 3 operations. Notably, the age
range was 4 to 68 years and included 12 pediatric injuries.
Mortality was 1.5% with significant complications in 14% but
despite this a 95% limb salvage rate was recorded.
This experience matches earlier reports. Sfeir and col-
leagues described a population of 366 lower limb–wounded
vascular cases, sustained by a mixed population of combatant
and noncombatants during the Lebanese civil war over a
16-year period ending in 1990. Two-thirds of patients had
received gunshot wounds. Patients included 118 who had pop-
liteal arterial injuries, 252 with femoral injuries and 16 who
had tibial vessel injuries. The overall mortality rate was 2.3%
16 SECTION 1  /  BACKGROUND
with no mortality in the popliteal and tibial injury group
whereas there were nine deaths in the femoral injuries group.
The overall amputation rate was 6% (11.7% for the popliteal
injuries group). Mirroring more contemporary experience,
the authors associated failure of limb salvage with physiologi-
cal instability, delay in repair (of more than 6 h from injury)
and presence of long bone fracture.
Vascular Trauma and
Civilian Populations
The overall impact of vascular trauma in civilian society is
largely unknown in societies without recourse to large popula-
tion datasets. Even in the United States, which is served by the
National Trauma Data Bank (NTDB; a national trauma reg-
istry administered by the American College of Surgeons and
receiving data from more than 900 trauma facilities), large-
scale studies are few. In 2010, Demetriades and colleagues
attempted to characterize the nature of vascular trauma in
22,089 patients—including children—drawn from a general
trauma population of more than 1.8 million case files recorded
on the NTDB system. Accepting the almost inevitable report-
ing bias that accompanies analysis of such retrospective data,
it was determined that the overall incidence of vascular injury
during the study period (2002-2006) was 1.6%. Four-fifths of
the injured were male, and the average age was 34 years. It was
reported that 51% sustained a penetrating mechanism; the top
four mechanisms of injury were motor vehicle collisions,
firearm injuries, stab wounds, and falls from height. Just under
a fourth were shocked on admission, and over half had an
Injury Severity Score of more than 15. Abdominal injuries and
chest injuries accounted for more than 24.8% and 23.8% of
the trauma burden, respectively, with arm and leg injuries
accounting for 26.5% and 18.5%. Adult mortality was 23.2%;
vessels associated with the highest amputation rates were the
axillary artery (upper limb amputation rate of 6.3%) and
popliteal artery (lower limb amputation rate of 14.6%).21 This
impressive dataset summarized national epidemiological data;
but what is of concern to individual trauma and vascular
surgeons is the local epidemiology of vascular injury among
their patients, because this will determine workload, case mix,
and outcome.
Urban Populations
Inner-city populations in countries such as the United States
and South Africa have been characterized as having high rates
of interpersonal violence, much of it mediated by low-energy
handgun or bladed weaponry. South Africa has an intentional
homicide rate of 32 per 100,000, whereas the United States
figure is 4.8 per 100,000 and the UK figure is 1.7 per 10,000.22-24
However, there is considerable regional variation in violence
rates even within societies where violent injury is common.
For instance, in South Africa, the numbers of homicides
within a region is a function of population size and also rates
of crime within that population, with Limpopo (a rural region
with a population of 5.5 million) experiencing 762 murders
in 2009-2010 and Gauteng (an urban region with a population
of 8.8 million, including Johannesburg) experiencing 3444
murders over the same time frame.22 Similarly, the murder rate
in nonsuburban U.S. cities is approximately twice that of sub-
urban areas.25 Of course, the relationship between urbanicity
concentration and population homicide rates is not universal.
Australia has an overall murder rate of 1.2 per 100,000, yet the
homicide rate in the sparsely populated Northern Territories
is 3.96 per 100,000, compared to 0.8 in Victoria State.26 The
degree to which national and urban murder statistics translate
to violent vascular injury is difficult to quantify, but it is unsur-
prising to note that the majority of classical reports detailing
the burden, type, and outcomes from vascular trauma come
from urban institutions serving inner-city and poorer popula-
tions. As described above, population-wide data garnered
from the National Trauma Data Bank suggests the contempo-
rary overall prevalence of vascular injury in patients is 1.6%21
whereas that presenting for treatment in urban areas has been
quoted as 2.3% in a New York Level I trauma center27 and 3.4%
in a Level II center in El Paso, Texas.28 These reports typify the
perceived demographic as almost always male and usually
young. Mortality is approximately twice that of nonvascular
patients27 and penetrating trauma is overrepresented in vas-
cular patients, with the El Paso authors recording a 40% pen-
etrating injury mechanism in vascular patients against a rate
of 10% in the general trauma population.28
The largest U.S. single center study of vascular trauma to
date was published in 1988 and emanated from Houston.29 It
typifies the experience of many large inner-city urban trauma
facilities and was undertaken with the aim of deriving epide-
miological conclusions that would guide trauma-center and
health logisticians. The study encompassed a 30-year period,
describing 5760 cardiovascular injuries in 4459 patients. The
authors set themselves the task of accounting for the entire
vascular injury cohort, rather than restricting themselves to
specific vessels, utilizing multiple corroborative documentary
sources rather than a single registry. Their study confirmed
that the burden of vascular trauma in the city was being borne
by young men (86% male, average age 30 years), 90% of whom
had been injured by firearms (gunshot wound 51.5%; shotgun
injury 6.8%) or knives (31.1%). The study once again dem-
onstrated that the wound pattern in civilian circumstances,
even where ballistic penetrating injury is the norm, does not
follow that seen in wartime. Torso and neck injuries accounted
for two-thirds of all injuries treated, while lower extremity
injuries (including the groin) comprised only a fifth. Whereas
very few soldiers with injuries to the large vessels of the
abdomen are seen by military surgeons, trauma to the abdom-
inal vasculature accounted for 33.7% of the total vascular
injury cohort seen in Houston—a fact attributed to the matu-
ration of the city’s Emergency Medical Services. Trends in
epidemiological factors—including changes in the local popu-
lation, changes in local crime patterns (noting the increased
burden of trauma that accompanied criminal narcotic activ-
ity), and provision of health-care infrastructure—were care-
fully described. The authors noted a sixfold surge in vascular
trauma, with 163 and 1069 injured patients in the first and
last respective 5 years of the study period, although as they did
not detail the denominator data (total number of trauma
patients treated for each time period), it was not possible to
assess for trends in the proportion of patients with vascular
trauma. Furthermore, trauma scores, physiology, and crude
outcome measures such as mortality were not given, thereby
limiting characterization of case mix and reducing the utility
of this impressive dataset for the purposes of comparison.
Despite these drawbacks, this classic study serves as template
for other investigators seeking to describe vascular trauma
epidemiology among their communities.30

South Africa urban centers have reported a number of large
series of vascular injuries pertaining to individual vessels and
bodily regions,31 though overall burdens of impact are less
clear. In Australia, Sydney and Perth have reported vascular
trauma rates of 1% to 1.8% with penetrating trauma mecha-
nisms contributing up to 42% of cases.32,33 Reports from indi-
vidual centers in the UK emphasize the relative rarity of
noniatrogenic vascular trauma in the general and university
hospital setting alike34-36; however, the rates of vascular trauma
among certain inner-city populations may approach those
seen in North American centers. In 2011, a 6-year study in the
lead trauma center for London determined that 256 patients
(4.4%) out of 5823 trauma admissions sustained vascular
injury (Personal Communication, Mr. Zane Perkins, Royal
London Hospital). Penetrating trauma caused 135 vascular
injuries (53%), while the remainder resulted from blunt
trauma patients, who were more severely injured (median
Injury Severity Score (ISS) 29) compared to those with pen-
etrating trauma (median ISS 11) and had greater mortality
rates (26% versus 10%) and higher limb amputation rates
(12% versus 0%). These differences remained when compar-
ing injuries in each anatomical zone. Blunt vascular trauma
patients were twice as likely to require massive blood transfu-
sions (47% versus 27%) and had a fivefold longer hospital
stays (median 35 days versus 7 days) when compared to
patients with penetrating vascular trauma. Recent develop-
ment of a national trauma registry and trauma systems
approach in the UK’s National Health Service will allow better
plotting of the impact of vascular trauma, especially with
regard to inner-city “hot spots.”37
Rural Populations
Large vascular series are dominated by urban centers, but
nonurban and rural populations have discrete epidemiologi-
cal injury profiles and patients who have bespoke require-
ments, particularly regarding timely access to vascular care.
Endeavors by North American researchers studying trauma
systems serving rural populations have shed light on injury
patterns in these more isolated settings.
In 1982 Koivunen et al reviewed 89 Missourians, a third of
whose injuries were farm related, and found that the delay
between injury and arrival at the center averaged 3.4 hours.
Their study also found that 82% of the injuries involved
extremities, and 35% of the injuries were ligated, with an
overall amputation rate of 16.4% and a mortality rate of 5.6%.
The complication rate associated with vascular repair was
12.4%. The authors noted that the majority of complications
and all deaths and amputations were in patients suffering
trauma from farm, industrial, and motor-vehicle accidents.38
Twelve years later the same group looked at the influence of
time to treatment on outcome in 210 patients from principally
rural areas,37 noting a time period of 6 hours before the intro-
duction of their helicopter retrieval service and 4 hours after-
ward. Amputation rates fell from 18% to 7%. In the largest
North American series to date, Oller examined 1148 vascular
injuries suffered by 978 patients reported from eight trauma
centers in a largely rural state. Over the course of the study,
vascular trauma accounted for 3.7% of all trauma cases
entered on the trauma registry. The amputation rate was 1.3%
among those with extremity injuries, which accounted for
47% of the total cohort. The authors reached broadly similar
conclusions to the Missouri group with respect to rural vas-
2  /  Epidemiology of Vascular Injury 17
cular injury patients—four-fifths of whom were transferred in
from peripheral facilities—in that these patients were older,
had a higher incidence of blunt trauma, had longer inpatient
admissions, and had higher mortality rates (14.2%). They
argued that, for optimum care, trauma services catering to
rural patients with vascular injuries must configure their
systems to enable prompt identification resuscitation and
early transport of vascular injury patients to major trauma
centers for definitive care.39
Vascular Trauma and Patient Age
The rate and effect of vascular trauma in pediatric and elderly
populations is important. Pediatric vascular trauma is a rare
phenomenon but has potential for long-term functional con-
sequences; any therapy—surgical or conservative—requires
the surgeon to take into account the developmental needs of
the child. Vascular injury in the older population occurs in the
context of native occlusive vascular disease, older and stiffer
vasculature, and less-resilient physiology.
A number of studies have revealed that the rate of vascular
injury is very low in pediatric trauma cases40-45—whichever
precise cutoff age is used to define the pediatric population.
Penetrating trauma in pediatric vascular injury is a common
mechanism and, as in adult vascular trauma, is overrepre-
sented as a cause of trauma as compared to nonvascular
injury.44,45 For instance, in Klinker et al’s 12-year study of 106
vascular injuries among 9108 patients aged 18 and younger,
who were treated at a specialist children’s hospital, 1.1% of all
trauma admissions were associated with vascular injury. The
prevalence of vascular trauma with blunt injury was 0.4%,
whereas that with penetrating trauma was 4.5%. Notably,
there were as many wounds caused by glass injury as there
were by gunshots (24 in each case). The authors commented
on the burden of extremity vascular trauma—with an overall
amputation rate of 10.7% (most of whom had mangled
extremities secondary to train or lawnmower accidents), a
mortality rate of almost 10% (frequently associated with head
injury)—and the virtual absence of thoracic aortic injury in
this cohort.43
Barmparas and colleagues’ analysis of pediatric vascular
injury among 251,787 U.S. National Trauma Data Bank
patients supports those findings.21 Pediatric cases—defined as
15 years of age or younger—were compared to the adult vas-
cular trauma patient cohort. The prevalence of pediatric vas-
cular injury was noted to be 0.6% against an overall rate of
1.6%. Pediatric patients had lower ISS scores with a high, but
less-frequent, incidence of penetrating injury (41.8% versus
51.2%). There were clear differences in injury patterns. In
contrast to adults, pediatric patients exhibited significantly
more blunt and penetrating upper extremity vascular injuries
but sustained less-penetrating chest and abdominal vascular
injuries. The upper arm bore the brunt of pediatric vascular
injury; brachial vessel trauma occurred in 13.2%, with forearm
vessel injury in 22%. The incidence of blunt thoracic aortic
injury was much lower in children, involving 8.9% of all blunt
pediatric vascular trauma cases versus 26.1% in bluntly injured
adults, with a linear relationship between age and incidence
of aortic injury. Mortality was significantly lower in the pedi-
atric cohort when compared to adults (13.2% versus 23.2%)—a
difference that persisted even after correcting for compound-
ing differences such as ISS, low GCS, and mechanism. There
18 SECTION 1  /  BACKGROUND
was no difference in the frequency of lower-extremity ampu-
tation between adult and pediatric patients who had sustained
lower-extremity vascular injuries (9.1%) compared to adults
(7.5%). The authors drew attention to the facts that, despite
the survival advantage observed in pediatric patients, the rate
of penetrating injury was sobering and a fifth of children who
had been shot died from their injuries.
There have been fewer studies of the epidemiology of vas-
cular injury in geriatric patients. In 2011, a further study of
NTDB data (based on the same population dataset utilized by
Demetriades’s group for their pediatric study) was reported.46
They characterized vascular trauma in patients over 64 years
of age. The study revealed an overall incidence of vascular
injury of 0.7% in patients over 64 compared to the 16-64 age
group figure of 2%. The older cohort was different from the
younger cohort with respect to sex distribution (60.8% versus
82.1%), injury severity score (26.6 versus 20.9), and frequency
of penetrating mechanism of injury (16.1% versus 54.1%).
Notably, the thoracic aorta—the most commonly injured
vessel in those suffering blunt trauma—was more frequently
injured in the elderly population than in the younger cohort
(38.9% versus 24.2%). Other differences in injury pattern
included higher rates of penetrating neck and arm injury and
more blunt chest and abdominal vascular injuries. The
authors described a linear increase in thoracic aortic injuries
with increasing age and a corresponding decrease in injuries
to the forearm vessels and femoropopliteal axis. Interestingly,
no significant difference in amputation rates was described
between older (2.5%) and younger (3.0%) patient cohorts in
terms of overall, upper limb, or lower limb injury patterns.
The younger patient cohort was significantly more likely to
undergo fasciotomy (9.6% versus 2.8%), although the authors
were unable to account for this. Overall mortality was signifi-
cantly higher in the older cohort when compared with
younger adults (43.5% versus 21.6%). Being over 64 was asso-
ciated with an odds ratio of death of 3.9 after adjusting for
sex, ISS, low GCS, presence of shock, mechanism of injury,
and body region of injury. Unsurprisingly, older patients had
longer ICU stays, although overall inpatient length of stay of
10.2 days did not differ significantly compared to the younger
cohort.
Iatrogenic Vascular Trauma
Many vascular surgeons encounter vascular injury not as a
result of accident or criminal assault but due to inadvertent
misadventure where vessels are damaged during surgery or
endovascular instrumentation. These injuries typically happen
to older patients with multiple comorbidities and who are
undergoing procedures for the treatment of chronic cardio-
vascular disease. Iatrogenic etiology may be the chief cause of
vascular trauma in peaceful countries where percutaneous
cardiac, neurological, and endovascular therapies are estab-
lished and popular therapies. One European review of the
burden of iatrogenic vascular trauma estimated incidence of
35% to 42%.47 However, even in underdeveloped countries,
iatrogenic trauma may account for a significant proportion of
the vascular injury workload.48 In Sweden, where repairs for
vascular trauma constitute 1.3% of all emergency and elective
vascular workloads, a review of national vascular registry data
revealed that iatrogenic etiology accounted for 48% of all
vascular injuries, with penetrating trauma and blunt trauma
accounting for 29% and 23%, respectively.49 The most com-
monly injured vessel was the right femoral artery, in keeping
with complications from endovascular interventions. As
expected the iatrogenic group was older, with a median age of
68 and had a higher incidence of comorbid conditions such
as cardiac disease (58%) and renal dysfunction (18%) than
patients injured by noniatrogenic etiologies. Mortality was
approximately double that of noniatrogenic patients (4.9%
versus 2.5%). The authors noted that iatrogenic vascular
trauma had increased over the 1993-2004 study period by
150% and attributed this to the increased uptake of endovas-
cular procedures. Two small but recent studies from both pro-
vincial and tertiary referral vascular centers in England, where
71% to 73% of all vascular injuries were found to be iatrogenic
in nature,36,50 echoed these results. Both studies found worse
outcomes in the iatrogenic group compared to the noniatro-
genic cohorts, with patients undergoing noncardiac or periph-
eral vascular interventions faring the worst following their
iatrogenic injury.
Vascular Trauma, Lifestyle, and
Socioeconomic Factors
Several investigators have focused on one type of vascular
injury pattern in order to investigate the effect of various
epidemiological variables known to influence outcome in
general trauma populations. For instance, how does obesity
(an ever growing problem in developed societies and one asso-
ciated with poor outcome in polytrauma patients)51-53 affect
patients with vascular injury? Simmons and colleagues studied
115 patients with lower-extremity vascular injuries over a
5-year period ending in 2005 and dichotomized the group by
a body mass index (BMI) of 31 or more.54 Interestingly, they
found that obese patients in general exhibited no difference in
amputation rate or mortality, although a BMI of greater than
40 was not associated with a favorable outcome.
In North America, poverty and race are increasingly recog-
nized as influences on outcomes from trauma.55-57 It is unclear
to what extent these factors are intrinsic drivers of outcome
and to what extent they represent summary descriptors of
multiple competing and compounding subfactors. In order to
answer this, Crandall sought a more homogeneous trauma
grouping and thus examined the fate of patients with lower-
extremity vascular injury to investigate the impact of race and
insurance status.58 Using a large NTDB population of 4928
patients, the authors found that those who were of Latino,
African American, Asian American, or Native American origin
had a significantly higher odds ratio of death (1.45), as did the
uninsured cohort (1.62). The African American and Latino
cohorts made up 51.1% and 19%, respectively, of penetrating
vascular patients, but these groups only contributed 12.1%
and 10.5% to the blunt-injury cohort. When the outcomes
were stratified by mechanism of injury, no difference was
found with respect to mortality in bluntly injured patients,
whatever their insurance status or race. Penetrating patients
who were uninsured had significantly worse mortality, but
race only trended toward statistical significance in the predic-
tion models studied. The authors concluded that by focusing
on one injury pattern they had observed a lessening of the
compounding effect of injury heterogeneity, pointing out
that genotypic differences in the response to penetrating inju-
ries, provider factors, or poor capability of standard injury

measurements to describe the effect of penetrating injury may
all contribute to residual observed differences.
Certainly, it is doubtful whether current trauma scoring
systems truly capture the effect of vascular trauma on popula-
tions. This is unsurprising given the low frequency of vascular
trauma within the reference populations used to construct the
index models that these systems employ to empower predic-
tion. Loh and colleagues explored this issue in a small series
of 50 patients with vascular trauma, matched to an injury
severity score of 25, against 50 nonvascular trauma patients.24
Predicted mortality in the vascular injury group was estimated
at 14.3, 4, 15.1, and 18.9% by ISS, Revised Trauma Score
(RTS), acute physiology and chronic health evaluation II
(APACHE II), and Trauma Score-Injury Severity Score
(TRISS), respectively. The actual mortality of the cohort was
24%. The authors observed that these systems were better in
predicting mortality in patients without vascular injury
(15.6%, 9.6%, and 15.8% for ISS, APACHE II, and TRISS
versus actual mortality of 11.8%) and concluded that conven-
tional trauma-scoring systems underestimate the impact of
vascular injury on mortality.
Summary
Contemporary measures of general trauma epidemiology
confirm that injury remains a global blight. Road traffic acci-
dents currently cause 1.3 million deaths per year and are
anticipated to rise from the ninth to the fifth most prevalent
cause of death by 2030.59 Worldwide, violence accounts for
526,000 deaths per year with around 10% of these caused by
armed conflicts.60 While the vascular contribution to injury
mortality and morbidity is relatively well understood within
discrete populations—notably within the coalition forces
fighting in Afghanistan and Iraq, where the prevalence of vas-
cular injury is 12% and much higher than that encountered
in Korea and Vietnam—the level of characterization is much
lower and in most cases largely absent in civilian populations
where data injury is not collected and analyzed systematically.
The incidence and prevalence of vascular trauma is not well
investigated; where data is available for analysis it would seem
that the prevalence of vascular trauma is lower in civilian
trauma cohorts, who exhibit a different pattern of injury with
proportionally more torso wounds seen. Iatrogenic trauma is
a significant contributor that is increasing in prevalence as
endovascular solutions are increasingly employed in devel-
oped societies grappling with the challenges of servicing the
health needs of older societies. If vascular and trauma sur-
geons are to tackle the consequences of vascular injury in a
holistic manner, then understanding the local circumstances
of the epidemiology of vascular trauma is key to better target-
ing of surgical endeavor, hospital resource and preventative
measures. Good data acquisition and analysis in local, regional
and national populations-at-risk underwrites good epidemi-
ology and must be considered when planning for and imple-
menting trauma systems responsible for patients with vascular
injury.
REFERENCES
1. Merrill RM: Introduction to epidemiology, 5th ed, London, 2010, Jones
and Bartlett Publishers.
2. Caps MT: The epidemiology of vascular trauma. Semin Vasc Surg 11:227–
231, 1998.
2  /  Epidemiology of Vascular Injury 19
3. Smith General Sir Rupert: The utility of force, London, 2005, Allen Lane.
ISBN 0-7139-9836-9.
4. Holcomb JB, McMullin NR, Pearse L, et al: Causes of death in U.S. Special
Operations forces in the global war on terrorism 2001–2004. Ann Surg
245:986–991, 2007.
5. Champion HR, Bellamy RF, Roberts CP, et al: A profile of combat injury.
J Trauma 54:S13–S19, 2003.
6. Kelly JF, Ritenour AE, McLaughlin DF, et al: Injury severity and causes of
death from Operation Iraqi Freedom and Operation Enduring Freedom:
2003–2004 versus 2006. J Trauma 64:S21–S26, 2008.
7. Bellamy RF: The cause of death in conventional land warfare: implica-
tions for combat casualty care research. Mil Med 149:55–62, 1984.
8. Bowlby A, Wallace C: The development of British surgery at the front.
Brit Med J 1:705–721, 1917.
9. DeBakey ME, Simeone FA: Battle injuries of the arteries in World War II:
an analysis of 2471 cases. Ann Surg 123:534–579, 1946.
10. Hughes CW: The primary repair of wounds of major arteries: an analysis
of experience in Korea in 1953. Ann Surg 141:297–303, 1955.
11. Hughes CW: Arterial repair during the Korean War. Ann Surg 147:555–
561, 1958.
12. Rich NM, Hughes CW: Vietnam vascular registry: a preliminary report.
Surgery 65:218–226, 1969.
13. Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam:
1,000 cases. J Trauma 10:359–369, 1970.
14. White JM, Stannard A, Burkhardt GE, et al: The epidemiology of vascular
injury in the Wars in Iraq and Afghanistan. Ann Surg 253:1184–1189,
2011.
15. Clouse WD, Rasmussen TE, Peck MA, et al: In-theater management of
vascular injury: 2 years of the Balad vascular registry. J Am Coll Surg 204:
2007.
16. Sohn VY, Arthurs ZM, Herbert GS, et al: Demographics, treatment, and
early outcomes in penetrating vascular combat trauma. Arch Surg 143:
783–787, 2008.
17. Fox CJ, Gillespie DL, O’Donnell SD, et al: Contemporary management of
wartime vascular trauma. J Vasc Surg 41:638–644, 2005.
18. Stannard A, Brown K, Benson C, et al: Outcome after vascular trauma
in a deployed military trauma system. British Journal of Surgery 98:228–
234, 2011.
19. AAP-6, NATO Glossary of terms and definitions 2010. North Atlantic
Treaty Organisation NATO Standardisation Agency, 2010.
20. Peck M, Clouse D, Cox M, et al: 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.
J Vasc Surg 45:1197–1205, 2007.
21. Barmparas G, Inaba K, Talving P, et al: Pediatric vs adult vascular
trauma: a National Trauma Databank review. J Pediatr Surg 45:1404–
1412, 2010.
22. http://www.saps.gov.za/statistics/reports/crimestats/2011/categories/
murder.pdf. Accessed November 2011.
23. http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-in
-the-u.s.-2010/tables/10tbl01.xls. Accessed December 2011.
24. http://www.unodc.org/unodc/en/data-and-analysis/homicide.html.
Accessed November 2011.
25. http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-in
-the-u.s.-2010/tables/10tbl17.xls. Accessed November 2011.
26. Recorded crime victims. 4510.0. Australian Bureau of statistics 2009.
27. Loh S, Rockman C, Chung C, et al: Existing trauma and critical care
scoring systems underestimate mortality among vascular trauma patients.
J Vasc Surg 53:359–366, 2011.
28. Galindo RM, Workman CR: Vascular trauma at a military level II trauma
center. Curr Surg 57:615–618, 2000.
29. Mattox K, Feliciano DV, Burch J, et al: Five thousand seven hundred sixty
cardiovascular injuries in 4459 patients: epidemiologic evolution 1958 to
1987. Ann Surg 209:698–705, 1989.
30. Bongard F, Dubrow T, Klein S: Vascular injuries in the urban battle-
ground: experience at a metropolitan trauma center. Ann Vasc Surg 4:
415–418, 1990.
31. Bowley D, Degiannis E, Goosen J, et al: Penetrating trauma in Johan-
nesburg, South Africa. Surg Clin N Am 82:221–235, 2002.
32. Gupta R, Rao S, Sieunarine K: An epidemiological view of vascular
trauma in Western Australia. Aust NZ J Surg 71:461–466, 2001.
33. Sugrue M, Caldwell E, D’Amours S, et al: Vascular injury in Australia.
Surg Clin N Am, 82:211–219, 2002.
34. Golledge J, Scriven MW, Fligelstone LJ, et al: Vascular trauma in civilian
practice. Ann R Coll Surg Engl 77:417–420, 1995.
20 SECTION 1  /  BACKGROUND
35. Magee TR, Collin J, Hands LJ, et al: A ten year audit of surgery for vascular
trauma in a British teaching hospital. Eur J Vasc Endovasc Surg 12:424–
427, 1996.
36. De’Ath HD, Galland RB: Iatrogenic and non-iatrogenic vascular trauma
in a district general hospital: a 21-year review. World J Surg 34(10):2363–
2367, 2010 Oct.
37. Stannard A, Brohi K, Tai N: Vascular injury in the United Kingdom.
Perspect Vasc Surg Endovasc Ther 23:27–33, 2011.
38. Koivunen D, Nichols WK, Silver D: Vascular trauma in a rural population.
Surgery 91:723–727, 1982.
39. Oller D, Rutledge R, Thomas C, et al: Vascular injuries in a rural state:
a review of 978 patients from a state trauma registry. Journal of Trauma
32:740–746, 1992.
40. Whitehouse WM, Coran AG, Stanley JC, et al: Pediatric vascular trauma:
manifestations, management, and sequelae of extremity arterial injury in
patients undergoing surgical treatment. Arch Surg 111:1269–1275, 1976.
41. Meagher DP, Jr, Defore WW, Mattox KL: Vascular trauma in infants and
children. J Trauma 19:532–536, 1979.
42. Myers SI, Reed MK, Black CT, et al: Noniatrogenic pediatric vascular
trauma. J Vasc Surg 10:258–265, 1989.
43. De Virgilio C, Mercado PD: Noniatrogenic pediatric vascular trauma:
a ten-year experience at a level I trauma center. Am Surg 63:781–784,
1997.
44. Linda M, Harris MD, Hordines John: Major vascular injuries in the pedi-
atric population. Ann Vast Surg 17:266–269, 2003.
45. Klinkner DB, Arca MJ, Lewis BD, et al: Pediatric vascular injuries: pat-
terns of injury, morbidity, and mortality. J Pediatr Surg 42(1):178–182,
discussion 182–3, 2007.
46. Konstantinidis A, Inaba K, Dubose J, et al: Vascular trauma in geriatric
patients: a national trauma databank review. J Trauma 71(4):909–916,
2011.
47. Fingerhut A, Leppaniemi AK, Androulakis G, et al: The European experi-
ence with vascular injuries. Surg Clin North Am 82:175–188, 2002.
48. Igun GO, Nwadiaro HC, Sule AZ: Ramyil VM, Dakum NK. Surgical
experience with management of vascular injuries. West Afr J Med 20:102–
106, 2001.
49. Rudström H, Bergqvist D, Ogren M, et al: Iatrogenic vascular injuries in
Sweden. A nationwide study 1987–2005. Eur J Vasc Endovasc Surg 35:
131–138, 2008.
50. Bains SK, Vlachou PA, Rayt HS, et al: An observational cohort study of
the management and outcomes of vascular trauma. Surgeon 7(6):332–
335, 2009.
51. Brown CV, Neville AL, Rhee P, et al: The impact of obesity on the out-
comes of 1153 critically injured blunt trauma patients. J Trauma 59:1041–
1052, 2005.
52. Byrnes MC, McDaniel MD, Moore MB, et al: The effect of obesity on
outcomes among injured patients. J Trauma 58:232–237, 2005.
53. Hoffmann A, Lefering R, Gruber-Rathmann M, et al: The impact of BMI
on polytrauma outcome. Injury 2011. doi: 10.1016/j.injury.2011.05.029.
54. Simmons JD, Duchesne JC, Ahmed N, et al: The weight of obesity in
patients with lower extremity vascular injuries. Injury 2010. doi: 10.1016/j.
injury.2010.04.025.
55. Rosen H, Saleh F, Lipsitz S, et al: Downwardly mobile: the accidental cost
of being uninsured. Arch Surg 144:1006–1011, 2009.
56. Dozier KC, Miranda MA, Jr, Kwan RO, et al: Insurance coverage is associ-
ated with mortality after gunshot trauma. J Am Coll Surg 210:280–285,
2010.
57. Maybury RS, Bolorunduro OB, Villegas C, et al: Pedestrians struck by
motor vehicles further worsen race- and insurance-based disparities in
trauma outcomes: the case for inner-city pedestrian injury prevention
programs. Surgery 148:202–208, 2010.
58. Crandall M, Sharp D, Brasel K, et al: Lower extremity vascular injuries:
increased mortality for minorities and the uninsured? Surgery 150:656–
664, 2011.
59. World Health Organization: Decade of Decade of Action for Road Safety
2011–2020: saving millions of lives. http://www.who.int/violence_injury_
prevention/publications/road_traffic/saving_millions_lives_en.pdf.
Accessed 6th Nov 2011.
60. Geneva Declaration Secretariat: Global Burden of Armed Violence:
Lethal Encounters http://www.genevadeclaration.org/measurability/
global-burden-of-armed-violence/global-burden-of-armed-violence
-2011.html. Accessed 6th Nov 2011.
Systems of Care in the
Management of
Vascular Injury
DONALD H. JENKINS, NIGEL R.M. TAI, AND KARIM BROHI
Introduction
While skilled surgical attention is critical in achieving the best
possible outcomes for patients with vascular trauma, the clini-
cal effect of surgeons will be diminished if care is not rendered
within systemized pathways and established clinical networks
that assure the philosophy of “the right care at the right place
at the right time.” This chapter will explore the function and
characteristics of contemporary trauma systems, using recent
military experience as an example, in order to emphasize
the necessity of systems-based approaches when seeking to
provide optimal care for the patient with vascular injuries.
Trauma Systems Overview
Managing severe injuries requires the timely intervention of
multidisciplinary teams across the patient pathway. Funda-
mentally, trauma systems save lives by rapidly delivering criti-
cally injured patients in optimal conditions to specialist
surgical teams, with a 10% to 20% reduction in mortality
compared to nonspecialist centers.1
Patients with vascular injuries are among the prime benefi-
ciaries of the organized delivery of trauma care. The early
delivery of patients with active hemorrhage or ischemic limbs
to a multidisciplinary vascular-trauma service can save lives
and limbs. Because major trauma centers are also likely to be
colocated with the regional vascular centers, there is consider-
able overlap in the personnel, expertise, resources, and infra-
structure required to deliver complex trauma care and complex
vascular care. These synergies can improve outcomes for
trauma patients and nontrauma emergency vascular patients
alike.
A regional trauma system is a public health model that
manages injury for a defined population.2 The system manages
trauma as a disease entity. The system covers the whole patient
pathway, from prehospital care through acute management
and into the reconstruction and rehabilitation phases. Included
in the public health approach is a responsibility for injury
prevention in order to actively reduce the burden of disease
to the population. It is crucial that there be a strong commit-
ment to system-wide data collection and analysis, which are
used as core enablers for performance improvement.
It is essential to recognize that a trauma system is not the
simplistic designation of a “Level I trauma center” conjoined
to bypass protocols that send all injured patients to this hos-
pital. While this model improves care for the severely injured
patients treated within these centers, it may actually worsen
outcomes for less severely injured patients treated within the
3 
same center. Patients with mild or moderate injuries—who
constitute 85% of all trauma patients—will suffer from depri-
oritization within an overloaded hospital. Systems that com-
prehensively address the needs of patients within a given area
(so-called “inclusive trauma systems”) incorporate all acute
hospitals in a region and have been shown to produce better
outcomes for a patient population.3,4 Hospitals in an inclusive
system are designated according to their capabilities and insti-
tutional commitment. In the United Kingdom, centers are
designated as major trauma centers (MTCs), which manage
severely injured patients, and trauma units (TU) which
manage mild and moderately injured patients (Fig. 3-1). In
the United States, more levels of capability are designated
within a system (Level I to Level IV); and other countries have
similarly tiered levels of care.
Key Components of
a Trauma System
The core purpose of a regional trauma system is to reduce
death and disability following injury. However, systems also
must make efficient use of resources and must be financially
and logistically robust. Not all hospitals can be staffed and
equipped to manage all injuries. Major trauma patients must
be identified early in their clinical courses and directed to
complex multispecialty care in a flexible and “error-tolerant”
system that can deliver high quality clinical outputs. Key facets
of a trauma system therefore include the following:
• A regional system integrating hospital and prehospital
care to identify and deliver patients to a place of definitive
care quickly and safely
• A specialized regional trauma center that has responsibil-
ity for the management of all injured patients in the
region
• A prehospital care system closely integrated into the
trauma system, with defined triage and bypass protocols
• A network of hospitals with defined capability and capac-
ity, and with predetermined transfer agreements for opti-
mizing casualty flow
• Acute rehabilitation services to improve outcomes and
restore casualties back to productive roles in society
• A continuous process of system evaluation, governance,
and performance improvement across the network
• Ongoing training and education for all health-care pro-
fessionals involved in the care of injured patients
• An active injury prevention program to reduce the
burden of injury for the population that the network
serves
21
 3  /  Systems of Care in the Management of Vascular Injury 21.e1

ABSTRACT
In North America and Australia, systems of trauma care
have been shown to reduce mortality and morbidity in
injured patient populations. These systems rely on a health
infrastructure that can rapidly match the patient’s needs to
the appropriate level of care, is able to ensure expeditious
transport to the right health facility, and can ensure that
treatment is rendered seamlessly across the whole of the
patient’s pathway. To function properly and to assure pro-
gressive improvement in standards, trauma systems are
dependent on continuous analysis of outcome and process
data allied to feedback mechanisms whose improvement
actions are underwritten by an agreed authority. Proven
in civilian circumstances, this concept was deployed in
Afghanistan and Iraq to remarkable effect. The “owner-
ship” of the vascular-injured trauma patient, whether
treated within an overarching system of care or not, varies
according to national and local circumstances. Vascular-
trained surgeons have a stake in making sure that the same
principles that increasingly govern their systems of care for
patients with degenerative and chronic vascular disease are
applied to patients with vascular injury. Trauma-trained
surgeons have responsibilities to ensure that the domain
knowledge and endovascular expertise of the vascular sur-
gical community is continuously leveraged. By developing
this dialogue, surgeons can safeguard the progressive sys-
temization of care for patients with vascular injury and can
set the conditions for continued improvement in outcome.

Key Words:  trauma systems,

quality improvement,
vascular networks,
performance indicators,
and joint theater trauma systems
22 SECTION 1  /  BACKGROUND
Major
trauma
Injured
patients
Prehospital
Trauma Major trauma
unit center
Rehabilitation
FIGURE 3-1  Regional trauma system overview.
• A responsibility toward research into trauma and its
effects, to continuously improve care and outcomes fol-
lowing injury
• A system-wide response to disaster and mass casualty
incidents
The first functions of the system are to identify each trauma
patient as soon as possible in their clinical course, to render
appropriate treatment, and to ensure swift transfer to the most
appropriate facility. In the case of major trauma, this will
usually involve directing the patient from the point of wound-
ing directly to the nearest MTC. However, the system must
ensure that the minority of severely injured patients who are
transported to TUs—because they are conveyed by friends or
bystanders, or because local prehospital triage protocols are
misapplied or function poorly, or because patients are decom-
pensating too rapidly to survive the longer journey—are not
disadvantaged. TUs therefore must maintain trauma capaci-
ties and skills in early resuscitation and damage control and
must offer a clear and rapid pathway for secondary transfer of
the patient to the MTC. An important feature of inclusive
systems is MTC “ownership” of the severely injured patient.
The MTC has responsibility for the transfer of patients from
TU to MTC and thus must either accept the patient (usually
regardless of MTC bed state) or must arrange transfer to a
neighboring MTC (if there are exceptional capacity issues).
Patients may be transferred in a very unstable condition, and
there must be expertise within the system to provide this
assurance of care.
The MTCs must have a demonstrable institutional com-
mitment to the delivery of specialist trauma care. Infrastruc-
ture must ensure timely availability of the required specialist
services, a consultant-led trauma team, a trauma service that
manages the ongoing care of all trauma patients, and a per-
formance improvement structure. The MTC has a clear
responsibility to the population of the whole regional system,
not just to patients within its physical walls. The MTC assumes
a leadership role across the network in trauma training,
education, and research and leads injury prevention programs
relevant to its patient population.
The system also incorporates acute and chronic rehabilita-
tion services. Patients managed in the MTC are repatriated to
their local community as soon as possible following definitive
care. This maintains capacity within the MTC while ensuring
that patients can access appropriate community teams. Reha-
bilitation services are integrated across the region so that there
is seamless provision of services as the patient moves along
the care pathway.
The whole system is monitored by a clinical governance
and quality improvement (QI) program. QI can be conceptu-
alized as follows:
A method of evaluating and improving processes of patient
care which emphasizes a multidisciplinary approach to
problem-solving, and which focuses not on individuals
but on systems of patient care that may be the cause of
variations. QI consists of periodic scheduled evaluation
of organizational activities, policies, procedures, and
performance to identify best practices and target areas in
need of improvement and includes implementation of
corrective actions or policy changes where needed.5
Trauma QI is not merely the province of mature systems
in well-resourced settings. The principles are equally appli-
cable to trauma care in low- and middle-income countries.
This key element monitors the health of the system against
a series of performance indicators.6,7 Through proper injury
stratification of treated populations, these performance indi-
cators can be compared with regional or national norms.8,9
Deficiencies in the system are identified and resources, path-
ways, training, or other interventions developed and then
implemented. This process occurs at a regional level but also
within each MTC, TU, and ambulance service. Importantly, a
regional system delivers trauma care that achieves these
benchmarks with local solutions that reflect its own particu-
lar geography, resources, and capabilities.10 Provision of
quality care is linked to both designation status and financial
reimbursement. It is possible for MTCs to lose their status,
and for TUs to become minor injury units if they cannot
demonstrate quality care and a commitment to performance
improvement.
There is now a large body of evidence to show that the
institution of a regional trauma system can rapidly improve
outcomes for trauma patients, reducing mortality by around
40% and reducing preventable deaths to below 1%, while
optimizing resource use and reducing costs. Inclusive trauma
systems have been implemented in many regions around the
world, including parts of the United States, Canada, Australia,
Holland, and Germany. Alone, MTCs can reduce mortality
from severe injury by around 20%. There is a volume effect in
addition to changes in service configuration, and MTCs that
see more than 650 major trauma patients a year seem to have
an additional outcome benefit. Incorporating MTCs within an
inclusive trauma system consistently achieves an additional
20% reduction in mortality. With inclusive systems, the benefit
is for an entire region rather than for only those patients
managed in the MTC.
The Victoria State Trauma System in Australia recently
reported their experience with instituting a regional trauma
system for a population of approximately 5 million with
 3  /  Systems of Care in the Management of Vascular Injury 23
around 1400 major trauma patients a year.3 One pediatric and
two adult hospitals were designated as MTCs, 18 hospitals
were designated as TU equivalents, and the remaining 117
hospitals were also assigned roles within the system. Within 3
years, the system was able to demonstrate a 38% reduction in
the risk of death for patients treated by the trauma system.
The provision of regional trauma systems is inexpensive
compared to other interventions in modern health care.
The cost per disability-adjusted life year (DALY) saved by a
trauma system is estimated at around $2500 compared to, for
example, preventive cardiovascular interventions such as
aspirin ($22,000) or statins ($245,000) for patients over 50
years of age; dialysis ($50,000) or transplant ($10,000) for
end-stage kidney disease; and tamoxifen ($124,000) or Her-
ceptin ($210,000) for breast cancer.11 Additionally, it has been
demonstrated that instituting a system to optimize trauma
care has significant beneficial effects on the management of
all emergency patients by reducing wait times in the emer-
gency department, improving access to operating rooms,
reducing bed stays, and improving outcomes.
Trauma Center Function
When a hospital is designated as a regional trauma center, it
accepts responsibility for the delivery of injury care to all
people living and working within its catchment area. The
trauma center has a duty to ensure that injured patients
will receive high-quality trauma care at the most appropriate
hospital and in a timely manner. Further, it is responsible for
the continuum of care, from the first prehospital response
through completion of rehabilitation, including the quality of
care received at other trauma-receiving hospitals within its
region. The center also has a public health duty to reduce
the injury burden through injury prevention activities for its
population.
The volume and type of work that a trauma center receives
is important and must be carefully planned and monitored.
There is a strong relationship between outcome and the
volume of major trauma patients seen, with up to 50%
improvements in mortality observed in the highest-volume
trauma centers. Thus the population base that a regional
center serves must be large enough. It is recommended that,
at a minimum, trauma centers should admit a minimum of
250 severely injured trauma patients per year (and ideally 400-
600). This equates to one trauma center for each 3-4 million
people depending on regional differences in injury load and
specific geographic concerns. Having too many centers that
see too few patients is detrimental to a trauma system and
patient outcomes—as experienced by several cities in the
United States and Australia.12
Conversely, a trauma center cannot manage all injured
patients within its region. Most patients do not have major
trauma or multisystem injuries and will overload a single unit,
reducing overall outcomes. These patients are managed more
efficiently in secondary trauma receiving units (TRUs). These
are part of the regional trauma system and are held to the
same standards of care, but will not have all specialties and
may not have dedicated trauma services. The links between a
regional specialist center and the secondary trauma centers
within a region must be robust and assure patient care, educa-
tion, and clinical governance across the locality. Transferring
patients to a higher level of care is based on clinical imperative,
not on the current availability of resources (e.g., intensive-care
beds) at the TU. At all times, the responsibility for delivery of
trauma care rests with the regional unit.
Trauma specialist centers have all surgical specialties
(including interventional radiology) required for the care of
multisystem trauma patients on-site and in-house, 24 hours a
day. There is capacity and expert support from diagnostic
radiology, transfusion, critical care, rehabilitation, and other
allied services. However the mere presence of these services
will not be sufficient for designation as a regional specialist
unit, because improvements in outcomes and the process of
care are only seen when the overall responsibility of the care
of trauma patients is managed by a specialist trauma service.12
The function of the trauma service is to provide expert care
for trauma patients, integrating the care of multiple teams and
advocating for patients, both within the hospital system and
during ongoing community care. The service is responsible
for trauma education to all staff involved in trauma care,
ensuring appropriate certification and ensuring that best-
practice guidelines are understood and implemented. Typi-
cally the service will review all trauma patients following
admission and will perform a tertiary survey and radiology
review. Patients with a single system injury (e.g., isolated brain
injury, femur fracture), may be signed off on by the service to
the care of a specialty team, but patients with combined inju-
ries (brain injury and femur fracture) remain under the care
of the trauma service with appropriate specialty input. The
final responsibility to ensure delivery of quality trauma care
remains with the trauma service for all admitted patients.
The trauma service is a multidisciplinary team made up of
surgeons, specialist nurses, occupational therapists, physio-
therapists, data collection staff, and administrative staff. Inter-
nationally most systems are headed by trauma-trained general
surgeons, but there are regional variations. More importantly,
there are dedicated trauma specialists within all surgical spe-
cialties (anesthesia, critical care, radiology, transfusion) who
interface with the trauma service and their departments.
Trauma program managers, trauma-nurse coordinators, and
nurse case managers are central to the daily activities of the
service, while the data collection and analyses staff monitor
the health of the system.
The glue that binds and assures all facets of a trauma cen-
ter’s activities is its performance improvement program,
which includes clinical governance and quality-assurance
monitoring. Trauma center standards are set as quality,
process, and outcome measures. For example, patients with
intraabdominal hemorrhage would have quality targets such
as “be met immediately by a consultant-led, fully ATLS–
qualified trauma team” and “immediate availability of ultra-
sound in the resuscitation room.” Process standards would
include “time to emergency laparotomy of less than 1 hour,”
and outcome standards would include posttrauma laparot-
omy complication rates and mortality outcomes compared to
other national trauma centers. This requires a trauma registry
and data collection system to identify variances from these
standards, as well as a robust peer-review program to review
the deviations and to implement change within relevant
departments. How each trauma center actually achieves these
targets requires a local solution, which will be different for
each institution.
Turning a multispecialty hospital into a specialist trauma
center is not a trivial task, and it involves a significant
24 SECTION 1  /  BACKGROUND
investment in staff and resources, as well as changes in the
delivery of health care and clinical governance. The ideology
of the specialist center as being responsible for its entire popu-
lation base is at variance with the ivory-tower mentality of
most specialty units in large academic institutions. Managing
the interface between other hospitals in the region and pre-
hospital care providers requires commitment, communica-
tion, education, and a lot of hard work. Despite this, the cost
of implementing trauma specialist centers and regional
systems is very cheap, and the potential savings due to mini-
mized disability result in a net gain for society.
Trauma Systems in Combat
Casualty Care
United States, United Kingdom, and other NATO military
medical forces deployed in support of Operations in Iraq and
Afghanistan have provided continuous combat casualty care
for more than a decade at the time of publication. Initially,
this medical response lacked a cohesive and structured
approach. Referencing the positive impact of civilian trauma
systems on patient outcomes, a group of military clinicians
advocated a theater trauma system based on the civilian
model. The United States Central Command (CENTCOM)
implemented an inclusive system of trauma care in its theater
of combat operations, designated as the Joint Theater Trauma
System (JTTS).13 The United Kingdom’s Defence Medical Ser-
vices reached a similar conclusion and began an independent
yet strikingly similar endeavor to build an ad hoc trauma
system for its forces engaged in Iraq and Afghanistan.14 The
stated vision of the JTTS was to ensure that every soldier,
marine, sailor, and airman injured on the battlefield had the
optimal chance for survival and had maximal potential for
functional recovery: the right patient to the right care in the
right place at the right time.15 Although the epidemiology of
military trauma differs from civilian experience, the structure,
function, and role of the JTTS is largely modeled after the
civilian trauma system principles, as outlined in the American
College of Surgeons Committee on Trauma (ACS COT)
Resources for the Optimal Care of the Injured Patient.2 This
document identifies criteria for civilian trauma care resources
and practices for optimization of standards of care, policies,
procedures, and protocols for care of the trauma patient. The
content of the manual provides guidance for medical care
personnel from the prehospital arena, through hospital and
subspecialist care. The ACS COT Verification Review Com-
mittee (VRC) was initially developed in the early 1970s and
functions as the oversight process and verifying entity for the
American trauma care system.
Following the example of the ACS COT, the JTTS identifies
and integrates processes and procedures to enable recording
of trauma patient–related data at all levels of care to promote
continual process improvement. This essential data facilitates
prediction of needed resources, evaluation of outcomes, edu-
cation, and training needs in order to improve continuity of
care across the combat care continuum and to facilitate real-
time changes (based on data) in these conflicts. Oversight and
direction for the theater trauma system above Level I is
directed by the CENTCOM surgeon. The US-based parent
organization, now known as the Joint Trauma System (JTS),
embraces the system concept for the entire continuum of
care from point of injury to medical facility and onward to
rehabilitation in continental U.S. facilities. A philosophy of
continuous improvement has driven and matured the system;
and it now exceeds the capabilities of the U.S. trauma care
system on which it was modeled.
After 8 years of continuous development, the JTTS has
arrived at a crucial junction, and it is imperative to codify this
experience for all future Department of Defense (DoD)
deployed medical operations and to maintain its existence
through funding, planning, and staffing. This will ensure that
the benefits of the current system will be available to future
surgeons working in conflict situations and will ensure that
corporate memory is preserved.
Organization of the Joint Theater
Trauma System
There are five levels, or echelons, of care in the U.S. military
trauma-care system, each with progressively greater resources
and capabilities (Tables 3-1 and 3-2). Level I care provides aid
at or near the point of injury. Level II care consists of surgical
resuscitation provided by forward surgical teams that directly
support combatant units in the field. Level III care provides a
much larger and resource-capable facility and serves as the
highest level of care within the theater of operation. Gener-
ally speaking, military Level III centers offer advanced
medical, surgical, subspecialist, and trauma care, similar to a
civilian Level I trauma center or MTC. Transfer of casualties
may between levels I and III is generally via rotary or fixed-
winged tactical airframes. Level IV care is the first echelon at
which more definitive surgical management is provided
outside the combat zone. For U.S. forces in the Afghanistan
(and Iraq) theater, this is the Landstuhl Regional Medical
Center (LRMC) in Germany. Level V care is the final stage of
evacuation to one of the major military centers in the conti-
nental United States (CONUS), where definitive care is also
provided and more comprehensive rehabilitation services are
provided. Transfer of casualties between Level III and Level
IV/V care is by specialist strategic aeromedical evacuation.
The UK military system has similarly echeloned in-theater
Table 3-1 Comparison of U.S. Trauma Center
Levels: Civilian Versus Military
Military U.S. Civilian
Designation Description Designation
V (e.g., BAMC/ISR Major trauma center with I
and WHMC) teaching and research
IV (none) Major trauma center II
III (e.g., Landstuhl, Regional trauma center, III
Germany, and limited capability,
theater hospitals 30-day ICU holding
in Iraq) capability
IIB (e.g., FRSS, Community hospital with IV
FST, EMEDS) limited emergency
surgery capability
IIA Aid station —
Outpatient clinic
I EMS/corpsman/medic —
BAMS, Battlefield aid medical station; EMEDS, expeditionary medical
services; FRSS, forward resuscitative surgical system; FST, forward
surgical team; ISR, U.S. Army Institute of Surgical Research; WHMC,
U.S. Air Force Wilford Hall Medical Center.
 3  /  Systems of Care in the Management of Vascular Injury 25
Table 3-2 U.S. Trauma System Organization
Civilian Trauma System Components
National/Federal American College of Surgeons, Committee on Trauma
level • Registry (National Trauma Data Bank)
• Academic organizations influencing trauma care
(American Association for Surgery of Trauma/
Eastern Association for Surgery of Trauma/Western
Association for Surgery of Trauma)
State/Command State trauma system
level • State director (Texas: Governor’s EMS and Trauma
Advisory Committee Chair)
• State registry
• State trauma system plan
Regional level Regional trauma areas
• Registry
Local level Lead trauma center
• Trauma registry
Local/Regional Regional advisory council
components • RAC chair
• Rural/Urban organizations
• EMS (ground/air)
• Hospital representatives, all levels
• PI/Comm/Rehabitation/Prev
AOR, Area of responsibility; Btln, battalion; COCOM, combatant command; EMS, emergency medical service; JTTR, Joint Theater Trauma System;
JTTS, Joint Theater Trauma System; PI, performance improvement; RAC, Regional Advisory Council.
care, from Role 1 through to Role 3—generally analogous to
U.S. Level I-III, with the Royal Centre for Defence Medicine
at University Hospitals Birmingham, United Kingdom acting
as the highest tier.
The elements that comprise a trauma system have been set
out above. These elements were bound by an overarching
trauma system leadership function to continually assess
system structure, function, and outcomes and must be enabled
to create policy and/or guidelines based on analysis of these
assessments. Understanding of the epidemiology of injury
mechanism and casualty injury burden is essential to placing
these functions in proper context.16-18 Each of these three func-
tions; assessment, key policy/guideline development, and
assurance is central to adjudicating trauma system efficacy as
follows:
• Assessment functions include the ability to thoroughly
describe the epidemiology of injury within the theater
jurisdiction and to scrutinize the efficacy of care via
access to databases depicting performance metrics across
the continuum of care.
• Key policy/guideline development functions include
comprehensive authority to maintain trauma system
infrastructure, as well as planning, oversight, and com-
mand authority to create and enforce policy and guide-
lines on behalf of the welfare of the injured.
• Assurance functions include education and coalition
building with leaders and participants across the system
(to foster cohesion and collaboration); the use of analyti-
cal tools to monitor performance and to promote injury
prevention, and the ability to evaluate and verify that
system components meet agreed-on criteria or clinical
requirements.
Successful implementation of these functions with regard
to military trauma care capabilities in Operation Iraqi Freedom
(OIF) and Operation Enduring Freedom (OEF) have led to
Military Trauma System Components
Department of Defense, Health Affairs, Joint Surgeon’s
Office
• Joint Theater Trauma Registry
• Defense Medical Readiness Training Institute/
Combat Trauma Surgery Committee/Committee on
Tactical Combat Casualty Care
COCOM
• COCOM surgeon
• JTTR-derived COCOM data
• JTTS; COCOM specific
AOR (Operation Iraqi Freedom, Operation Enduring
Freedom [Afghanistan])
• JTTR-derived AOR data
JTTS Leadership
• Local trauma database; begin capture of JTTR data
Command Surgeon
• JTTS director
• Level II/III facilities
• Level I/Medevac Btln
• Level II/III facilities
• PI/Comm/Prev
the lowest case-fatality rates recorded for combat casualty
populations.
The current challenge is to turn the recent successes of the
JTTS approach, developed in Afghanistan and Iraq, into strat-
egies that will assure care to military populations deployed on
future operations. JTTS was built around a very static and
stable network of medical facilities, backed up by robust and
largely guaranteed aeromedical evacuation routes and dealing
with large volumes of injured over several years, often being
treated by seasoned clinicians who served on multiple tours.
Such enduring conditions were fertile for systemization and
quality improvement. Future operations are likely to be lighter
and shorter, with less assured logistic and evacuation options.
The “opportunity cycle” within which it is possible to charac-
terize problems, launch improvement initiatives, observe for
effect, and revise accordingly may be much less favorable than
during the most recent JTTS era. Developing swifter, more
agile systemization methodologies and improvement mecha-
nisms that not only take account of these new operational
realities but thrive within them is an emerging problem that
must be tackled successfully for JTTS to continue to deliver to
its best effect.
Challenges of Systemizing
Vascular-Injury Care
If it is clear that the outcomes for injury can be improved by
a systemized approach, what are the barriers and challenges
faced by surgeons wishing to address the specific problems of
vascular injury?
Ownership and Responsibilities
With increasing concentration of tertiary-level clinical ser-
vices, vascular centers are often colocated with MTCs. “Own-
ership” of the vascular trauma patient will depend on local
26 SECTION 1  /  BACKGROUND
circumstances, but must be defined, authorized, and acknowl-
edged. Trauma surgical cadres may be the traditional leaders
of the system and may be best placed to ensure that the system
works holistically. However, vascular surgeons embody the
technical subject matter expertise, particularly with regard to
endovascular treatments. As general and vascular training
programs become discretized the ability of general trauma
surgeons to deliver and design optimal vascular treatment
pathways and to lead associated improvement strategies, may
be denuded. This should not necessarily lead to loss of system
control. The principle province of vascular surgery is age-
related degenerative disease. Noniatrogenic vascular trauma
represents a small amount of vascular emergency workload,
and interest and enthusiasm among vascular surgeons to
lead on system improvements may be variable. Nonetheless,
vascular surgeons have led on improvements to systems
addressing aneurysm screening, stroke prevention, and limb
revascularization and are increasingly familiar with quality
improvement,19,20 and efforts to improve outcomes from vas-
cular trauma should leverage this expertise accordingly. In the
London trauma system, this approach has been used to design
bypass protocols for patients with vascular injury and to
develop pan-London injury registries.
It is essential that both vascular and trauma surgeons
serving a region or population take every opportunity to
jointly champion the benefits of a systemized approach. Even
within mature trauma systems, internal and external pressures
may degrade the ability of the system to function, and these
must be anticipated and countered. Challenges such as cost-
containment, resourcing of administration, clinician disen-
gagement, and competing health policy agendas must be
understood and effectively managed without losing sight of
the patients and their needs.
Data Collection and Comparison
Generic data should be collected as part of the baseline per-
formance dataset, but there are few guidelines on the specific
data fields that should be maintained for vascular patients. In
general, data collected for utility as measures of performance
should be readily measurable, should reflect or be associated
with outcome, should be set at a threshold that mirrors current
standards of good practice, should be amenable to risk strati-
fication, and should signal system-wide quality.6 Clearly such
discrete metrics are required if the vascular-specific processes
and outcomes are to be monitored and included in feedback
mechanisms. A suggested list of potential data fields—in addi-
tion to usual data pertaining to trauma epidemiology, indices
of physiology, and resuscitative measures—is included in Box
3-1. Judgments must be made regarding which process data
should be used as measures of system efficacy. These judg-
ments should be based on evidence. Similarly, outcome data
should be based on agreed definitions. For instance, the terms
“early,” “late,” “primary,” “secondary,” “emergent,” and “elec-
tive” amputation are defined differently among different insti-
tutions and contexts. The goal is standardized, evidence-based
benchmarks and outcomes of functional recovery that enable
population-stratified comparisons of process and outcome
with respect to time and institution. The challenge is not only
to develop the data that describe performance, but to ensure
that the data is collected over a large enough population to
ensure sufficient volumes of information are available for
meaningful analysis of an infrequent injury pattern. Pursuing
Box 3-1 Candidate Vascular-Specific Process and
Outcome Fields for a Vascular-Injury
Database
QUALITY
Provider
Training level of provider (revascularization; amputation)
Specialty of provider (revascularization; amputation)
Training level of anesthesia provider
Institution
Accredited vascular teaching program
Accredited endovascular program
Vascular quality assurance program
PROCESS
Time interval: point of injury to vascular imaging
Time interval: point of injury to surgical vascular control
Time interval: point of injury to reperfusion of limb
Time interval: point of injury to definitive vascular repair of limb
Time interval: from point of consent/assent to amputation or to
surgery
Provision of definitive rehabilitation prescription
Time to definitive limb fitting
OUTCOME
Postoperative compartment syndrome (rate)
Postoperative vascular repair perfusion failure/end organ
ischemia (rate)
Postoperative wound or graft infection (rate)
Postoperative amputation (within 30 days) (rate)
a regional or national conversation to map out and resource
this infrastructure—or to piggyback onto existing trauma or
vascular registries—is key to sustaining quality improvement
in vascular trauma.
Uptake of Clinical Practice Guidelines
The JTTR approach to the wars in Afghanistan and Iraq led
to the dissemination of vascular practice guidelines to reduce
heterogeneity of practice and to improve standardization of
therapy. It is clearly desirable for civilian organizations to
develop and refine their own versions of these. Those with
most utility use a systematic review methodology such as
those provided by the Eastern Association for the Surgery of
Trauma or the Society for Vascular Surgery21,22; the London
trauma system has also published its own guidelines under-
standing of local knowledge and systems combined with pro-
vider education and local championship. Implementation of
guidelines should not be a one-off but should be followed
up by impact analysis and regular review schedules. Clinical
practice guidelines (CPGs) may gain effective traction among
the clinical community when championed by senior decision
makers and introduced alongside associated programs of pro-
vider education. Merely dropping unannounced CPGs into
the clinical environment as stand-alone edicts risks a counter-
productive effect.
Introduction and Tracking  
of New Technology
All trauma systems should have defined and governed means
of reviewing applicant candidate technologies, filtering out
those which are a liability, introducing new therapies, and
 3  /  Systems of Care in the Management of Vascular Injury 27
assessing for impact on patient care. Both vascular and trauma
surgeons are familiar with the research paradox encompassed
by the increasingly rapid development of exciting new adjuncts
to management of their patients. The endovascular revolution
has allowed multiple types of devices and of techniques to be
introduced to practice—with a varying degree of governance
and data to support this. A well-worn narrative implies that
developments have occurred at such a pace that lengthy efforts
to properly trial the novel interventions are not practical as
the results do not reflect emerging or even established practice
by the time the results are disseminated. Countless examples
from multiple different domains run counter this view—
including well-run and informative trials such as CRASH-2
and multiple randomized trials scrutinizing the benefits of
carotid stenting for stroke prevention.23,24 However, in the
absence of trial data, and recognizing that new treatments
emerge continuously, leaders must have local policies regulat-
ing the introduction and surveillance of new treatments that
enable follow-up (even though trauma patient populations
may be challenging to track). Properly run device or therapy
registries (containing prospectively gathered data) are feasible
and vital knowledge-generating tools and should be managed
the regional or national level.
Conclusion
The development, implementation, and maturation of trauma
systems within the civilian and military communities have
resulted in reduced morbidity and mortality from severe
injury. Because of its unique capacity to cause death and major
disability, vascular trauma as a specific injury pattern warrants
unique consideration within this discussion. Furthermore, it
is likely that skilled coordination and application of evidence-
based management of vascular trauma within an environment
of continuous process improvement will lead to the greatest
gains reducing preventable death following injury.
REFERENCES
1. Celso B, Tepas J, Langland-Orban B, et al: A systematic review and meta-
analysis comparing outcome of severely injured patients treated in
trauma centers following the establishment of trauma systems. J Trauma
60:371–378, 2006.
2. American College of Surgeons: Resources for optimal care of the injured
patient. Chicago ACS 1999.
3. Cameron PA, Gabbe BJ, Cooper DJ, et al: A statewide system of trauma
care in Victoria: effect on patient survival. Med J Aust 10:546–550,
2008.
4. Cornell EE, 3rd, Chang DC, Phillips J, et al: Enhanced trauma program
commitment at a Level I trauma center: effect on the process and outcome
of care. Arch Surg 138:838–843, 2003.
5. Mock C, Juillard C, Brundage S, et al: Guidelines for trauma quality
improvement programmes, Geneva, 2008, World Health Organization.
http://whqlibdoc.who.int/publications/2009/9789241597746_eng.pdf.
6. Willis CD, Gabbe BJ, Cameron PA: Measuring quality in trauma care.
Injury 38:527–537, 2007.
7. Moore L, Stelfox HT, Boutin A, et al: Trauma center performance indica-
tors for nonfatal outcomes: a scoping review of the literature. J Trauma
74:1331–1343, 2013.
8. Boyd CR, Tolson MA, Copes WS: Evaluating trauma care: the TRISS
method. J Trauma 27:370–378, 1987.
9. Champion HR, Copes WS, Sacco WJ, et al: The major trauma outcome
study: establishing national norms for trauma care. J Trauma 30:1156–
1165, 1990.
10. Eastridge BJ, Wade CE, Spott MA, et al: Utilizing a trauma systems
approach to benchmark and improve combat casualty care. J Trauma
69(1):S5–S9, 2010.
11. Rotondo MF, Bard MR, Sagraves SG, et al: What price commitment?
What price benefit? The cost of a life saved in a level I trauma center.
Presented at the American Association of Surgery of Trauma’s 65th annual
meeting, New Orleans, LA, September 2006.
12. Davenport R, Tai N, West A, et al: A major trauma centre is a specialty
hospital not a hospital of specialties. British Journal of Surgery 97:109–
117, 2010.
13. Eastridge B, Jenkins D, Flaherty S, et al: Trauma system development in
a theater of war: experiences from operation Iraqi freedom and operation
enduring freedom. J Trauma 61:1366–1372, 2006.
14. Hodgetts T, Davies S, Russell R, et al: Benchmarking the UK military
deployed trauma system. JR Army Med Corps 153(4):237–238, 2007.
15. Eastridge BJ, Costanzo GS, Jenkins DH, et al: Impact of joint theater
trauma system initiatives on battlefield injury outcomes. Am J Surg
198(6):852–857, 2009.
16. Holcomb JB, McMullin NR, Pearse L, et al: Causes of death in U.S. special
operations forces in the global war on terrorism. Ann Surg 245:986–991,
2001–2004, 2007.
17. Holcomb JB, Stansbury LG, Champion HR, et al: Understanding combat
casualty care statistics. J Trauma 60:397–401, 2006.
18. Kelly JF, Ritenour AE, McLaughlin DF: Injury severity and causes of death
from OIF and OEF: 2003–04 versus 2006. J Trauma 64:s21–s27, 2008.
19. Abdominal aortic aneurysm quality improvement programme. Interim
report. Vascular Society of Great Britain and Ireland. 2011.
20. Quality improvement framework for major amputation surgery. Vascular
Society of Great Britain and Northern Ireland. 2010.
21. Eastern Association for the Surgery of Trauma. Guidelines for the treat-
ment of penetrating lower extremity and arterial trauma. http://www
.east.org/resources/treatment-guidelines/penetrating-lower-extremity
-arterial-trauma,-evaluation-and-management-of.
22. Lee WA, Matsumura JS, Mitchell RS, et al: Endovascular repair of trau-
matic thoracic aortic injury: clinical practice guidelines of the Society for
Vascular Surgery. J Vasc Surg 53:187–192, 2011.
23. The CRASH-2 collaborators. The importance of early treatment with
tranexamic acid in bleeding trauma patients: an exploratory analysis of
the CRASH-2 randomised controlled trial. The Lancet 376:23–32, 2010.
24. Meier P, Knapp G, Tamhane U, et al: Short term and intermediate term
comparison of endarterectomy versus stenting for carotid artery stenosis:
systematic review and meta-analysis of randomised controlled clinical
trials. BMJ 340:c467, 2010.
 Pathophysiology of
4  Vascular Trauma
CHARLES J. FOX AND JOHN B. HOLCOMB
Introduction
Acute limb ischemia in the setting of extremity vascular
trauma is a common cause of morbidity in civilian and
wartime settings.1 The traditional objective of surgeons in
these settings has been expeditious restoration of blood flow
to obtain the best limb-salvage rates. However, immediate
extremity reperfusion at inexperienced civilian centers or at
far-forward locations on the battlefield may not always be
possible. Furthermore, the decision to restore extremity blood
flow after prolonged ischemia may yield unpredictable out-
comes due to deleterious metabolic effects in the tissue of the
limb. Therefore the pathogenesis and mitigation of ischemia
and reperfusion injury in the setting of vascular trauma
remain topics of great interest. This chapter provides a basic
review of the pathophysiology of extremity vascular trauma
including a discussion on the impact of time to limb reperfu-
sion, the role of hemorrhagic shock on functional limb salvage,
and the optimal resuscitation fluids to mitigate ischemic
reperfusion injury. Recognition of these elements of basic and
translational science in vascular trauma is crucial for achiev-
ing the best probability of functional limb salvage and for
advancing future clinical practice.
Pathogenesis of Ischemia
and Reperfusion
Complete and partial ischemia occurs during the interruption
of oxygen delivery and the accumulation of toxic metabolites.
In the setting of hemorrhagic shock, reduction in blood flow
further impairs the removal of these metabolic waste prod-
ucts. Energy depletion initiates both functional and structural
cellular derangements that activate inflammatory responses.
Reperfusion is the reestablishment of normal blood flow, and
it is during this period that most of the injury is thought to
occur. Reperfusion injury is largely due to neutrophil activa-
tion, infiltration into the ischemic tissue, and subsequent
endothelial damage that leads to edema formation, microvas-
cular thrombosis, and irreversible tissue necrosis. Ischemic
reperfusion injury is based in part on the duration of isch-
emia. Prolonged ischemia results in primary membrane dis-
ruption due to depletion of energy reserves. Failure of the
adenosine triphosphate (ATP)–dependent ionic pump dis-
rupts osmotic gradients, resulting in cellular swelling and
global failure of energy-dependent mechanisms. Ischemic
endothelial cells play a major role as metabolic enzymes
produce oxygen-derived free radicals upon reperfusion. The
28
production of free radicals initiates a complex molecular
interaction of various chemical mediators that are responsible
for neutrophil activation.
Some of the key molecules in this process are complement,
prostaglandins, cytokines, and platelet-activating factor (PAF).
Activated neutrophils increase cell adhesion molecule activity
that produces endothelial injury. Endothelial injury then leads
to increased vascular permeability, cell swelling, edema, and
changes in vasomotor tone from diminished release of nitric
oxide. Neutrophils adhere in regions where luminal size is
compromised by endothelial swelling, and increased vasomo-
tor tone flow may stop entirely. This condition is known as
the “no reflow” phenomenon. The amount of tissue injury is
based on the degree of ischemia. A short period of ischemia
does not cause primary injury or activation of a pathological
inflammatory response. Prolonged ischemia results in wide-
spread tissue injury secondary to energy depletion and the
subsequent pathologic reperfusion injury.
Traditional teaching has been that irreversible cellular and
mitochondrial damage, inability to regenerate ATP, and vari-
able degrees of tissue necrosis occur at 6 hours of ischemia.
However, recent translational research suggests that the neu-
romuscular ischemic threshold of the extremity likely is less
than 5 hours of ischemia and that this threshold is even less
(less than 3 hours) in the setting of hemorrhagic shock. The
challenge on the battlefield is to understand what intermediate
periods of ischemia in the setting of hemorrhagic shock can
be tolerated without permanent tissue destruction and loss of
nerve and skeletal-muscle function in an otherwise salvaged
extremity with a normal pulse exam.
Clinical Practice on the Battlefield
Military operations in Afghanistan and Iraq resulted in over
40,000 extremity injuries and nearly 2500 amputations.2 This
burden of injury represents approximately 75% of all Afghani-
stan and Iraq war-related injuries, and the rate of extremity
vascular injury is now fivefold higher than reported in previ-
ous conflicts.1 The widespread use of tourniquets has resulted
in improvements in survival in those with compressible ex-
tremity hemorrhage. The success of tourniquets and improved
survival of extremity injury eventually shifted much attention
to casualties with ischemic limbs in need of expedited reperfu-
sion in order to save both life and limb.3-5 In the beginning of
these wars, the accepted clinical paradigm, which touted the
ability to salvage an extremity following as many as 6 hours
of ischemia, was challenged. As the concept of outcomes
evolved from statistical limb salvage to functional or quality
 4  /  Pathophysiology of Vascular Trauma 28.e1

ABSTRACT
Vascular trauma results in a number of system-wide conse-
quences to the individual (due to blood loss and shock)
and local consequences to tissue beds (due to ischemia as
a result of disrupted perfusion). These changes—and the
mitigation that good resuscitation and timely surgery can
offer—govern the potential for both patient survival and
functional recovery. A comprehensive understanding of
the important intercellular and intracellular signalling path-
ways that mediate these effects may allow identification of
modulators that will serve as future therapies. Ischemia-
reperfusion injury is enacted at the endothelial level, with
endothelial integrity further ameliorated or exacerbated by
the chosen resuscitation strategy. In particular, the struc-
tural integrity of the glycocalyx appears central to these
processes. Shock and ischemia combine, potentiate, and
compound their individual effects such that the standard
timelines for successful revascularization cannot be relied
on to secure functional limb salvage. The time period
before revascularization no longer guarantees that optimal
recovery is shorter than previously understood and may be
influenced by the quality of fluid resuscitation.

Key Words:  vascular trauma,

ischemia,
reperfusion,
damage control,
resuscitation,
combat,
wartime,
military,
endothelial cell,
plasma,
red blood cells,
platelets,
TGF-β

limb salvage, investigators examined the potential for restor-
ing extremity blood flow earlier and farther forward on the
battlefield with the use of temporary vascular shunts. Dawson
and colleagues at Lackland Air Force Base, in San Antonio,
Texas, set the stage for the use of temporary shunts to main-
tain limb perfusion after arterial injury based on the findings
of an animal study that demonstrated excellent patency and
decreased lactic-acid production.6 Early reports from the war
in Iraq demonstrated the feasibility and general benefit of this
surgical adjunct, and the use of temporary vascular shunts
subsequently expanded to nearly a quarter of all extremity
vascular injuries.7,8 Although shunt patency often exceeded
90% for over 5 hours,9 the effectiveness of shunts in protecting
against ischemic injury was not definitively established until
Rasmussen and colleagues performed several randomized
large animal studies at Lackland Air Force Base a decade after
the original studies by Dawson.
The Ischemic Threshold
In an attempt to evaluate the physiologic benefit of temporary
vascular shunts, a porcine model of extremity hind-limb isch-
emia showed that early restoration of perfusion using shunts
protected from further ischemic insult and reduced circulat-
ing markers of tissue injury.10 During reperfusion, specimens
were collected to assess circulating markers of muscle injury
and inflammation and included lactate, myoglobin, potas-
sium, creatine phosphokinase, aspartate aminotransferase,
and lactate dehydrogenase. The values were used to compute
an ischemia index score. This was the first investigation to
demonstrate that early restoration of flow with a temporary
vascular shunt before 3 hours of ischemia was associated with
reduced tissue and circulating markers of muscle injury. This
study was in contrast to previous animal research that focused
only on small animals lacking translational wartime applica-
bility.10 Gifford and colleagues also reported that the presence
of the shunt did not increase the ischemic injury and that
patency was maintained in the absence of systemic anticoagu-
lation (i.e., heparin). This report refuted the surgical doctrine
that a 6-hour time window was adequate or acceptable and
validated the use of temporary shunts in forward maneuver
units. Although the lack of tissue studies limited the ability to
translate these markers to actual damage, Gifford and col-
leagues paved the way for a subsequent analysis of neuromus-
cular recovery.10
Although several small animal studies suggest an ischemic
interval after which irreversible neuromuscular injury occurs,
this has been incompletely and variably defined. Burkhardt
and colleagues used a porcine survival model to define an
ischemic threshold beyond which surgical restoration may not
be beneficial. The group randomized swine with iliac artery
occlusion for various time intervals followed by ligation or
vessel repair and 14 days of recovery. In this series of studies,
a physiologic measure of recovery served as the functional
outcome endpoint and included the Tarlov gait score, and
electromyography (EMG) measures the results of which were
coupled with muscle and nerve histology. In this study, surgi-
cal and therapeutic adjuncts to restore extremity perfusion
early (1 to 3 hours) after extremity vascular injury were found
to provide improved neuromuscular outcome compared to
delayed restoration of flow or ligation. Interestingly, the group
also reported that ligation instead of repair after 6 hours of
4  /  Pathophysiology of Vascular Trauma 29
ischemia was associated with improved neuromuscular recov-
ery and determined that this benefit intercepts the slope of
physiologic recovery at 4.7 hours of ischemia. The authors
suggested that knowledge of the ischemic threshold may stim-
ulate the development of adjuncts (shunts, fasciotomy, phar-
macologic agents) that continue to shift the threshold in a
more favorable direction.2,11
As an extension of these translational large animal studies,
Hancock and colleagues noted that extremity vascular injury
typically occurs in association with hemorrhage and that the
potential deleterious effect of shock on the ischemic threshold
was unknown. The researchers extended the original Burkhardt
study by characterizing the impact of hemorrhagic shock on
neuromuscular recovery in the setting of defined hind-limb
ischemia (1, 3, and 6 hours). This study found that animals
with less than 1 hour of ischemia had clinically normal limb
function by the end of the 14-day recovery period with
minimal histologic alterations of muscle and nerve tissue.
However, in the presence of Class III hemorrhagic shock (35%
blood volume reduction) only 3 hours of ischemia resulted in
impaired functional recovery with moderate to severe degen-
eration of extremity muscle and nerve tissue. Interestingly,
Class III shock was associated with a decrement in neuromus-
cular recovery across all groups but was greatest in groups who
experienced more than 3 hours of ischemia. The researchers
concluded that hemorrhagic shock reduces the ischemic
interval of the limb and that, in this constellation of injury
(extremity ischemia and shock), revascularization within 1
hour is necessary for best neuromuscular recovery and func-
tional limb salvage. These findings underscored the impor-
tance of recognizing and treating shock with optimal
resuscitation fluids designed to maximize hemoglobin con-
centration and oxygen delivery to prevent further neuromus-
cular impairment.12
Damage Control Resuscitation
Damage control resuscitation (DCR) has evolved as an effec-
tive strategy to treat hemorrhagic shock.4,13-16 This includes
earlier and increased use of packed red blood cells (PRBCs),
thawed plasma, and platelets, while limiting (4 L/24 hours)
crystalloid fluids. Several studies have associated improved
survival with the early, aggressive use of this plasma-based
resuscitation strategy.14,16-19 DCR has changed the current
practices in military and civilian trauma centers. Recent
evidence suggests that DCR also modulates the ischemic
reperfusion response to vascular injury as the treatment of
hemorrhagic shock extends the ischemic threshold.12 Fresh
red blood cells (RBCs) have greater oxygen delivery, and
freshly thawed plasma products may stabilize cell membranes,
which reduces capillary edema and endothelial permeability
that is known to exacerbate reperfusion injury and the no
reflow phenomenon observed with microvascular thrombo-
sis.17,20,21 Studies on RBCs have led to the concept of the
“storage lesion” that has been associated with proinflamma-
tory changes and deleterious effects.22-24 These studies have
suggested deleterious effects associated with aged RBCs. In
both patients and in vitro studies, the storage age of RBCs has
been associated with increased inflammatory gene expression,
infection, and decreased survival. Moreover, recent work has
shown that storage of platelets increases a variety of growth
factors, including transforming growth factor-β, that have the
30 SECTION 1  /  BACKGROUND

potential to destabilize the vasculature contributing to unde-
sirable outcomes.
Because many trauma centers now place thawed plasma
directly in the emergency department, the optimal age of the
transfused plasma is being questioned. According to the
American Association of Blood Banks, thawed plasma may be
stored at 1° C to 6° C for up to 5 days before transfusion.
Although this may reduce waste, experiments have shown
decreased hemostatic potential and clotting factors in stored
plasma compared to freshly thawed plasma. Letourneau and
colleagues demonstrated that aged (5 days old) plasma trans-
fusion increases mortality in a rat model of uncontrolled hem-
orrhage. In addition, aged plasma has diminished endothelial
repair activity.25 Further studies investigating the interaction
between endothelial biology and resuscitative fluids continue.
For example, Pati and colleagues demonstrated that increased
endothelial permeability is associated with aged plasma when
compared to freshly thawed plasma. Their group hypothesized
that in addition to reversing coagulopathy, fresh frozen plasma
has protective and stabilizing effects on the endothelium that
translate into diminished endothelial cell permeability. Endo-
thelial permeability was induced by hypoxia and this group
studied the passage of 70-k-Da Dextran between monolayers.
Pati and colleagues noted that thawed plasma inhibits perme-
ability in vitro and that those effects of plasma on vascular
endothelium diminish over 5 days of standard storage.21
Endothelial cell stability is crucial for vascular integrity. Tight
junctions are important to structural support and, when this
fails, endothelial cells become fragile and water and other
molecules begin to invade the interstitial space (Fig. 4-1). This
may be an important mechanism demonstrated in the massive
extremity edema commonly associated with reperfusion of an
acutely ischemic limb necessitating fasciotomy to avoid com-
partment syndrome and limb loss. Additionally, exposure of
the subendothelium can lead to unwanted activation of the
coagulation cascade and propagate microvascular thrombosis.
In concert with the luminal contraction by expansive edema,
the no reflow phenomenon can be either prevented or exac-
erbated depending on the resuscitation.
Duan and colleagues studied the effect of refrigeration
on fresh frozen plasma and noted that endothelial cell migra-
tion is essential for vascular repair or healing after vascular
injury by endothelialization. This repair process can be delayed
by antimigratory activity. Their group has shown that refrig-
eration of plasma diminished its beneficial effects on endo­
thelial cell function yet the underlying mechanisms remain
unknown.26 Transforming growth factor-β (TGF-β) is a
known inhibitor of endothelial cell migration, and migration
plays an important role in restoring barrier function after
endothelial damage.27,28 Interestingly, these researchers found
that fresh frozen plasma contained a significant amount of
TGF-β, which increased during refrigeration. Importantly,
5-day-old plasma also showed diminished endothelial cell
migration. This supported the hypothesis that refrigeration of
day 5 fresh frozen plasma increases TGF-β levels, leading to a
diminished plasma efficacy on endothelial cell migration.
A protective effect of plasma on the endothelial glycocalyx
has also been described recently. The glycocalyx consists of
glycoproteins and proteoglycans that provide structural
support and protect the underlying endothelium. Adhesion
molecules are the major components of the glycocalyx and
appear to play a key role in pathologic neutrophilic adhesion
to the endothelium following ischemic injury. Kozar and col-
leagues were the first to describe this process in a rodent
model, noting that the protective effects of plasma may be due
in part to its ability to restore the endothelial glycocalyx after
hemorrhagic shock. Interestingly, this protection was not
observed in those animals resuscitated with lactated Ringer

Normal capillary Vascular permeability

Tight
Fragile
endothelial
endothelial
junctions
junctions

Water and other

Interstitial molecules leak
space Glycocalyx into interstitial
space. Damaged
Glycocalyx

FIGURE 4-1  Working biological model of the mechanism of action of fresh frozen plasma. This figure depicts the working biological model of
the mechanism of action of fresh frozen plasma. Hemorrhagic shock leads to a deviation of the vasculature from homeostasis. Hemorrhagic
shock induces hypoxia, endothelial cell tight-junction breakdown, inflammation, and leukocyte diapedesis. Fresh frozen plasma repairs and
normalizes the vascular endothelium by restoring tight junctions, by building the glycocalyx, and by inhibiting inflammation and edema, all
detrimental processes that are caused by iatrogenic injury with fluids such as lactated Ringer solution. (From Pati S, Matijevic N, Doursout MF,
et al: Protective effects of fresh frozen plasma on vascular endothelial permeability, coagulation, and resuscitation after hemorrhagic shock are time
dependent and diminish between days 0 and 5 after thaw. J Trauma 69[1]:S55–S63, 2010.)

FIGURE 4-2  Emergency release of blood products is initiated early
and transfused in the admitting area. Equal ratios of plasma to red
blood cell units, or fresh whole blood are advocated. Only a single
bag of crystalloid is noted on the operating room floor in this photo-
graph, as practice shifts from high-volume crystalloid resuscitation to
a plasma-based strategy to reduce morbidity.
providing further insight into the potentially damaging effects
of crystalloid resuscitation.29
The evidence from these studies demonstrates that endo-
thelial integrity, migration, and permeability are compro-
mised by hypoxia and the inflammatory mediators induced
by hemorrhagic shock. Numerous investigators have noted the
potentially deleterious effects of crystalloid resuscitation.30-33
While optimal DCR ratios have demonstrated favorable out-
comes,16,34 Cotton and colleagues in a landmark study of
nearly 400 patients reported a significant survival benefit,
reduced crystalloid (Median: 14L versus 5L), and, interest-
ingly, reduced RBC administration (13U versus 7U) with DCR
when compared to nonDCR groups. Iatrogenic injury from
massive crystalloid resuscitation in the revascularization of an
acutely ischemic limb often aggravates compartment syn-
drome, delays ambulation, and prolongs hospital stay. The
evidence is very strong that crystalloid is not a resuscitative
fluid; yet moving away from high-volume crystalloid resusci-
tation requires a process of continuous education from the
prehospital setting to the emergency department to the oper-
ating room to the intensive care unit (Fig. 4-2). Whether a
plasma-based strategy will reduce morbidity and improve
functional limb salvage remains uncertain. However, research
efforts to secure quality limb salvage following repair of a
vascular injury should be placed within the context of isch-
emia-reperfusion injury and development of our understand-
ing of how those injury mechanisms are modulated by current
resuscitation therapies. Skillfully designed and executed
animal and in vitro studies suggest that effective treatment of
hemorrhagic shock and use of fresh components have the
ability to modulate the inflammatory responses that have clas-
sically led to reperfusion injury.
Conclusion
Brief episodes of ischemia following vascular trauma are well
tolerated, and treatment consists of basic restoration of blood
4  /  Pathophysiology of Vascular Trauma 31
flow. When prolonged, functional limb salvage may be highly
unpredictable because of skeletal muscle energy depletion,
oxygen free radical induced inflammation, and endothelial cell
damage that leads to reperfusion injury. Optimal reperfusion
of the extremity following major vascular injury generally
should be in less than 3 hours; however, the degree of hemor-
rhagic shock significantly lowers that threshold for neuromus-
cular recovery. Impairment in oxygen delivery, the degree of
hemorrhagic shock and the age of transfused blood compo-
nents all serve as negative immunomodulatory functions
on the vascular endothelium. These molecular mechanisms
provide insight into intracellular signaling pathways and serve
as future therapeutic targets for optimizing resuscitation after
extremity vascular trauma.
REFERENCES
1. White JM, Stannard A, Burkhardt GE, et al: The epidemiology of vascular
injury in the wars in Iraq and Afghanistan. Ann Surg 253:1184–1189,
2011.
2. Burkhardt GE, Gifford SM, Propper B, et al: The impact of ischemic
intervals on neuromuscular recovery in a porcine (Sus scrofa) survival
model of extremity vascular injury. J Vasc Surg 53:165–173, 2011.
3. Kragh JF, Jr, Walters TJ, Baer DG, et al: Survival with emergency tourni-
quet use to stop bleeding in major limb trauma. Ann Surg 249:1–7,
2009.
4. Fox CJ, Gillespie DL, Cox ED, et al: The effectiveness of a damage control
resuscitation strategy for vascular injury in a combat support hospital:
results of a case control study. J Trauma 64:S99–S106, 2008.
5. Fox CJ, Perkins JG, Kragh JF, Jr, et al: Popliteal artery repair in massively
transfused military trauma casualties: a pursuit to save life and limb.
J Trauma 69:S123–S134, 2010.
6. Dawson DL, Putnam AT, Light JT, et al: Temporary arterial shunts to
maintain limb perfusion after arterial injury: an animal study. J Trauma
47:64–71, 1999.
7. Gifford SM, Aidinian G, Clouse WD, et al: Effect of temporary shunting
on extremity vascular injury: an outcome analysis from the Global War
on Terror vascular injury initiative. J Vasc Surg 50:549–555, 2009.
8. Rasmussen TE, Clouse WD, Jenkins DH, et al: The use of temporary
vascular shunts as a damage control adjunct in the management of
wartime vascular injury. J Trauma 61:8–12, 2006.
9. Taller J, Kamdar JP, Greene JA, et al: Temporary vascular shunts as initial
treatment of proximal extremity vascular injuries during combat opera-
tions: the new standard of care at Echelon II facilities? J Trauma 65:595–
603, 2008.
10. Gifford SM, Eliason JL, Clouse WD, et al: Early versus delayed restoration
of flow with temporary vascular shunt reduces circulating markers of
injury in a porcine model. J Trauma 67:259–265, 2009.
11. Burkhardt GE, Spencer JR, Gifford SM, et al: A large animal survival
model (Sus scrofa) of extremity ischemia/reperfusion and neuromuscular
outcomes assessment: a pilot study. J Trauma 69(Suppl 1):S146–S153,
2010.
12. Hancock HM, Stannard A, Burkhardt GE, et al: Hemorrhagic shock
worsens neuromuscular recovery in a porcine model of hind limb vascu-
lar injury and ischemia-reperfusion. J Vasc Surg 53:1052–1062, 2011.
13. Cotton BA, Reddy N, Hatch QM, et al: Damage control resuscitation is
associated with a reduction in resuscitation volumes and improvement
in survival in 390 damage control laparotomy patients. Ann Surg 254:
598–605, 2011.
14. Borgman MA, Spinella PC, Perkins J, et al: The ratio of blood products
transfused affects mortality in patients receiving massive transfusions at
a combat support hospital. J Trauma 63:805–813, 2007.
15. Fox CJ, Gillespie DL, Cox ED, et al: Damage control resuscitation for
vascular surgery in a combat support hospital. J Trauma 65:1–9, 2008.
16. Holcomb JB, Wade CE, Michalek JE, et al: Increased plasma and platelet
to red blood cell ratios improves outcome in 466 massively transfused
civilian trauma patients. Ann Surg 248:447–458, 2008.
17. Spinella PC, Perkins JG, Grathwohl KW, et al: Effect of plasma and red
blood cell transfusions on survival in patients with combat related trau-
matic injuries. J Trauma 64:S69–S77, 2008.
18. Spinella PC, Perkins JG, Grathwohl KW, et al: Warm fresh whole blood
is independently associated with improved survival for patients with
combat-related traumatic injuries. J Trauma 66:S69–S76, 2009.
32 SECTION 1  /  BACKGROUND
19. Stinger HK, Spinella PC, Perkins JG, et al: The ratio of fibrinogen to red
cells transfused affects survival in casualties receiving massive transfu-
sions at an army combat support hospital. J Trauma 64:S79–S85, 2008.
20. Spinella PC, Sparrow RL, Hess JR, et al: Properties of stored red blood
cells: understanding immune and vascular reactivity. Transfusion 51:894–
900, 2011.
21. Pati S, Matijevic N, Doursout MF, et al: Protective effects of fresh frozen
plasma on vascular endothelial permeability, coagulation, and resuscita-
tion after hemorrhagic shock are time dependent and diminish between
days 0 and 5 after thaw. J Trauma 69(Suppl 1):S55–S63, 2010.
22. Spinella PC, Carroll CL, Staff I, et al: Duration of red blood cell storage
is associated with increased incidence of deep vein thrombosis and in
hospital mortality in patients with traumatic injuries. Crit Care 13:R151,
2009.
23. Spinella PC, Doctor A, Blumberg N, et al: Does the storage duration of
blood products affect outcomes in critically ill patients? Transfusion
51:1644–1650, 2011.
24. Inaba K, Branco BC, Rhee P, et al: Impact of the duration of platelet
storage in critically ill trauma patients. J Trauma 71:1766–1773, 2011.
25. Letourneau PA, McManus M, Sowards K, et al: Aged plasma transfusion
increases mortality in a rat model of uncontrolled hemorrhage. J Trauma
71:1115–1119, 2011.
26. Duan C, Cao Y, Deng X, et al: Increased transforming growth factor beta
contributes to deterioration of refrigerated fresh frozen plasma’s effects
in vitro on endothelial cells. Shock 36:54–59, 2011.
27. Castanares C, Redondo-Horcajo M, Magan-Marchal N, et al: Signaling by
ALK5 mediates TGF-beta-induced ET-1 expression in endothelial cells:
a role for migration and proliferation. J Cell Sci 120:1256–1266, 2007.
28. Lorenowicz MJ, Fernandez-Borja M, Kooistra MR, et al: PKA and Epac1
regulate endothelial integrity and migration through parallel and inde-
pendent pathways. Eur J Cell Biol 87:779–792, 2008.
29. Kozar RA, Peng Z, Zhang R, et al: Plasma restoration of endothelial gly-
cocalyx in a rodent model of hemorrhagic shock. Anesth Analg 112:1289–
1295, 2011.
30. Alam HB, Rhee P: New developments in fluid resuscitation. Surg Clin
North Am 87:55–72, vi, 2007.
31. Rhee P, Koustova E, Alam HB: Searching for the optimal resuscitation
method: recommendations for the initial fluid resuscitation of combat
casualties. J Trauma 54:S52–S62, 2003.
32. Cotton BA, Guy JS, Morris JA, Jr, et al: The cellular, metabolic, and sys-
temic consequences of aggressive fluid resuscitation strategies. Shock
26:115–121, 2006.
33. Cotton BA, Jerome R, Collier BR, et al: Guidelines for prehospital fluid
resuscitation in the injured patient. J Trauma 67:389–402, 2009.
34. Zink KA, Sambasivan CN, Holcomb JB, et al: A high ratio of plasma and
platelets to packed red blood cells in the first 6 hours of massive transfu-
sion improves outcomes in a large multicenter study. Am J Surg 197:565–
570, 2009.
 SECTION 2

Diagnosis and Early

Management
Diagnosis of Vascular Injury
MICHAEL J. SISE
Introduction
Vascular trauma with vessel disruption presents in a variety
of settings and results in findings that range from life-
threatening hemorrhage and/or significant ischemia (i.e., hard
signs of vascular injury) to less-detectable or soft signs of
injury. In some instances, vascular injury may present without
any hard or soft physical examination findings and exist as an
occult injury. Effective management of vascular trauma is
based on early diagnosis and prompt treatment. Isolated vas-
cular injuries are becoming less common at modern urban
trauma centers because there is an increasing prevalence of
multisystem trauma that includes vascular injury, making
early diagnosis more challenging.1-3 Successfully identifying
vascular injury in a timely manner requires an organized
approach with attention to the mechanism of injury, with the
presence of hemorrhage at the scene or during transport, and
with a thorough physical examination. In many instances,
the physical examination must be augmented with Doppler
extremity pressure measurements, the multidetector com-
puted tomographic angiography (MDCTA), and/or the selec-
tive use of contrast arteriography to diagnose vascular injury.
Imaging techniques are discussed at length in subsequent
chapters.
Analyses of human error suggest that the following three
factors play roles in most major errors: familiarity, distraction,
and fatigue.4 The modern trauma center creates an environ-
ment where all three factors are constantly at play and, as such,
trauma care is an error-prone process. Avoiding error in the
care of the injured patient requires not only an organized
approach but also the use of short but effective checklists that
assure the application of that organized approach. Unfortu-
nately, most physicians are familiar with long, detailed, and
all-inclusive checklists that have not been created by them or
by colleagues who provide trauma care. Most physicians do
not find these types of checklists useful so they are not often
used. The experience of military and civilian aviation com-
munities strongly supports the use of short, practical check-
lists created by experienced aircrews and thoroughly tested at
the point of service until they are effective.4 The essential
history and physical elements that lead to the prompt diagno-
sis of vascular injury are displayed as a checklist in Box 5-1.
The Mechanism, Setting,
and Patterns of Injury
The evaluation of an injured patient must begin with consid-
eration of the mechanism of injury and the setting in which
that injury occurred.5 This is particularly important in patients
5 
injured in high-speed motor-vehicle crashes. The advent of
modern automobile passenger-restraint systems has resulted
in many occupants surviving what were previously fatal
crashes. However, this also resulted in a rising incidence of
blunt cerebrovascular and thoracic arterial injuries.6 These
injuries are often asymptomatic, associated with few physical
findings on presentation, and occur in the setting of a variety
of injury patterns. In most instances, blunt cerebrovascular
and thoracic arterial injuries can be found only with further
imaging studies. Thus considering both the mechanism and
setting of injury will lead to the appropriate diagnostic evalu-
ation. Further consideration of injury patterns will also
prompt appropriate early workup and timely recognition and
will result in successful management.
Penetrating vascular injuries are rarely occult and usually
present with hard signs of hemorrhage, including hematoma,
active bleeding, and shock.7 The nature of bleeding at the
scene should always be determined as initial pulsatile flow or
large amounts of blood at the scene may be indicative of sig-
nificant vascular injury. Bleeding during prehospital transport
should also be considered a sign of vascular trauma. This
information may not be readily available when patients are
transported by bystanders or if they flee the scene of the
injury. Redirecting attention to apparently nonbleeding
wounds in the patient in shock without evidence of chest or
abdominal trauma may reveal an underlying extremity vascu-
lar injury which has ceased bleeding.
Injury Pattern Recognition
The early diagnosis of vascular injuries requires a high index
of suspicion based on both mechanism of injury and injury
patterns. The following discussion reviews each anatomic area
and the important considerations of both mechanism of
injury and injury pattern. Such familiarity will prompt the
provider to perform further diagnostic studies to identify vas-
cular injuries in a timely manner. The goal of this review is to
generate pattern recognition and decisive action.
Head and Neck Vascular Injuries
The neck and face are areas of relatively superficial major
vascular structures. Additionally, the neck is a zone of multi-
axis motion with cerebrovascular arterial structures in close
proximity to bony prominences. This is a high-risk zone for
both blunt and penetrating vascular injuries.2 Although pen-
etrating injuries are usually obvious because of hemorrhage,
blunt injuries are almost always occult. Low-velocity gunshot
wounds may cause injuries other than the typical laceration
and hemorrhage. As an example, arterial-wall disruption from
35
 5  /  Diagnosis of Vascular Injury 35.e1

ABSTRACT
Vascular trauma remains a significant challenge in the man-
agement of injured patients, and early diagnosis and
prompt treatment are essential to achieving a good
outcome. Consideration of the mechanism, setting, and
pattern of injury coupled with a thorough vascular physical
examination help identify vascular injuries in a timely
manner. Life-threatening hemorrhage requires immediate
action, and diagnosis is relatively quickly made in conjunc-
tion with control measures. Limb-threatening, arterial
occlusive injuries are successfully diagnosed with an appro-
priate extremity examination. Occult injuries require
adjunctive imaging studies. Each anatomic zone requires a
special focus to be cleared for the presence of major vas-
cular injury. Head and neck vascular trauma may be obvious
with external hemorrhage or large hematoma. Blunt-force
cerebrovascular injuries are often occult. Torso injuries with
hemorrhage and shock require immediate operative inter-
vention for vascular control and diagnosis. Significant
extremity vascular injury is promptly identified with physi-
cal examination augmented with Doppler pressure mea-
surements. The problem of inaccurate pulse examination is
pervasive throughout trauma and emergency care. Doppler
pressure measurements at the wrist or ankle should be
added when pulses are of questionable quality on physical
examination. The diagnosis of compartment syndrome
should be considered in all arterial occlusions, fractures,
and dislocations at or below the knee and elbow, in all
extremity crush injuries, and in any patient complaining of
increasing pain following injury. The definitive diagnosis of
vascular trauma must be tailored to meet the patient’s
resuscitation priorities and must be orchestrated with the
overall care of associated injuries.

Key Words:  vascular-injury diagnosis,

computed tomography,
Doppler ultrasound,
contrast angiography,
pulse deficit,
compartment syndrome,
multidetector computed tomographic angiography
(MDCTA),
ankle-brachial index (ABI),
portable angiography
36 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
Box 5-1 Checklist for Prompt Recognition of
Vascular Injury
Review the following questions in the trauma bay:
Consider further evaluation for vascular injury for any positive
answer.
1. High-risk mechanism of injury
• Significant blunt-force loading and anatomic extent across
major vessels?
• Penetrating path in area of major vessels (i.e., proximity)?
2. Blood loss at the scene
• History of pulsatile bleeding from the wound?
• Significant blood at the scene, on clothing, or trail of
blood?
• Fled the scene and history of significant bleeding from
wounds?
3. Bleeding indicators
• Prehospital hypotension present and trauma in the area of
a major vessel?
• Prehospital shock index (HR/SBP) >0.90?
• Shock unexplained, with nonbleeding extremity or neck
lacerations?
4. Physical Examination
• Pulsatile bleeding, copious venous bleeding, or large
hematoma?
• Absent extremity pulses, absent Doppler signals, ankle-
brachial or injured extremity of index <0.9?
• Bruit or thrill over injury site?
• Major deficit in peripheral nerve located in proximity to
major vessel?
5. High-risk fractures or joint dislocations?
• Cervical spine fracture—vertebral artery injury
• Thoracic spine fracture—thoracic aortic injury
• Supracondylar humerus fracture—brachial artery injury
• Knee dislocation—popliteal artery injury
• Tibial plateau fracture—below-knee popliteal artery injury
and/or leg compartment syndrome
bullets passing in proximity may cause arterial thrombosis
(Fig. 5-1) or pseudoaneurysm formation. Pattern recognition
of both blunt-force loading and associated injuries is essential
for prompt diagnosis of blunt cerebrovascular injury.
The most common underlying mechanism of significant
blunt cerebrovascular injury in the neck and at the skull base
is stretching of the vessel, often across a bony prominence, or
from direct compression by a fracture fragment.6,8 Less likely
is focal blunt force with direct compression and partial arterial
rupture. There are key anatomic areas where these events
occur. At the base of the skull, fracture of the temporal bone
in the area of the carotid canal may be associated with internal
carotid artery dissection. Hyperextension of the neck may
stretch the internal carotid artery across the transverse process
of C2 also causing dissection. Hyper-flexion may lead to com-
pression of the internal carotid between the angle of the man-
dible and the transverse process of C2 with arterial thrombosis.
Hyperrotation of C1 on C2 can cause a stretch injury of the
vertebral artery resulting in dissection and thrombosis. Any
cervical spine fracture that involves transverse processes may
cause vertebral artery injury. At the prominent transverse
process of C6, direct blunt-force trauma may compress the
common carotid artery creating a partial wall disruption and
pseudoaneurysm.
Direct trauma to the neck also requires attention to the
possibility of vascular injury.6,8 Handlebar trauma and other
direct blows to the neck may disrupt the carotid artery.
Attempted hanging or strangulation may cause blunt carotid
disruption. The shoulder harness of an automobile passenger-
restraint system may also compress the common carotid
artery and cause disruption and thrombosis. External signs of
direct neck trauma (e.g., seat-belt sign on the neck) should
direct attention to the possibility of carotid injury. Particular
attention should be paid to direct lower-neck trauma and
hoarseness in the absence of direct laryngeal trauma. The
vagus nerve lies adjacent to the common carotid artery, and
trauma sufficient to cause injury to the vagus above the takeoff
of the recurrent laryngeal trauma may also injure the common
carotid artery (Fig. 5-2).
Thoracic Vascular Injuries
Penetrating trauma to the thorax with major vascular injury
presents with life-threatening hemorrhage that requires
immediate operative intervention to identify the injury and
control hemorrhage. In contrast, blunt injuries are often
occult, and early diagnosis requires attention to both mecha-
nism and injury pattern. Rapid deceleration or acceleration
can create visceral rotation and stretch of the mediastinal
structures causing sheer stress at transition points between
relatively mobile and fixed vessel segments.2,9 The heart and
proximal great vessels have been described as moving like a
bell clapper in the chest in certain scenarios of high-speed
impact. The result of such injuries is that the aorta is partially
torn at the isthmus, a transition point between mobile and
fixed elements.9 This type of movement can also stretch and
partially tear the branches of the aortic arch. Direct trauma
from compression and fracture of the sternum, manubrium,
or clavicles can cause vascular injuries. This type of direct
compression may injure the aortic arch and its proximal
branches or the pulmonary artery at its bifurcation area
(Fig. 5-3).
A variety of fracture patterns have been described with
blunt thoracic aortic injury. Although first-rib fracture is often
described as a harbinger of blunt aortic injury, thoracic spine
fracture is the most commonly associated fracture finding.9,10
This type of fracture is the result of major force loading on
the thorax and indicative of the risk of great vessel injury.
Although clavicle fractures are very common, blunt subcla-
vian artery and venous injuries are rarely associated with this
finding.1,2
The portable anteroposterior chest radiograph is an impor-
tant tool in the early recognition of occult mediastinal vascu-
lar injury. Despite a wide variety of findings described as being
associated with thoracic aortic injury, two are of particular
importance.9,10 An increased width of the superior mediasti-
num and the absence of a normal left-side aortic contour are
both indications of a mediastinal hematoma and warrant
additional CT scan imaging to rule out vascular injury. Finding
of rib fractures, thoracic spine fractures, and sternal fractures
are less strongly associated with thoracic aorta and great vessel
injuries but should also prompt additional imaging with con-
trast CT.
Abdominal Vascular Injuries
Penetrating abdominal vascular injuries present in a manner
similar to thoracic vascular injuries.10,11 Hard signs of vascular
 5  /  Diagnosis of Vascular Injury 37

Right

1.91cm Right

FIGURE 5-1  Internal carotid artery thrombosis from gunshot wound transitting the retromandibular area and lodging adjacent to the mastoid
process. There was a lack of hemorrhage or hematoma, and the patient had a normal neurologic examination.

injury such as intraabdominal hemorrhage and shock require
immediate operative intervention both to identify and to
control the site of bleeding. Blunt vascular injuries occur in a
fashion similar to thoracic injuries.11 The major difference in
the abdomen is the paucity of mobile segments in major arter-
ies due to the retroperitoneal location of the aorta and its
proximal branches. The renal hilum is an exception and blunt
stretch injuries of the renal arteries are not uncommon.2,10,11
The abdominal aorta and proximal mesenteric arteries may
be injured by blunt-force trauma such as lap-belt or passenger-
restraint compression of the distal aorta against the sacral
promontory in a high-speed motor-vehicle crash. Survivable
blunt tears of the celiac and superior mesenteric arteries occur
infrequently.2,10,11
Upper Extremity Vascular Injuries
Penetrating upper extremity vascular injuries typically
produce hard signs of vascular injury such as external
38 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
hemorrhage or acute limb ischemia and are usually obvious
in presentation (Fig. 5-4). Blunt injuries, although less obvious,
are usually associated with musculoskeletal injuries.1,2 Blunt
posterior distraction of the shoulder with brachial plexus
stretch injury can result in tearing and thrombosis of
FIGURE 5-2  Pseudoaneurysm of the common carotid artery in a
patient who suffered blunt trauma from striking his neck on the
handlebars of a motorcycle. He presented to the emergency depart-
ment complaining of hoarseness. Examination revealed a contusion
at the base of the neck and a bruit over the carotid artery.
A B
the axillary artery with absent pulses at the wrist. Proximal
fracture of the humerus or humeral head dislocation rarely
causes brachial artery occlusion. However, supracondylar
humerus fracture is associated with distal brachial artery
occlusion and forearm ischemia.1,2 Other fractures of the
upper arm are infrequently associated with major vascular
injuries unless they involve a crush injury.
Lower Extremity Vascular Injuries
Penetrating injuries of the groin and leg resulting in vascular
injury most often produce hard signs similar to the upper
extremity with either obvious hemorrhage or distal isch-
emia.2,10 Although proximal femur fractures and hip disloca-
tions rarely result in vascular injury, distal femur fracture may
be associated with superficial femoral artery injury. The distal
superficial femoral artery and proximal popliteal artery are
relatively fixed by the transition through the adductor canal.
Stretch injury and thrombosis may occur. The most common
musculoskeletal injury associated with vascular trauma is pos-
terior knee dislocation.1,2,10 The popliteal artery is fixed proxi-
mally by the adductor canal and distally in the upper calf by
the trifurcation into the anterior tibial, peroneal, and posterior-
tibial arteries. The posterior dislocation of the tibial plateau
stretches and disrupts the popliteal artery resulting in throm-
bosis and distal ischemia. Knee dislocation is associated with
as high as a 30% incidence of popliteal vascular injury.1,3,10
Crush injuries of the lower extremity may cause arterial
disruption at any level. Bumper strike trauma in pedestrians
struck by a motor vehicle has a particular association with
blunt vascular injury in the lower extremity. Compartment
syndrome is also a risk in this type of injury. All below-knee
fracture of the leg must lead to a suspicion of compartment
syndrome. However, tibial plateau fracture is the most com-
monly associated fracture with calf compartment syndrome.3,12
Fractures of the tibia and fibula often involve significant dis-
traction and angulation of fracture segments with ripping of
compartment fascial planes. An auto-fasciotomy and decom-
pression of the compartments often result. Tibial plateau
FIGURE 5-3  A, CT angiogram of coronal
reconstruction demonstrating innominate
artery pseudoaneurysm in a patient with
blunt-force compression of the anterior
chest from a high-speed motor-vehicle
crash. B, Posterior volume rendering tech-
nique (VRT) view of innominate artery
pseudoaneurysm.

A B
FIGURE 5-4  A, Transiting gunshot wound of the volar aspect of the right forearm in a patient with distal pulses absent. B, The patient was
taken directly to the operating room where the bullet tract was found to transect the brachial artery and both ends were thrombosed and
retracted. The median nerve was intact.
fracture usually requires significant force loading but does not
result in distraction of fracture segments, and the fascial
planes remain intact. Hemorrhage within any of the leg com-
partments results in a scenario that risks the development of
compartment syndrome.
Other High-Risk Injury Patterns
A high index of suspicion for either torso or extremity vascu-
lar injury should also attend the evaluation of a variety of
other injuries. High-speed side impacts may be particularly
high risks for thoracic vascular injuries, as is a fall from a
significant height.9,10 Aircraft-crash survivors should be evalu-
ated for thoracic aorta and great vessel injuries. Victims of
motor-vehicle crash with prolonged entrapment should have
careful evaluation for extremity arterial occlusion and com-
partment syndrome. All crush injuries are similarly at risk and
should prompt a careful evaluation for the presence of vascu-
lar injury and/or extremity compartment syndrome.1,2,10
Physical Examination
Vascular trauma very quickly sorts itself into the following
three major categories with implications for physician exami-
nation and adjunctive diagnostic measures:
1. Life-threatening hemorrhage requires immediate
action, and the diagnosis is quickly made in conjunction
with control measures.
2. Occlusive injuries with distal ischemia are successfully
diagnosed with an appropriate extremity examination.7
3. Occult injuries are not easily found on physical
examination.7,10
Adjunctive measures, often based on pattern recognition of
mechanism and associated injuries, are required to identify
these less-than-obvious injuries. There are commonly
described hard and soft signs of vascular injury that must
always be recalled and carefully considered during physical
examination (Box 5-2).
The Advance Trauma Life Support guidelines for initial and
definitive patient assessment are useful in the evaluation of
patients at risk for vascular injury.5 Acute hemorrhage is
5  /  Diagnosis of Vascular Injury 39
Box 5-2 Hard and Soft Signs of Vascular Injury
HARD SIGNS
• Pulsatile hemorrhage
• Expanding hematoma
• Bruit of thrill over area of injury
• Absent extremity pulses
• Arterial pressure index <0.9
SOFT SIGNS
• History of hemorrhage
• Wounds of neck or extremities and unexplained hemorrhagic
shock
• Neurologic deficit in peripheral nerve in proximity to vessels
• High-risk fracture, dislocation, or penetrating proximity wound
addressed during the primary survey. For extremity bleeding,
control measures are applied, including direct manual pres-
sure and tourniquet application, whereas expedited operative
intervention is required for torso hemorrhage. Timely opera-
tive control and repair (i.e., surgical hemostasis) should
immediately follow in either instance. During the secondary
survey, a thorough physical examination should identify most
extremity vascular injuries. In patients with injury mecha-
nisms and patterns placing them at risk for occult injuries,
appropriate imaging studies should be promptly obtained.
Pulse examination at the wrist and foot must be carefully
performed but recognized as subjective and prone to incon-
sistency among providers in the trauma bay. There is a
common error in overcalling pedal pulses or describing them
as palpable when they are not. The dorsalis pedis and posterior
tibial pulses should only be described as present when they are
clearly palpable and as easily felt as a normal radial pulse.
Weak or diminished pulses that are often described as “1+” or
“2+” in patients with proximal arterial occlusion are often
either pulsation of, or in, the examiners fingertips or simply
imagined. Mistakenly describing a pulse as present in an
extremity with a proximal arterial occlusion misdirects the
management strategy and threatens limb viability and limb
40 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
salvage. Conversely, missing a pulse that is, in fact, present by
calling it absent leads to further investigation that confirms
adequate flow. The erroneous palpation of pedal pulses in an
ischemic limb is unfortunately a common event. The need
for attention to detail in this portion of the physical examina-
tion and the necessity for adjunctive measures such as con-
tinuous wave Doppler examination are crucial elements of
early diagnosis and successful management of extremity vas-
cular injury.7,10,13
The problem of inaccurate pulse examination is pervasive
throughout trauma and emergency care.10 Preventing these
errors in diagnosis calls for an organized approach to the
education of the trauma team members such as emergency
department staff, critical nursing staff, and medical-surgical
floor staff in the priorities of peripheral vascular examination.
This includes not only careful pulse examination but also
demonstration of the techniques of adjunctive Doppler pres-
sure measurements. This education effort should be repeated
at regular intervals to refresh the knowledge base of the team
members who are essential in recognizing extremity vascular
compromise.
Doppler Ultrasound Adjunctive Measures
The primary adjunctive measure in the examination of
extremity blood flow is the use of the Doppler ultrasound and
a blood pressure cuff at the wrist or ankle.14 There are Doppler
myths that need to be considered. The first is that the presence
of arterial signals is equal to the presence of adequate perfu-
sion. The more dangerous myth is that the presence of Doppler
signals indicates the absence of injury. Although an experi-
enced Doppler ultrasound operator can identify the triphasic
characteristics of a normal patent extremity artery, most phy-
sicians and nurses cannot distinguish the differences between
normal and abnormal Doppler signals. Collateral flow around
an occluded artery may produce Doppler signals of a dimin-
ished quality over the pedal vessels and may be misinterpreted
as the absence of injury.
The best use of continuous wave Doppler in the evaluation
for extremity vascular injury is in conjunction with a blood
pressure cuff at the wrist or ankle.14 In these instances, the
Doppler probe is placed over a distal artery in the injured
extremity, and the cuff is slowly inflated. The pressure at which
the Doppler signal is no longer audible should be recorded as
the arterial pressure in that extremity. This ankle or wrist pres-
sure is then compared to the occlusion pressure of the other,
noninjured extremity. The ratio of the arterial occlusion pres-
sure in the injured extremity compared to that in the normal
extremity should be 0.9 or greater.14 Normal ankle-brachial
index (ABI) in an uninjured healthy young person is 1.0.14
Caution should be used when interpreting the ABI in patients
who are hypotensive, are in severe pain, or are hypothermic.
Peripheral vasoconstriction is a normal response to significant
trauma and shock and, if severe, may result in depression of
the ABI in the absence of an injured vessel. In this context,
measurement of Doppler occlusion pressures and determina-
tion of ratios should be viewed as dynamic and should be
repeated after resuscitation, adequate pain control, and/or
rewarming of the patient.10
Duplex color flow imaging, although highly accurate, is not
practical for the acute assessment of vascular injury.15 This
technology is highly operator dependent, and the ability
to obtain satisfactory images is impaired by wounds, by
hematoma, by the presence of air in the tissue, and by the
presence of dressings.10 However, it is very useful for subse-
quent examination of certain vascular injury patterns and the
outpatient follow-up of vascular reconstruction.
Clearing the Trauma Patient for the
Presence of Vascular Injury
The physical examination has proven valuable in ruling out
spinal injuries in stable trauma patients who can be examined
adequately. This process has been dubbed “clearing the spine.”
In a similar manner, physical examination and adjunctive tests
can clear each of the major anatomic areas for the presence of
a clinically significant vascular injury. Numerous studies have
proven the value of a normal pulse examination in the extrem-
ity without active hemorrhage or hematoma.3,7,13,15,16 In the
hemodynamically stable patient with no high-risk injury pat-
terns and a normal extremity neurovascular examination, vas-
cular injury is not present. Further imaging studies are not
needed. This includes proximity penetrating trauma not asso-
ciated with significant hemorrhage, hematoma, or distal neu-
rologic deficit.3,15-17 Box 5-3 outlines the process of clearing a
patient for major vascular injury in each anatomic area.
Further evaluation with imaging studies is reserved for patients
who do not meet the criteria for clearance. Proceeding with
those studies in the absence of indications risks delay in treat-
ment of other injuries and, increasingly more important, risks
unnecessary exposure to radiation. The burden of unneces-
sary CT imaging in young trauma patients and the resultant
cancer risk cannot be underestimated.18 Each CT imaging
study must be indicated by the real risk of injury and the
absence of alternative diagnostic approaches. Thoughtful
Box 5-3 Clearing Trauma Patients for the
Presence of Vascular Injury
HEAD AND NECK
• Alert, hemodynamically stable patient
• Absence of high-risk mechanism
• Normal neurologic examination
• Negative physical examination of the head and neck
• Absence of cervical spine or basilar skull fractures
CHEST AND ABDOMEN
• Normal chest and abdominal examination
• Absence of high-risk mechanism
• Normal chest and pelvis x-rays and negative FAST
UPPER EXTREMITY
• Alert, hemodynamically stable patient
• Normal upper extremity neurovascular examination
• If upper extremity fracture or penetrating proximity injury:
• Absence of significant hematoma or hemorrhage
• Absence of neurologic deficit in distal arm or hand
• Normal pulse examination or wrist pressure index ≥ 0.9
LOWER EXTREMITY
• Alert, hemodynamically stable patient
• Normal lower extremity neurovascular examination
• If lower extremity fracture or penetrating proximity injury:
• Absence of significant hematoma or hemorrhage
• Absence of neurologic deficit in distal leg or foot
• Normal pulse examination or ankle pressure index ≥ 0.9
 5  /  Diagnosis of Vascular Injury 41

Active arterial, major

venous hemorrhage
from wound
Take directly to the
Hard signs of Ischemia, obvious operating room.
vascular injury site of occlusion

Unstable patient

CT angiography and Take to the operating

positive for major injury room ASAP.

Multilevel extremity
CT angiography and
injury, unclear vascular
positive for minimal injury
status (i.e., soft signs)
CT angiography
nondiagnostic
Perform orthopedic
repairs as needed.
Follow closely for
compartment syndrome
and late thrombosis.
Formal catheter angiography

Unclear vascular status
and there is a need for
immediate operation
for other injuries
Perform single-injection
Pressure index < 0.9 local angiography and
operative repair, if indicated.
Pressure index ≥ 0.9 Serial examinations

FIGURE 5-5  Algorithm of the indications for immediate operation and the role of imaging modalities.

serial physical examinations, adjunctive measures, and judi-
cious use of plain film radiography can significantly reduce
the radiation exposure without missing or delaying diagnosis
of vascular injuries.
Definitive Diagnosis of
Vascular Injury
The final diagnostic steps to confirm or definitively rule out
vascular injury include immediate operation with direct
examination of vessels, emergency center or intraoperative
angiography, MDCTA, and formal catheter angiography.3
Each has its role in the definitive diagnosis of vascular injury.
Every trauma center must have the capability and the practice
guidelines to perform each of these definitive steps. The fol-
lowing discussion provides the context for each of these diag-
nostic techniques and presents a practice recommendation
that can serve as a template for your trauma practice group’s
guideline.
Surgical Exploration for Vascular Injury
When should one take his or her patient—who is at risk for
major vascular injury—directly to the operating room? Maybe
the more important question in an era of aggressive applica-
tion of MDCTA is: When doesn’t one need an imaging study
before beginning an operation? The simple answer to these
questions is that a direct trip to the operating room without
imaging is called for when physical examination clearly indi-
cates the location and extent of injury and imaging adds
nothing of significant decision-making value or incurs a delay
that risks worsening the patient’s outcome.3,19 Active arterial
hemorrhage from a penetrating wound and complete isch-
emia secondary to either penetrating or blunt trauma are the
two most frequent indications for immediate operation.3 If a
patient has a tourniquet for hemorrhage placed on an extrem-
ity, the next stop should be the operating room. The value of
immediate operation for either hemorrhage or ischemia has
significantly increased in the era of vascular damage-control
techniques. Rapidly establishing vascular continuity with
shunts and obtaining control of bleeding allow time for treat-
ment of other injuries and allow subsequent imaging studies
for further workup without negatively impacting the outcome.
Figure 5-5 outlines the indications for immediate operation
and the role of imaging modalities.
Portable Angiography in the Trauma Bay  
or the Operating Room
Severely injured patients with life-threatening injuries who
must be taken to the operating room pose a challenge if vas-
cular injury is suspected and hard signs are not present.
MDCTA may not be possible. In these instances, an arterio-
gram can be obtained in the trauma resuscitation bay or in
the operating room by cannulating the artery proximal to the
suspected vascular injury, injecting 20-25 ml of full strength
contrast and taking an x-ray or using fluoroscopy.20,21 The
timing from a rapid injection to shooting a single plain film
is important. If these studies are inconclusive and a major
concern remains about the presence of a vascular injury, there
is a role for operative exploration and direct assessment of the
artery.3 However, in the absence of hard signs, these patients
may be better served by obtaining MDCTA when they are
stable.
Multidetector CT Angiography
The advent of 64-slice MDCTA has changed the time course
of definitive radiologic imaging for vascular trauma diagnosis.
42 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
This imaging technique has largely replaced catheter angiog-
raphy and is especially appealing in the severely injured patient
who may require CT imaging of other body regions (head,
torso, or spine) at the same time.22 CTA is an accurate and easy
study to obtain and has excellent diagnostic imaging.23
MDCTA is discussed at length in a subsequent chapter of this
text. However, patients with unequivocal evidence of active
hemorrhage or complete arterial occlusion well localized by
physical examination should not undergo MDCTA. The delay
to the operating room, the small but real risk of contrast-
induced nephropathy, and radiation exposure are not worth
the expense in terms of time delay and morbidity. Unfortu-
nately, the widespread availability of MDCTA leads to a very
high rate of unnecessary studies. Each MDCTA must be justi-
fied by balancing the value of diagnostic information against
the cost of lost time and possible increased morbidity.
Catheter Angiography in   mental status from injury, alcohol or drug intoxication, and
Fixed-Imaging Suite
In certain instances there is also a role for formal catheter-
based diagnostic imaging performed in a fixed-imaging suite.
This type of examination provides the benefits of better
imaging quality and often availability of endovascular supplies
than the portable fluoroscopic units used in the operating
room and is particularly relevant when endovascular treat-
ment of arterial injury is an option. Formal, fixed angiography
is also an important step in definitive diagnosis when MDCTA
does not adequately image at-risk vessels (Fig. 5-5). The pres-
ence of multiple metallic fragments, such as those seen in
shotgun injuries, compromises the quality of MDCTA; and
formal angiography is often required for definitive imaging is
this setting. This technique is also discussed in a subsequent
chapter. The most important consideration in formal angiog-
raphy in a fixed-imaging suite separate from the operating
room is the time required to mobilize the personnel to com-
plete this study. The 1- to 2-hour (or greater) time period
required for this study must be carefully weighed against the
overall priorities in the care of the injured patient. Increasingly
trauma centers are moving to position high-quality, fixed fluo-
roscopic imaging units into trauma operating rooms to allow
for better quality arteriography and performance of endovas-
cular procedures in the same setting where open operations
can be performed.
Compartment Syndrome
Although not a specific vascular injury, the phenomenon of
extremity compartment syndrome is very closely linked to
vascular trauma. As such, no review of the diagnosis of vas-
cular injury is complete without consideration of the topic
and diagnostic measures that may be taken to identify its pres-
ence as early as possible. Extremity compartment syndrome
may occur shortly after initial injury, in the subsequent resus-
citation phase after life-threatening hemorrhage, or 12 to 24
hours after reperfusion following vascular repair.12,24 Failure
to diagnose and treat extremity compartment syndrome is one
of the most common causes of preventable limb loss following
injury. The most common location is in the leg, and in such
instances the anterior compartment is particularly vulnerable
to this complication. Forearm compartment syndrome is the
next most common. However, compartment syndrome can all
occur in the thigh, upper arm, foot, hand, and buttocks. This
syndrome most commonly occurs secondary to prolonged
ischemia with subsequent reperfusion and resuscitation or
crush injury. Occlusion of venous outflow of the extremity
either from extremity vein injury or thrombosis also contrib-
utes to the development of elevated pressures within the com-
partments of the limb. A high index of suspicion, including
checking for compartment syndrome as part of an organized
approach to the workup of all injured patients, augmented
with compartment pressure measurements are necessary to
detect this complication in its early stage. Like other aspects
of diagnosing vascular injury, evaluation for extremity com-
partment syndrome can be repeated over time with frequent
physical examinations in high-risk patients.
Although the first clinical finding is loss of light touch
sensation in the distribution of the nerve in the compartment
(i.e., peroneal in the anterior compartment of the leg), this
finding is difficult to identify in many patients due to altered
distracting injuries.12,24 The more useful initial finding is pain
on passive stretch of the extensor hallucis longus muscle elic-
ited by pulling the great toe down in placing its extensor
muscle on stretch. Less specific is tenderness on direct com-
pression. In the young and physically fit patient, the turgor of
the compartments to direct compression is a discriminating
physical finding. Extremity sensory and motor examinations
are also not specific enough to be helpful in making the diag-
nosis of compartment syndrome. The loss of arterial pulses is
a very late and relatively uncommon finding unless there is
underlying arterial injury.12
The diagnosis of compartment syndrome should be con-
sidered in all fracture dislocation at or below the knee and
elbow, in all extremity crush injuries, and in any patient com-
plaining of worsening pain following injury. In view of the
nonspecific nature of the physical examination findings and
the multiple distracting factors, it is not surprising that delay
in diagnosis of compartment syndrome is unfortunately
common. Early diagnosis is only possible through measure-
ment of compartment pressures. The normal tissue compart-
ment pressure ranges from 0 mm Hg to 9 mm Hg. Although
controversy exists about the pressure that defines compart-
ment syndrome, the safest approach is to perform fasciotomy
when the compartment pressure exceeds 25 mm Hg.12,24
There is a variety of methods used to measure compart-
ment pressure. The Stryker Pressure Monitor™ is the most
practical and commonly used device. If not available, an alter-
native device can be created with a blood pressure cuff
manometer and saline flush tubing (Fig. 5-6). The pressure is
measured in the four calf compartments of the leg or the
appropriate compartments in other areas of the extremities.
If borderline elevation is noted, frequent serial measurements
are essential in view of the progressive nature of extremity
compartment swelling. Fasciotomy techniques are discussed
elsewhere in this text.
Summary
Early diagnosis and prompt treatment are essential to the suc-
cessful management of vascular trauma. Timely diagnosis
requires an organized approach based on recognition of high-
risk injury patterns, thorough physical examination with
adjunctive pressure measurements in the extremities, and
effective imaging techniques. The patient’s major anatomic

FIGURE 5-6  Alternative device for pressure monitoring constructed
from a blood pressure cuff gauge, pressure tubing, a stopcock, and a
syringe. Saline is flushed through the line to the 18-gauge needle. The
compartment is entered with the needle and 3 to 5 mL of saline are
flushed into the compartment. The stopcock is turned to the gauge
to measure the compartment pressure.
regions must each be evaluated for vascular injury by applying
this organized approach. The definitive diagnosis of vascular
trauma must be tailored to meet the patient’s resuscitation
priorities and orchestrated with the overall care of associated
injuries. This ranges from immediate operation in unstable
patients to delayed imaging in patients with suspected occult
injuries.
REFERENCES
1. Rozycki GS, Tremblay LN, Feliciano DV, et al: Blunt vascular trauma in
the extremity: diagnosis, management, and outcome. J Trauma 55:814–
824, 2003.
2. Mattox KL, Feliciano DV, Burch J, et al: Five thousand seven hundred
sixty cardiovascular injuries in 4459 patients: epidemiologic evolution
1958 to 1987. Ann Surg 209:698–707, 1989.
3. Feliciano DV, Moore FA, Moore EE, et al: Evaluation and management of
peripheral vascular injury. Part 1. Western Trauma Association/Critical
Decisions in Trauma. J Trauma 70:1551–1556, 2011.
4. Reason J: The human contribution. Unsafe acts, accidents, and heroic
recoveries, Surrey, England, 2008, Ashgate Publishing Ltd.
5. American College of Surgeons: Advanced trauma life support for doctors,
2010. <http://www.facs.org/trauma/atls/index.html>.
5  /  Diagnosis of Vascular Injury 43
6. Biffl WL, Moore EE, Ryu RK, et al: The unrecognized epidemic of blunt
carotid arterial injuries: early diagnosis improves neurologic outcome.
Ann Surg 228:462–470, 1998.
7. Frykberg ER, Dennis JW, Bishop K, et al: The reliability of physical exami-
nation in the evaluation of penetrating extremity trauma for vascular
injury: Results at one year. J Trauma 31:502–511, 1991.
8. Miller PR, Fabian TC, Bee TK, et al: Blunt cerebrovascular injuries: diag-
nosis and treatment. J Trauma 51:279–286, 2001.
9. Mattox KL, Wall MJ: Thoracic great vessel injury. In Feliciano DV, Mattox
KL, Moore EE, editors: Trauma, ed 6, New York, 2008, McGraw-Hill,
pp 588–606.
10. Sise MJ, Shackford SR: Extremity vascular trauma. In Rich NM, Mattox
KL, Hirshberg A, editors: Vascular trauma, ed 2, Philadelphia, 2004,
Elsevier Saunders, pp 353–389.
11. Dente CJ, Feliciano DV: Abdominal vascular trauma. In Feliciano DV,
Mattox KL, Moore EE, editors: Trauma, 6th ed, New York, 2004,
McGraw-Hill, pp 738–757.
12. Whitesides TE, Heckman MM: Acute compartment syndrome: update on
diagnosis and treatment. J Am Acad Orthop Surg 4:209–218, 1996.
13. Frykberg ER, Vines FS, Alexander RH: The natural history of clinically
occult arterial injuries: A prospective evaluation. J Trauma 29:577–583,
1989.
14. Johansen K, Lynch K, Paun M, et al: Non-invasive vascular tests reliably
exclude occult arterial trauma in injured extremities. J Trauma 31:515–
522, 1991.
15. Kundson MM, Lewis FR, Atkinson K, et al: The role of duplex ultrasound
imaging in patients with penetrating extremity trauma. Arch Surg 128:
1033–1038, 1993.
16. Frykberg ER, Crump JM, Vines FS, et al: A reassessment of the role of
arteriography in penetrating proximity extremity: a prospective study.
J Trauma 29:1041–1052, 1989.
17. Dennis JW, Frykberg ER, Crump JM, et al: New perspectives on the man-
agement of penetrating trauma in proximity to major limb arteries. J Vasc
Surg 11:85–93, 1990.
18. Brenner DJ, Hall EJ: Computed tomography—an increasing source of
radiation exposure. N Engl J Med 357:2277–2284, 2001.
19. Sirinek KR, Levine BA, Gaskill HV, 3rd, et al: Reassessment of the role of
routine operative exploration in vascular trauma. J Trauma 21:339–344,
1981.
20. O’Gorman RB, Feliciano DV: Arteriography performed in the emergency
center. Am J Surg 152:323–325, 1986.
21. Morozumi J, Ohata S, Homma H, et al: Introducton of mobile angiogra-
phy into the trauma resuscitation room. J Trauma 67:245–251, 2009.
22. White PW, Gillespie DL, Feurstain I, et al: Sixty-four slice multidetec-
tor computed tomographic angiography in the evaluation of vascular
trauma. J Trauma 68:96–102, 2010.
23. Inaba K, Branco BC, Reddy S, et al: Prospective evaluation of multidetec-
tor computed tomography for extremity vascular trauma. J Trauma 70:
808–815, 2011.
24. Feliciano DV, Cruse PA, Spjut-Patrinely V, et al: Fasciotomy after trauma
to the extremities. Am J Surg 156:533–536, 1988.
 Imaging for the Evaluation
and Treatment of Vascular
6  Trauma
DAVID L. DAWSON
Historical Background
The use of imaging for the evaluation and treatment of vas-
cular injury has evolved in part due to the evolution of avail-
able technologies. Egas Moniz, a neurologist, is recognized as
the first to use arteriography in 1927. Subsequent to that,
surgeons performed arteriography via translumbar or open
surgical approaches. The technique for safe percutaneous
access and catheter exchange over a wire was developed in
1953 by Sven-Ivar Seldinger, a radiologist. Radiology became
the dominant specialty to perform angiography, but the
increased use of endovascular and image-guided therapies by
other specialties, including surgery, has broadened the use of
angiography.
The introduction of new imaging capabilities has changed
medical practice. For example, arteriography was once the
standard for nonsurgical evaluation of penetrating extremity
wounds without “hard signs” of vascular injury, but noninva-
sive tests became widely adopted with the introduction of
Doppler and ultrasound imaging options (coupled with the
observation that there were many negative arteriographic
examinations). Computed tomography (CT) scan was first
introduced to clinical practice in 1972, but it took more than
2 decades of innovation (including helical acquisition with
high-resolution multidetector arrays and the development of
image postprocessing capabilities) to develop systems that
could be used for detailed vascular evaluation. CTA is now a
standard for many vascular trauma applications.
Imaging Modalities
Angiography
Angiography is the direct imaging of any vascular structure
while arteriography and venography refer more specifically to
imaging of arteries or veins, respectively. Intravascular injec-
tion of contrast agents allows visualization of anatomy and
can be accomplished after direct vascular puncture and place-
ment of a needle or a catheter or through a catheter that is
manipulated into the desired position from a remote access
site. Angiographic techniques are standard parts of general,
trauma, and vascular surgical practice and are typically applied
in the resuscitation or operating room (OR). Diagnostic
studies and interventions are also performed by radiologists
in specialized imaging suites.
Transcatheter angiography provides the highest-resolution
imaging of most vascular beds. It provides anatomic defini-
44
tion and a road map for surgical planning or intervention
(Tables 6-1 and 6-2). Vascular injury associated with hemor-
rhage can be demonstrated by extravasation of contrast if
bleeding is brisk and ongoing, but it may not be visualized if
the bleeding is slow or under tamponade. Bleeding may also
be missed if the contrast bolus is too small, if it is injected into
a different vessel, or if image acquisition is terminated too
soon.
Angiographic interruption of vessel continuity usually
indicates vessel disruption or thrombosis. With sufficient con-
trast injected, distal reconstitution of flow (i.e., beyond the
disrupted segment) from collateral vessels can typically be
demonstrated. Imaging of distal arterial beds can be compro-
mised by hypoperfusion and vasoconstriction, typical mani-
festations of hemorrhagic shock. Vasospasm, with tapering of
arteries (sometimes to occlusion) and slow flow, can be more
prominent in young patients who have a greater degree of
vasomotor reactivity.
Early venous filling after intraarterial contrast injection
indicates the presence of an arteriovenous fistula. Traumatic
pseudoaneurysms result from focal disruption of arterial-wall
integrity, with blood flow contained by adventitia or sur-
rounding tissues. A pseudoaneurysm appears as a focal out-
pouching of contrast beyond the normal artery wall. Intimal
flaps and focal segments of nonocclusive thrombosis may be
detected as filling defects or lucencies within the contrast
column, sometimes with a delay in distal contrast flow.
Indications
Transcatheter angiographic evaluation is a useful intraopera-
tive tool for trauma patients who have been taken to the OR,
either to diagnose or to localize and treat vascular injury.
CTA, which is commonly used for evaluation of the injured
patient, can be limited by artifacts from metallic fragments
and occasionally by soft-tissue air or streak artifacts. In such
cases, conventional angiography may be necessary. Shotgun
or fragmentation wounds that have multiple metallic frag-
ments are often best evaluated with direct catheter angiogra-
phy. Arteriography is also indicated when a known vascular
injury requires detailed anatomic characterization to guide
management.
In a modern wartime experience at Walter Reed Army
Medical Center, military surgeons found that examination
and clinical assessment were not sensitive for detection of
delayed or occult arterial injuries from complex extremity
wounds. Routine arteriography in this patient group helped
identify lesions that were amenable to endovascular therapies.
 6  /  Imaging for the Evaluation and Treatment of Vascular Trauma 44.e1

ABSTRACT
Hemorrhage is the sine quo non of vascular trauma. Extrem-
ity bleeding is often obvious, while bleeding in the chest
or abdomen is identified at operation. When the diagnosis
is not obvious, imaging is needed to evaluate severity and
extent and to facilitate operative planning whether it is
open operation or endovascular therapy. Imaging options
depend on clinical circumstances, mechanism of injury, and
available resources. Transcatheter angiography has a role,
especially when endovascular therapy is to be considered.
Noninvasive modalities, such as Doppler pressure measure-
ments and duplex ultrasound (US), screen for vascular
injury or assess completed repairs, whereas computed
tomography angiography (CTA) is the workhorse due to its
availability and effectiveness. Triage of patients with extrem-
ity vascular injury is possible with physical examination and
with measurement of the injured extremity index (IEI).
However, CTA is the study of choice for extremity vascular
injury and for those injuries in the torso or cervical regions.1,2
Finally, surgeons should have knowledge to employ ultra-
sound and angiographic techniques to allow the diagnosis
vascular injury or the assessment of a vascular repair.

Key Words:  angiography,

embolization,
therapeutic/methods,
tomography,
x-ray,
computed,
ultrasonography,
Doppler,
duplex
 6  /  Imaging for the Evaluation and Treatment of Vascular Trauma 45

Table 6-1 Angiographic Findings With Common Vascular Injuries

Lesion Findings Notes
Arterial stenosis • Narrowing of contrast column • Intimal flap
• Delayed distal filling • Extrinsic compression
• Focal area of lucency with intimal flap • Spasm
• Smooth, tapered stenosis with spasm
Arterial occlusion • Occluded segment is not visualized. • Presence of prominent collaterals suggests
• Limited collateral may be present with acute occlusion. preexisting occlusion.
• Meniscus sign with embolic occlusion
Active hemorrhage • Contrast seen tracking into extravascular tissues • Patient may be hemodynamically unstable.
Pseudoaneurysm • Saccular aneurysm appearance • Extravasation may be active if pseudoaneurysm
• May have appearance of outpouching or bubble arising is not contained.
from artery wall
Arteriovenous fistula • Early filling of adjacent arteries • May have reduced or absent distal arterial flow
• Contrast moving into more central venous circulation

Table 6-2 Ultrasound Findings With Common Vascular Injuries

Lesion B-Mode Image
Arterial stenosis • Flap may be visualized
in superficial vessels.
Arterial occlusion • Echogenic material may
be visualized in lumen.
Pseudoaneurysm • Hypoechoic area
extrinsic to artery
• Moving blood may be
directly visualized in
pseudoaneurysm due to
increased echogenicity
of rouleaux aggregate.
Arteriovenous • Hematoma may be
fistula present near site of
injury.
Venous • Vein does not collapse
thrombosis with probe compression.
• Echogenic material in
vein lumen
Color Doppler
• Color aliasing (speckled
pattern)
• No color filling in
occluded segment
• Proximal or distal
collaterals may be seen.
• Flow extrinsic to artery
• Alternating red and
blue color (Ying-Yang
pattern)
• Color aliasing
• Tissue bruit (speckling
overlying tissue)
• Absence of flow
• No augmentation with
distal limb compression
Pulsed Doppler Notes
• Increase in peak systolic • Intimal flap
velocity (velocity ratio ≥2.0) • Extrinsic compression
• Spectral broadening • Spasm
• Absent flow or preocclusive • Distal pulse absent
thump • Arterial Pressure
• Damped waveform distal to Index <0.90
occluded segment
• Bidirectional to-fro flow in • Extravasation from
pseudoaneurysm or its actively bleeding
arterial connection vessel may not be
seen with
ultrasound.
• High-velocity jet at arterial
injury
• Spectral broadening
• Pulsatile flow pattern and
increased Velocity in
outflow vein
• Absence of flow • Calf veins may be
difficult to visualize.

Transcatheter arteriography should be considered in cases of
complex trauma involving high-energy, penetrating mecha-
nisms or wounding patterns in proximity to named vessels.3
Transcatheter angiography is often used as part of a strat-
egy for endovascular therapy of vascular injury. If angiogra-
phy demonstrates significant arterial injury in the acute
setting, low-pressure inflation of a compliant balloon may be
used for inflow occlusion. In such cases, endovascular tech-
niques may be used for hemorrhage control or even definitive
management of the injury.
Preparation
As intravascular contrast agents are used for transcatheter
arteriography and CTA and have the potential for nephrotox-
icity, it is important to be aware of risk factors for contrast-
induced nephropathy (CIN). This complication of contrast
use is usually defined as either a greater than 25% increase of
serum creatinine or an absolute increase in serum creatinine
of 0.5 mg/dL after use of a contrast agent. Factors associated
with increased CIN risk include hypotension (systolic blood
pressure <80 mm Hg), heart failure, advanced age (>75 years),
anemia, diabetes, preexisting renal insufficiency, and increas-
ing volume of contrast.
Baseline assessment of renal function is advised. Patients
with a history of allergic reactions to contrast may be pre-
medicated with intravenous corticosteroids and histamine
blockers. Avoiding use of large doses of contrast (as may
occur in patients undergoing multiple imaging procedures),
avoiding hypovolemia (a practical concern in many trauma
patients), and monitoring renal function are recommended.
There is limited evidence suggesting that the use of N-
acetylcysteine, theophylline, sodium bicarbonate, and statins
reduce incidence of CIN. Other interventions such as renal
replacement therapy, angiotensin-converting enzyme (ACE)
inhibitors, dopamine, and Fenoldapam do not have confirmed
benefits.4
46 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
Pitfalls and Danger Points
The risks of contrast angiography include the following:
• Vascular access site complications such as vessel
injury (e.g., hematoma, pseudoaneurysm, embolization,
thrombosis)
• CIN
• Anaphylactoid response to contrast
• Technical and time requirements
• False-negative studies
• Risks of ionizing radiation
Catheterization for angiography poses a small risk of iat-
rogenic vascular injury at the site of access. The risk of access
site injury is minimized with the use of ultrasound guidance,
direct operative exposure, and/or the initial use of small-
caliber access needles and wires (i.e., micropuncture devices).
Use of isoosmolar contrast (iodoxinol) and reduced volumes
of contrast reduce CIN risk. Allergies to shellfish do not
predict risk of a contrast reaction, but history of prior contrast
reactions may. As premedication to reduce risk of a reaction
requires steroid treatment hours before exposure, use of alter-
native imaging modalities may be needed if a patient is deter-
mined to be a high-risk for a reaction.
Diagnostic yield depends on the angiographic technique
used and the size and location of the vessel being imaged.
Injuries may be missed in high-flow vessels (such as the aorta)
due to rapid washout of contrast, or an injury may be missed
if imaging is performed in only a single plane. Improper
timing or an insufficient contrast bolus may result in poor
quality imaging, especially if the contrast is not directly
administered into the vessel of interest via selective or subse-
lective catheterization.
There is attendant risk with the use of ionizing radiation
(x-rays) for angiography, though the risks to most patients are
usually negligible. Surgeons and staff who have regular expo-
sure to X-rays during procedures should have specific training
in radiation safety and practices to minimize their own occu-
pational radiation exposures. It is important to note that
scatter from the patient is the main source of radiation to
which medical personnel are exposed. Practices to maintain
exposure to levels as low as reasonably achievable (ALARA)
should be mandated. Occupational radiation doses may be
affected by factors that cannot be readily modified, including
the size of the patient and the part of the body being imaged.
Specific actions to reduce radiation doses include reduction
of the time of exposure, increase of the distance from the
source of the scattered radiation, and effective use of shielding
(including lead garments and glasses).
Operative Strategy
There are three tiers of technical sophistication for trauma
arteriography, as follows: (1) simple “on table”; (2) portable
C-arm; and (3) fixed, floor, or wall-mounted system either in
an imaging suite (i.e., radiology department unit) or in a
traditional OR space. Resource availability and clinical cir-
cumstances typically dictate which approach is used. Patients
who are hemodynamically or physiologically unwell may need
to be taken immediately to the OR for management of their
injuries. Although modern trauma centers are moving to
building fixed imaging systems in their trauma or resuscitative
ORs, the advanced features associated with this capability may
not be available in most centers. As such, on-table angiogra-
phy using several single-picture x-rays or with a portable
C-arm using basic cine loop angiography (with or without
digital subtraction) is required.
In addition to diagnostic capability, endovascular tech-
niques can be used to manage hemorrhagic shock and certain
patterns of vascular trauma. Temporary deployment of an
endovascular balloon can provide proximal occlusion for
hemorrhage control during open operative resuscitation or
surgical management of vascular injuries.5 In selected cases,
transcatheter management can provide definitive therapy.6
Endovascular treatment with embolization is standard in the
management hemodynamically unstable patients with pelvic
fractures.7 The yield of angiographic identification of a pelvic
source of bleeding ranges from 43% to 78%. Sources of hem-
orrhage include injuries to major pelvic arterial and venous
structures, but a small vessel disrupted by fractures can bleed
substantially and transcatheter angiography often directly
identifies these sources of bleeding.
Angiographic findings indicative of vascular injury or
disruption include uncontained extravasation of contrast,
pseudoaneurysm or contained extravasation of contrast, arte-
riovenous fistulae, intimal tear, spasm, or occlusion. Selective
catheterization with flow-directed particulate embolization is
one method of controlling bleeding from small arteries at sites
of injury.8 Embolic coils may be deployed to proximally
occlude an injured vessel, but temporary occlusion alone may
be inadequate for pelvic trauma. As such, catheter-directed use
of inexpensive and readily available materials such as gelfoam
pledgets or slurry into the source vessels (Upjohn, Kalamazoo,
MI) can also be effective.
Traumatic injuries of the descending thoracic aorta are
preferentially managed with thoracic endovascular aortic
repair (TEVAR).9 Early experience with TEVAR highlighted
shortcomings of first-generation graft devices, which were
designed primarily to treat aortic aneurysms. However, current
devices are available in sizes that better fit a normal-caliber
aorta and that better appose to the distal transverse arch and
proximal descending thoracic aorta.
Covered stents and other endovascular strategies can be
used for extremity vascular injuries as well although their
benefit is less obvious in this setting.10 Because injuries in
patients who are in shock require immediate attention and
because extremity vascular injuries are often associated with
skeletal, soft-tissue, or other trauma, open surgical repair
remains more common than an endovascular approach.
However, endovascular techniques may be advantageous when
the extremity exposure is difficult or associated with consider-
able morbidity, as with injuries to the subclavian or axillary
arteries.
The operative strategy will vary with the situation. Factors
to consider include the patient’s hemodynamic and physio-
logic status, the level of interventional expertise, the quality of
the available imaging systems, and the inventory. Endovascu-
lar approach maneuvers may temporize or definitively control
hemorrhage (e.g., balloon catheter occlusion or emboliza-
tion). Some endovascular therapies may be delayed for hours
or even days (e.g., TEVAR for traumatic aortic injury [TAI]).
Surgeon training and experience, or the availability of an
interventional specialist, may determine whether an open sur-
gical therapy, an endovascular treatment, or a mixed or hybrid
approach is most practical. Simple endovascular maneuvers
for arterial access and pressure monitoring, hemorrhage
 6  /  Imaging for the Evaluation and Treatment of Vascular Trauma 47

control and resuscitation (i.e., resuscitative endovascular

balloon occlusion of the aorta), and arteriography should be
in the armamentarium of general and trauma surgeons.
Advanced endovascular techniques, subselective catheteriza-
tion, use of aortic endografts, and other complex maneuvers
require additional training and credentialing.
Most endovascular procedures for management of vascular
trauma or hybrid procedures that combine an open and endo-
vascular approach can be performed with portable or mobile
C-arm imaging systems. While imaging capabilities are often
superior in specialized fixed imaging suites or hybrid ORs,
basic diagnostic and therapeutic maneuvers are supported
with mobile fluoroscopy. When possible, more complex vas-
cular interventions should be performed where the best
imaging is available.
Angiography and simple endovascular interventions can be
performed with a relatively limited inventory of access needles,
wires, and sheaths as well as catheters, working wires, balloons,
and stents. As more complex interventions are contemplated,
it becomes necessary to include sufficient inventory to ensure
success. Supplies for involved interventions include aortic
endograft systems, large sheaths and compliant aortic bal-
loons, snares, microcatheters, embolic devices and agents, and
covered stents. It is also important to have an appropriate
range of sizes to meet a variety of needs. The availability of
anticipated supplies must be confirmed before embarking on
a plan of therapy. FIGURE 6-1  Intraoperative arteriography can confirm the presence
of and can localize vascular injuries in injured extremities. This example
Operative Technique demonstrates disruption and occlusion of the proximal left popliteal
artery in a patient with a comminuted supracondylar femur fracture.
On-table angiography requires rudimentary skills and equip-
ment. Contrast is injected by hand, and a single radiograph is
obtained. This technique may be of practical use during
operative management of extremity injuries when the pres- Use of mobile cine loop fluoroscopy also enables imaging
ence, location, or extent of an injury is uncertain (Fig. 6-1). It of selective catheterization maneuvers with shaped wires and
can also be used to evaluate the technical result of a vascular catheters. Mobile fluoroscopy provides the imaging needed for
repair. Vascular access is obtained, either in a percutaneous endovascular interventions such as embolotherapy or place-
manner or after open surgical exposure of the vessel. The ment of covered stents (Fig. 6-2). It is important to note that
artery in question is accessed using a needle, a butterfly set, a in order for fluoroscopy to be used effectively, the patient must
catheter, or a sheath placed using the Seldinger over-the-wire be positioned on a radiolucent operating table designed for
exchange technique. The imaging plate can be inserted in a imaging. Many of the endovascular tables float to allow easy
sterile wrap and positioned on the surgical field under a limb positioning of the patient by the surgeon while the fluoros-
to be imaged. copy unit remains stable. Alternately, the patient may be posi-
While this simple and useful arteriographic technique is tioned on any operating table that is radiolucent in the area
available for use in any situation, it has limitations. First, the to be imaged, as long as the C-arm can be positioned appro-
delay between contrast injection and imaging must be esti- priately. Many tables used for trauma surgery and orthopedic
mated, and errors in timing the transit of contrast to the area procedures, including the Jackson table, are radiolucent and
of interest will result in failure to opacify the vascular segment suffice for basic fluoroscopic imaging and endovascular inter-
of interest. Second, this technique provides only one image per vention. Use of a fixed table, however, requires the radiology
injection. Each individual image must be processed for evalu- technician to be more actively involved in C-arm positioning
ation of the adequacy of the technique, the projection, and the to center the field of view.
field of view. This can be time consuming. Fixed imaging systems refer to those that are wall, ceiling,
The limitations of single-image, on-table angiography can or floor mounted and that are integrated with a contrast man-
be overcome by the use of a portable C-arm fluoroscopy agement or injection system. Fixed imaging units are also
system with cine loop recording and digital subtraction capa- programmed with the table and projection screens to allow
bilities. By using cine loop angiography timing of imaging is efficient performance of catheter-based angiographic proce-
less critical as many images are recorded per second of any dures. Fixed imaging systems also provide larger imaging
single contrast injection. Digital subtraction angiography fields and magnification capability which provides striking
(DSA) provides superior definition of vessels as it removes the detail and resolution of select vessels of interest (Fig. 6-3).
image of overlying or surrounding structures from the vessels Centers that have invested in fixed imaging suites in the OR
of interest. Because of this advantage, DSA generally requires (i.e., hybrid ORs) also have a more extensive inventory of
less contrast than nonsubtracted angiography including that catheters, guidewires, interventional supplies, and accessory
of the aorta and visceral vessels. equipment.
48 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
A riography (DSA) provides better vascular definition. In this example,
B of bleeding and/or embolic or thrombotic complications.
C ities are needed to confirm that there has not been coverage
FIGURE 6-2  A, Impalement with a large knife with a trajectory
directed toward the aorta. B, Angiography shows the tip of the knife
overlying the descending thoracic aorta (left image); subtracted
images demonstrate extravasation of contrast. C, The placement of
a covered stent simultaneously with the withdrawal of the blade
achieved hemostasis without the need for open exposure.
The additional capabilities associated with a fixed imaging
unit come with a price because these rooms are expensive and
require specially trained radiology or cardiovascular technolo-
gists for operation. The physical space, the manpower require-
ment, and the baseline cost may limit the availability of fixed
imaging rooms for trauma in most centers today. However, as
diagnostic and therapeutic imaging for vascular trauma con-
tinues to prove more and more useful, the widespread avail-
ability of these hybrid ORs seems inevitable.
Postoperative Care
Removal of arterial catheters and sheaths should be done by
trained personnel following correction of coagulation abnor-
malities. Use of percutaneous arterial closure devices may be
relatively contraindicated if there is concern for a break in
A B
FIGURE 6-3  A, Arch aortogram (left anterior oblique [LAO] projec-
tion). B, Selective left subclavian arteriogram. Digital subtraction arte-
the aorta is uninjured, but blunt trauma has resulted in occlusion
of the left axillary artery, which is best demonstrated with selective
catheterization and direct contrast injection into the left subclavian
artery.
sterile technique, because the presence of foreign material may
increase risk of vascular infection. The arterial access site and
the extremity in which the access was obtained should be
monitored for evidence of injury following sheath removal.
Neurologic and extremity examinations should look for signs
Postprocedure laboratory tests should include serum creati-
nine and hemoglobin measurements.
Patients who have had interventions for hemorrhage
control or ischemia require careful observation to ensure that
there has been sustained technical success. Such patients
should be monitored with periodic physical examination, and
repeat measurement of hematocrit should be performed to
ensure the absence of bleeding. Stent grafts placed for trau-
matic aortic injury are evaluated with intraoperative imaging,
but postoperative pulse checks in the upper and lower extrem-
of the left subclavian artery or infolding of the graft resulting
in distal ischemia. CT angiography is generally used for endo-
graft imaging and surveillance in the days and weeks following
placement. It is important to note that for many endovascular
therapies, postprocedure noninvasive duplex ultrasound can
be used to confirm patency of treated segments. Duplex scans
are inexpensive and avoid the use of contrast, and radiation
and can be used for longer-term surveillance.
Complications
Inadequate hemostasis at the arterial puncture site leads to
bleeding and hematoma, and any communication between the
access artery and vein results in an arteriovenous fistulae. An
intimal flap, distal embolization, or de novo thrombosis at the
arterial access site can lead to varying degrees of limb ischemia
with or without neurologic deficit. As such, vascular access
sites should be carefully assessed for the presence of ecchymo-
sis, a mass, or bruit; and the distal limb should be examined
for signs of ischemia.
Ultrasound
Ultrasound imaging has many advantages that make it useful
in the care of the injured patient.11 It is noninvasive, relatively
 6  /  Imaging for the Evaluation and Treatment of Vascular Trauma 49
inexpensive, and increasingly available for point-of-care
examinations; and it can be used to image numerous organs
or regions of interest. Ultrasound is of particular utility in
evaluation of neck12 and extremity vessels following trauma13
due to their relative superficial location. Good image quality,
a selection of imaging modes and processing features, and a
range of transducer options are now available with most ultra-
sound systems. The introduction of compact systems for
point-of-care imaging has made it possible to perform ultra-
sound examinations in prehospital settings (including austere
or remote environments), as well as in a range of clinical set-
tings (including emergency rooms, ORs, and intensive care
settings). Imaging without the use of ionizing radiation allows
ultrasound systems to be used without concern for patient or
provider radiation exposure.
Early generations of compact, portable ultrasound systems
were substantially inferior to the larger, heavier, full-featured
systems used by radiology departments and vascular labo­
ratories. However, continued evolution in beam-forming
and image-processing technologies narrowed the capability
and quality gap between compact, highly portable devices and
traditional high-end systems. Size and mass of ultrasound
systems continues to decrease, making for a small device foot-
print, and acquisition costs for these systems continues to
decrease. As a result, use of point-of-care ultrasound systems
for trauma has become increasingly common.
B-mode imaging provides a 2-dimensional (2-D) gray scale
representation of tissue in the scan plane. Blood is hypoechoic.
The lumen of vessels will appear dark on B-mode imaging.
Real-time imaging can demonstrate dynamic features of
vessels, including the pulsatile expansion of arteries and col-
lapsibility of patent veins if external pressure is applied with
the probe (scan head) during the examination.
The resolution of B-mode ultrasound is related to the
transducer frequency and the depth of the imaged structure.
Resolution decreases with the use of lower-frequency trans-
ducers, which are used for the examination of deeper struc-
tures. When superficial anatomic features are evaluated with
high-frequency transducers, details of vessel walls can be seen,
including atherosclerotic plaque, dissection or intimal flap.
Conversely, use of B-mode ultrasound as a stand-alone modal-
ity may be insensitive for detection of vascular injury when
deeper vessels are evaluated. In these instances the only abnor-
mal finding may be a hematoma in proximity to the vascular
injury. Patient discomfort (or the agitation or the presence of
wounds), external fixators, or dressings may limit ultrasound
examinations for trauma.
Duplex scanning, with the addition of Doppler flow detec-
tion to the B-mode image, increases the utility of diagnostic
vascular ultrasound. Flow information from a specific point
of interest is displayed by the pulsed Doppler flow velocity
waveform. Color flow duplex scanning displays areas with
flow in color overlying the B-mode image of anatomy. Color
flow imaging assigns colored (rather than gray scale) pixels in
regions where moving tissue (e.g., blood) returns a Doppler-
shifted echo. The color flow display provides information
about the location of the flow, its direction, and its velocity.
In addition, a speaker provides an audio output of the Doppler
signal. With experience, users can learn to recognize charac-
teristic signatures of abnormal flow, including higher pitch
with elevated velocities; abrupt blunted signal proximal to an
occlusion; course sound with spectral broadening from tur-
bulence; or continuous low-resistance, diastolic flow associ-
ated with an arteriovenous fistula.
Use and interpretation of vascular ultrasound is integral to
the training of surgeons. The Registered Physician in Vascular
Interpretation (RPVI) credential of the Association of Regis-
tered Diagnostic Medical Sonographers (ARDMS) has been
established as a prerequisite for vascular surgery board certi-
fication. Vascular ultrasound may be useful for trauma care,
even if vascular specialty expertise is not available. Most radi-
ologists have training in general ultrasound, and many general
and trauma surgeons have skills with the use of point-of-care
ultrasound. Measurements of vessel size (detection of aneu-
rysms), detection of arterial or venous flow, assessment for
deep-vein patency, mapping of superficial veins, and other
simple evaluations can be learned without extensive formal
training.
Indications
Focused assessment with sonography for trauma or FAST as
part of the secondary survey of the injured patient may iden-
tify pericardial effusion and hemoperitoneum. The extended
FAST or eFAST includes ultrasound assessment of both tho-
races looking for pneumothorax. Although not part of the
traditional FAST, ultrasound can also confirm endotracheal
tube positioning and can provide an indication of intravascu-
lar volume by evaluating ventricular filling and the dimen-
sions of the inferior vena cava. A very practical aspect of
ultrasound in this setting is its ability to be repeated over time
to confirm initial impressions or show trends.
Duplex ultrasound scanning is indicated to detect or char-
acterize vascular injuries of the neck and extremities, espe-
cially where vessels are relatively superficial. Dissection,
stenosis, thrombosis, and arteriovenous fistula can all be dem-
onstrated using this imaging modality. Because duplex is safe,
inexpensive, and noninvasive, it is especially useful to confirm
a normal physical examination in patients who have injury
mechanisms that are associated with a risk of vascular injury,
such as penetrating trauma, posterior knee dislocation, hyper-
extension, and supracondylar fracture.
In most cases, the presence of an extremity vascular injury
can be excluded with a combination of physical examination
and noninvasive pressure measurement. Using continuous-
wave Doppler, the cuff occlusion technique measures the sys-
tolic blood pressure in the injured limb, which can be compared
to the pressure in the uninjured contralateral limb. An injured
extremity index of <0.90 suggests a flow-limiting arterial ste-
nosis or occlusion.14 Duplex scanning complements nicely a
measurement of the injured extremity index; however, in the
absence of clinically evident ischemia or bleeding, there is little
risk in delaying the duplex scan by hours or even days.
When minor vascular injuries are diagnosed, most may be
managed nonoperatively with expectation of spontaneous
healing. Injuries with low risk of late complications include
intimal injuries (intimal flap) that are associated with <50%
stenosis. The absence of a pressure gradient across the injured
segment (i.e., a normal injured extremity index) or a duplex
finding of peak systolic velocity increased by less than a factor
of two suggests the absence of a hemodynamically significant
injury. The noninvasive nature of duplex allows for serial
examination to confirm a benign injury outcome.
Severely injured patients are at risk for venous thrombosis
and pulmonary embolism.15 The presence of significant
50 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
injury causes thrombophilia (a procoagulant condition).
Duplex scanning is the diagnostic test of choice for the detec-
tion of venous thrombosis of the extremities. New unilateral
limb swelling is the best clinical sign that predicts deep vein
thrombosis (DVT), but clinical evaluation alone lacks the
sensitivity or specificity. Thus, duplex scanning to evaluate for
DVT is indicated when there are signs or symptoms of DVT
or to screen for DVT in asymptomatic high-risk patients.
Simple point-of-care testing should be aimed at probe com-
pression to verify that the popliteal and common femoral
vein collapse under manually applied pressure. With this
basic bedside maneuver, one can exclude the presence of a
major proximal limb DVT. To diagnose iliac vein thrombosis,
nonocclusive or limited segmental DVT, or calf vein throm-
bosis, a complete examination should be performed by a vas-
cular technologist.
As has been noted, the noninvasive and available nature of
ultrasound means that this imaging modality can be repeated
over time for surveillance or follow-up examination as needed.
For example, if limited thrombosis (e.g., isolated calf vein
DVT) is observed and is not treated with anticoagulation,
repeat duplex examination 5 to 7 days later may be used to
detect proximal thrombus progression. Intraoperatively, ultra-
sound can be useful for localization of vessel injuries and for
evaluation of technical results after repair of vascular trauma
(Fig. 6-4). Duplex can identify defects that may lead to early
thrombosis or late complications including abnormalities of
the intima at the site of vascular clamp placement (i.e., clamp
injury). Duplex can also detect flow-limiting stenosis at the
anastomosis of a vascular repair or the presence of intralumi-
nal thrombus. By detecting these injuries or technical defects
intraoperatively, surgical revision can be performed before
leaving the OR.
Preparation
No specific preparation is needed for most ultrasound exami-
nations. However, fasting before abdominal duplex may
reduce the amount of bowel gas that obscures the view of
deeply positioned abdominal, retroperitoneal, and pelvic
vessels.
Aorta
A B
FIGURE 6-4  A, A seat belt restrained 15-year-old girl injured in a car crash presented with a Chance fracture, a bowel injury, and a right lower
extremity ischemia. Intraoperative ultrasound imaging demonstrates patency of the aorta at the level of the inferior mesenteric artery. B, The
seat belt injury to the terminal aorta resulted in an extensive intimal tear, which is seen in this intraoperative transverse B-mode image.
Pitfalls and Danger Points
The hazards related to or limitations of ultrasound are negli-
gible but include the following:
• Results may be operator dependent.
• Tissue disruption, obesity, or edema may limit imaging.
• Ultrasound transmission through air is poor; imaging of
intrathoracic structures is limited; and bowel gas may
obscure abdominal and pelvic imaging.
• Bowel gas may be increased in nonfasting patients and in
trauma patients who have been ventilated with a mask
before intubation.
Strategy
Providers at the point of care can perform vascular-specific
examination or a technologist may perform an ultrasound
during the tertiary survey or at any subsequent step of a
patient’s care. Ultrasound can be used as a screening tool, to
detect injuries or vascular complications that are not evident
from clinical assessment. Examples of screening examinations
include evaluation of limbs with “soft” or no signs of vascular
injury that sustained mechanisms of trauma known to predis-
pose to vessel injury. Ultrasound can be used as a diagnostic
tool, either alone or in combination with other testing modali-
ties. Arterial disruption, intimal dissection or flap, thrombosis
and arteriovenous fistula can be definitively diagnosed using
ultrasound, especially in the extremities. If duplex is combined
smartly with thorough physical examination, additional
imaging such as CTA or angiography may be unnecessary. As
has been noted, duplex may complement other diagnostic
tests or maneuvers such as Doppler pressure measurements in
the initial screening of an injured extremity. In many cases, if
the initial examination is normal and there is no hard sign of
vascular injury, a more thorough evaluation with duplex can
follow on an elective basis.
The utility of ultrasound as a tool to guide invasive
procedures should not be overlooked. This modality has
become increasingly the standard to guide percutaneous
arterial or venous access and to help with localizing a vascu-
lar lesion during operative surgical management.16 Focal
Intima separated
from adventitia
 6  /  Imaging for the Evaluation and Treatment of Vascular Trauma 51
Bidrectional
“to-fro” flow
A
ATA
PTA
PA
B approach. The presence of intraabdominal fluid (blood) on a
Thrombus
Needle
C ultrasound. Imaging the vessel in a longitudinal scan plane
FIGURE 6-5  A, This patient presented 2 months after fasciotomy
with an increasingly symptomatic mass in the distal leg. Duplex scan-
ning shows a 2-cm pseudoaneurysm in the distal anterolateral leg.
The color and pulsed Doppler demonstrates the typical bidirectional
“to-fro” flow pattern seen with pseudoaneurysms. B, CT shows that
the pseudoaneurysm is separate from the anterior tibial artery, arising
from a branch vessel injury. C, US-guided thrombin injection for defini-
tive therapy.
pseudoaneurysms of extremity arteries may be managed with
US-guided thrombin injection, a technique that is commonly
used to treat iatrogenic femoral artery pseudoaneurysms, but
it can also be used for other arterial pseudoaneurysms (Fig.
6-5). Finally, ultrasound can be used for assessment of out-
comes, either during a procedure (when corrective action can
be taken if a technical defect is found) or later, if surveillance
is indicated.
Technique
The hand-held transducer (probe) transmits ultrasound
energy and receives reflected echoes. As air has high acoustic
impedance, a water-based gel is used for acoustic coupling
between the transducer and the skin for routine applications;
but blood or saline irrigation provides suitable coupling
during intraoperative use.
A transducer that is appropriate for the depth and the loca-
tion to be evaluated is selected. Deeper structures require the
use of lower ultrasound frequencies (1 to 5 MHz). High-
frequency transducers (6 to 12 MHz) provide better imaging
resolution, but with limited imaging depth. Transducer ele-
ments can be mounted in a curved or linear array to create a
sector or boxlike image. Phased array transducer can provide
a compact footprint, with a sectorlike scan. Probes designed
specifically for intraoperative use may have a T-shaped or
hockey-stick design to facilitate use in the operative field.
Transducers are typically designed to operate over a range of
frequencies (broadband) for greater versatility and better
imaging. Specifics of transducer design vary among manufac-
turers and systems used.
Vessels in the neck and extremities can be imaged directly.
Because air in the lungs and viscera interferes with ultrasound
transmission, ultrasound imaging to evaluate for truncal vas-
cular injury is limited. Subcostal and parasternal windows
allow for evaluation of the heart and pericardial sac, but the
thoracic aorta cannot be visualized with a transthoracic
FAST examination is indirect evidence of vascular disruption
or injury either of a main axial vessel or of those within the
hilum or parenchyma of a solid organ. Direct vascular exami-
nation of intraabdominal vessels is seldom performed in the
early phases of trauma evaluation and management (i.e., as
part of the FAST).
When ultrasound is used for procedural guidance or intra-
operative assessment, the transducer is sheathed in a sterile
sleeve. Acoustic coupling gel needs to be in the sleeve, with no
air gap or bubbles between the transducer face and the sleeve.
Sterile gel is used on the field for ultrasound-guided endovas-
cular procedures. Vascular access is facilitated with routine
ultrasound use for venous and arterial sites. During this
process, an 18- or 21-gauge needle can be observed or directed
into the vessel lumen with ultrasound. Needles with a stippled
surface may be more echogenic and easier to visualize with
allows the site of vascular entry to be selected, while changing
to a transverse image ensures that vessel entry is precisely at
the 12 o’clock position. Ultrasound imaging can also confirm
intraluminal positioning of catheters and guidewires.
There are some ultrasound imaging applications that
require specialized capabilities. Transesophageal echocardiog-
raphy (TEE) can be used to evaluate the thoracic aorta for
potential injury. TEE for trauma evaluations usually requires
general anesthesia and endotracheal intubation for airway
control. TEE may provide the initial diagnosis of thoracic
aortic injury (TAI) if a patient is taken immediately to the OR
for surgical stabilization, bypassing the CT scanner.
Intravascular ultrasound (IVUS) is an invasive technology
requiring vascular access, catheterization of a target vessel, and
introduction of an imaging catheter over a guidewire. The
aorta can be evaluated with an 8 French catheter over a 0.035-
inch wire. IVUS is not appropriate as a screening test, but it
can provide detailed morphologic information that can guide
the choice of therapeutic devices (stent grafts) for the endo-
vascular treatment of TAI.17 IVUS can be used to improve the
52 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
accuracy of sizing of aortic endografts for TEVAR as CTA may
underestimate aortic diameter, especially in the setting of
intravascular hypovolemia. IVUS allows real-time imaging
and diameter measurements in both systole and diastole while
the patient is on the OR table.
Postexamination Care
There are no specific postexamination care concerns.
Complications
Ultrasound is safe, is noninvasive, and is not associated with
any direct risk of complications. Tissue heating is negligible
with diagnostic ultrasound applications, and there is essen-
tially no risk of injury in typical clinical applications. The
primary risks associated with the use of diagnostic ultrasound
are the risks of interpretation errors.
Computed Tomography
Computed tomography (CT) is the workhorse imaging tech-
nology in contemporary emergency medicine and trauma
care including vascular trauma. Multidetector CT (MDCT)
with high-speed helical scanning has reduced imaging times
to minutes; and the availability of CT scanning has become
nearly ubiquitous, even in forward locations on the battlefield.
Data from a U.S. survey of nearly 100 million patients who
underwent CT scanning in emergency departments (EDs)
found CT use increased by 330% between 1996 and 2007.18
The best application of CT scanning in trauma is contro-
versial. In most institutions CT is routine for evaluation of
injuries to the brain, face, chest, abdomen, and pelvis, as well
as other skeletal injuries. However, recently some have recom-
mended more targeted use to avoid unnecessary health-care
costs and radiation-exposure risks. At the other end of the
spectrum, some advocate routine single-pass, whole-body CT
scanning (i.e., pan scan) for evaluation of those patients
having sustained significant injury. From the standpoint of
vascular trauma, contrast enhanced CT angiography can reli-
ably confirm and characterize clinically evident problems
(e.g., occluded extremity vessel with ischemia) and can also
detect subclinical injuries (e.g., asymptotic or minor TAI).19
Magnetic resonance imaging (MRI) and magnetic reso-
nance angiography (MRA) may be used in some centers as
alternatives to CT and CTA, with some potential advantages
from avoiding CT artifacts and radiation exposure. However,
MRI is not as readily available and has slower image acquisi-
tion; and there are more contraindications to its use, including
the presence of metallic implants. Also of practical impor-
tance, there are many pieces of medical equipment that may
not be compatible with use in the presence of a strong mag-
netic field.
Indications
The indications for CTA for evaluation of the injured patient
are broad. Any patient with a known or suspected vascular
injury may be a candidate for CTA, though CTA may not be
needed if there is sufficient information from clinical assess-
ment (i.e., hard signs of vascular injury). Additionally, other
noninvasive imaging modalities may suffice to make the
correct diagnosis of vascular injury and may allow for appro-
priate management.
Indications for CTA of the head and neck after blunt
or penetrating trauma include unexplained or incongruous
central or lateralizing neurological deficit. This modality is
also indicated for complex facial or mandible fractures, pen-
etrating injuries to the neck (zones I, II, and III), cervical spine
or spinal cord injuries, and thoracic injuries. CTA for sus-
pected arterial injuries of the neck without initial indications
for immediate operation allows characterization of lesions
such as partial or complete occlusion, pseudoaneurysm,
intimal flap, dissection, and arteriovenous fistula.20 With the
same examination, CT provides information about the cervi-
cal soft tissues, the aerodigestive tract, the spinal canal, and
the spinal cord. In cases of penetrating injuries, the bullet or
fragment trajectories and the locations of fragments may be
assessed (Fig. 6-6).
The most common indication for thoracic CTA for trauma
is evaluation of known or suspected TAI, usually in the setting
of high-energy deceleration injuries. CTA of the chest is also
useful in the setting of penetrating trauma with possible great
vessel injury.21 Chest x-ray findings that suggest TAI or other
vascular injury include a widened mediastinum, an apical cap,
and a displacement of the trachea, left main bronchus, or
nasogastric tube. However, a normal chest x-ray does not
exclude TAI. Blunt TAI has been characterized based on find-
ings on CTA as follows: type I, intimal flap; type II, intramural
hematoma; type III, pseudoaneurysm; and type IV, aortic dis-
ruption. This grading scheme separates those patients who
may be managed conservatively (type I) from those with
more-severe injuries (types II, III, and IV) that require opera-
tive or endovascular treatment (Fig. 6-7).
CT scanning of the abdomen and pelvis is an established
modality for the evaluation of patients after blunt trauma.
Standard imaging protocols are often employed, but contrast-
enhanced CTA provides additional information for the evalu-
ation of suspected vascular injuries that may not have been
clinically apparent or that lead to an immediate operation. For
example, the finding of a blunt abdominal aortic dissection or
of a visceral branch on CTA may not have been associated with
positive physical examination findings or clinical symptoms.
Most patients with truncal vascular injuries have associated
spine or spinal cord injury or injury to the viscera or solid
organs.22
The indications for CTA for the evaluation of extremity
trauma are similar to those for conventional arteriography.
However, the availability and diagnostic accuracy of CTA has
made it the imaging modality of choice in most centers.23
Adding extremity CTA to an already-planned scan of the
chest, abdomen, and pelvis adds little time or contrast but
does provide detailed information that may be particularly
useful in the polytrauma patient (Fig. 6-8). Studies of CTA in
the evaluation of extremity vascular trauma have demon-
strated high rates of sensitivity and specificity (90% to 100%).24
Preparation
Reliable intravenous access is needed for contrast administra-
tion. As previously stated, limiting the volume of iodinated
contrast agents (by limiting multiple diagnostic imaging pro-
cedures) and avoiding hypovolemia are recommended to
reduce CIN risk.
Pitfalls and Danger Points
Risks associated with CTA are similar to conventional arteri-
ography, but without the risks of arterial catheterization. CTA
hazards include the following:
 6  /  Imaging for the Evaluation and Treatment of Vascular Trauma 53

A B

C D
FIGURE 6-6  A, CT overview scan in AP projection demonstrates multiple metallic pellets from a shotgun. B, Metallic fragments create CT streak
artifacts that degrade imaging and interfere with postprocessing. C, Digital subtraction arteriography is useful after shotgun or blast injuries with
multiple fragments because there is a risk of significant injury to major arteries or branches. D, Arrows highlight locations of several pseudoan-
eurysms that appear as outpouchings from the artery.

Superior

Right Left

Inferior
FIGURE 6-8 CTA with 3-D reconstruction provides anatomic over-
view, demonstrating segmental occlusion of the left axillary artery.

FIGURE 6-7  Blunt aortic injury (BAI) of the descending thoracic aorta
from a motorcycle crash resulted in intimal disruption, pseudoaneu-
rysm, and mediastinal hematoma. Curved planar reformatting (CPR)
of the CT angiography is demonstrated on the right.
54 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
• Contrast induced nephropathy (CIN)
• Anaphylactic reaction to contrast
• Contrast extravasation outside of the vein
• Ionizing radiation
• Venous injuries may be missed if single-phase acquisition
is performed.
• Diagnostic (interpretation) errors
• Imaging limitations due to artifact
• Movement of the patient from a treatment area to the CT
imaging suite
From a population-based perspective, the risk of radia-
tion exposure from diagnostic CT scans is considerable.
However, on an individual basis, radiation-associated risks
are low and usually not major considerations in the context
of a potentially life- or limb-threatening vascular injury. The
most practical way to keep radiation exposures as low as
reasonably achievable in trauma care is to perform only
those studies needed for patient management. Of note,
overall radiation dose may be decreased with the initial per-
formance of a quality CTA, as its high diagnostic yield may
obviate the need for other radiographic studies. Technology
advances (detector design, image-processing systems) have
decreased radiation dose and other procedure-specific
changes (adjustments in tube current [mA], tube potential
[kVp], gantry rotation time, helical pitch) can further limit
exposure. Other pitfalls of CTA include sources of artifact
that can degrade imagine quality or one’s ability to interpret
the image.25
In evaluation of the trauma patient, motion can also
degrade image quality, creating black or white bands, dark
spots, loss of resolution, or anatomic distortion. Strategies to
reduce motion artifact include fast scanning, gating (e.g., to
reduce motion artifact from the cardiac cycle), tube align-
ment, corrective reconstruction, and postprocessing tech-
niques. The presence of high-density foreign materials can
also be problematic. Metal can create streak artifacts by causing
the detectors to operate in a nonlinear response region, and
even small fragments can create a star-pattern artifact. Patient
body habitus also affects image quality with more image dis-
tortion occurring in larger patients.
Performance of a CT scan relies on geometric precision
and measurement quality. Inaccurate geometry, inaccurate
alignment of the x-ray tube with the detectors, or incorrect
data can produce artifacts and blurring that limit spatial
resolution. Detector calibration errors and balance can also
occur detracting from image quality. Artifacts caused by
equipment malfunction can be eliminated by repair or pre-
ventive maintenance.
Beam attenuation is proportional to the average attenua-
tion coefficient in each volume element (voxel). Resolution
may be degraded when tissues with different absorption den-
sities are in the same voxel. Partial-volume effects are mini-
mized by the use of thin sections or “cuts” and by the selection
of a section that lies in the center of the object of interest for
attenuation measurements. Beam-hardening artifacts result
from preferential absorption of low-energy photons from the
x-ray beam. The effect may be pronounced in areas of high
attenuation, such as bone.
Specific to CTA, inadequate vascular opacification due to
poor delivery of contrast or circulatory delays in patients in
shock may render CT angiography (arterial or venous) non-
diagnostic. Timing delays may be most problematic for CTA
of distal extremity vessels or for more central venous
structures.
Finally, as experienced clinicians are aware, transporting
critically ill or injured patients to an imaging suite is associ-
ated with risks. Transport of patients form the resuscitation,
OR, or intensive care unit may require suspension of specific
therapies and may initiate a transition of care. Additionally,
movement of a seriously injured patient to the CT scan area
and bed may result in interruption of cardiovascular monitor-
ing and may increase the risk of displacement of lines or tubes.
Strategy
CT scanning has become nearly ubiquitous in the manage-
ment of the severely injured patient, with demonstrated effi-
cacy for detection of occult injuries and characterization of
known injuries. Standard imaging protocols detect most vas-
cular injuries, but dedicated CT angiographic studies are often
needed to better characterize some patterns of vascular
trauma, especially those to medium and smaller-sized vessels.
Technique
CT angiography is performed in targeted regions with IV
contrast infusion. A typical contrast bolus volume is 100 mL
with an infusion rate of 4 mL/s. The imaging delay is typically
estimated, but most systems will time the arterial phase acqui-
sition with bolus tracking, starting when the contrast arrives
at a preselected region of interest. A technologist performs CT
scans, typically with predefined protocols. The technologist
positions the patient, administers contrast materials, prepares
and operates the CT scan equipment, then sends image data
in Digital Imaging and Communications in Medicine
(DICOM) format to the picture archiving and communica-
tion system (PACS).
Conventional CT displays show the density of the imaged
tissue (the degree to which x-rays are attenuated) in gray scale.
CT densities are measured in Hounsfield units (HU), which
range from −1024 to +3071. As the human eye can discern
only 30 to 40 gray scale levels, the image display can be varied
to include HU ranges across a small or broad window, cen-
tered on a particular level of interest. Modern MDCT scanners
have isotropic resolution, with all three dimensions of the
individual image volumes (voxels) being the same (X = Y =
Z). Because of this, the CT dataset can be considered a three
dimensional (3-D) representation of the image volume
scanned, and these data can be displayed in several ways. Post-
processing of the volumetric imaging data from CTA can
greatly facilitate image interpretation.
Some postprocessing may be done automatically, but tech-
nologists, radiologists, and other clinicians are able to manip-
ulate the dataset to yield the views and projections of specific
diagnostic interest. Postprocessing techniques can create 2-D
or 3-D images. The use of dual energy levels (kVp) during
imaging can facilitate removal of bone from images or can
help distinguish calcium from contrast-enhanced blood. The
selection of the thickness of the imaging slice through the
imaged volume can be selected (though it cannot be thinner
than the collimation width used for imaging). Thin-slice
reconstructions have better edge definition, better high-
contrast resolution, and fewer partial-volume artifacts at the
cost of greater noise and poorer low-contrast resolution.
Two-dimensional CTA postprocessing techniques include
multiplanar reformatting (MPR) of images, as well as curved
 6  /  Imaging for the Evaluation and Treatment of Vascular Trauma 55
reformatting. MPR displays volumetric data in orthogonal
planes (axial, sagittal, coronal), as well as in oblique planes
selected and manipulated by the user. Samples through the
volume dataset can be thin slices or thick slabs. Curved refor-
mats (CR) are used to view vessels over their entire course,
which facilitates evaluation of segment patency or stenosis.
Three-dimensional postprocessing includes maximum
intensity projections (MIP) and surface shaded volume ren-
dering (VR). With MIP displays, the highest attenuation along
the line projected through the image is brought forward. MIP
effectively displays structures with high HU, such as contrast-
filled vessels. VR images are helpful for understanding complex
structural relationships, and many surgeons prefer this view
for operative planning. No additional information is provided
by VR. In fact, some information may be lost as vessels without
sufficient contrast may not be displayed. Smaller imaging
increments (with overlap of adjacent slice acquisition) provide
for better 3-D rendering.
CTA signs of arterial trauma in the extremities include
extravasation of contrast (i.e., pseudoaneurysm), narrowing
(i.e., stenosis), loss of opacification (i.e., occlusion), and rapid
venous contrast (i.e., arteriovenous fistula).
Postexamination Care
There are few specific concerns after CTA, although hypovo-
lemia should be avoided. Urine output and renal function
should be monitored.
Complications
CT is safe, is noninvasive, and is associated with few direct
risks of complications. Complications of CT are primarily
those associated with contrast administration (extravasation,
renal failure, allergic-type reactions). Other risks associated
with CT CTA are those associated with errors in image
interpretation.
REFERENCES
1. Patterson BO, Holt PJ, Cleanthis M, et al: London Vascular Injuries
Working Group. Imaging vascular trauma. Br J Surg 99(4):494–505, 2012.
2. Fox N, Rajani RR, Bokhari F, et al: Eastern Association for the Surgery of
Trauma. Evaluation and management of penetrating lower extremity
arterial trauma: an Eastern Association for the Surgery of Trauma practice
management guideline. J Trauma Acute Care Surg 73(5 Suppl 4):S315–
S320, 2012.
3. Johnson ON, 3rd, Fox CJ, White P, et al: Physical exam and occult post-
traumatic vascular lesions: implications for the evaluation and manage-
ment of arterial injuries in modern warfare in the endovascular era.
J Cardiovasc Surg (Torino) 48(5):581–586, 2007.
4. Kwok CS, Pang CL, Yeong JK, et al: Measures used to treat contrast-
induced nephropathy: overview of reviews. Br J Radiol 86(1021):20120272,
2013.
5. Morrison JJ, Rasmussen TE: Noncompressible torso hemorrhage: a
review with contemporary definitions and management strategies. Surg
Clin North Am 92(4):843–858, vii, 2012.
6. Arthurs ZM, Sohn VY, Starnes BW: Vascular trauma: endovascular man-
agement and techniques. Surg Clin North Am 87(5):1179–1192, x–xi,
2007.
7. Scott R, Broadwell SR, Ray CE: Transcatheter embolization in pelvic
trauma. Semin Intervent Radiol 21(1):23–35, 2004.
8. Niola R, Pinto A, Sparano A, et al: Arterial bleeding in pelvic trauma:
priorities in angiographic embolization. Curr Probl Diagn Radiol 41(3):
93–101, 2012.
9. Azizzadeh A, Charlton-Ouw KM, Chen Z, et al: An outcome analysis of
endovascular versus open repair of blunt traumatic aortic injuries. J Vasc
Surg 57(1):108–114, 2013.
10. Katsanos K, Sabharwal T, Carrell T, et al: Peripheral endografts for the
treatment of traumatic arterial injuries. Emerg Radiol 16(3):175–184,
2009.
11. Gaitini D, Razi NB, Ghersin E, et al: Sonographic evaluation of vascular
injuries. J Ultrasound Med 27(1):95–107, 2008.
12. Larsen DW: Traumatic vascular injuries and their management. Neuro-
imaging Clin N Am 12(2):249–269, 2002.
13. Zierler RE, Zierler BK: Duplex sonography of lower extremity arteries.
Semin Ultrasound CT MR 18(1):39–56, 1997.
14. Johansen K, Lynch K, Paun M, et al: Non-invasive vascular tests reliably
exclude occult arterial trauma in injured extremities. J Trauma 31(4):515–
519, Discussion 519–22, 1991.
15. Meissner MH: Deep venous thrombosis in the trauma patient. Semin
Vasc Surg 11(4):274–282, 1998.
16. Jackson MR, Brengman ML, Rich NM: Delayed presentation of 50 years
after a World War II vascular injury with intraoperative localization by
duplex ultrasound of a traumatic false aneurysm. J Trauma 43(1):159–
161, 1997.
17. Azizzadeh A, Valdes J, Miller CC, 3rd, et al: The utility of intravascular
ultrasound compared to angiography in the diagnosis of blunt traumatic
aortic injury. J Vasc Surg 53(3):608–614, 2011.
18. Kocher KE, Meurer WJ, Fazel R, et al: National trends in use of computed
tomography in the emergency department. Ann Emerg Med 58(5):452–
462, 2011. PubMed PMID: 21835499.
19. Tillou A, Gupta M, Baraff LJ, et al: Is the use of pan-computed tomogra-
phy for blunt trauma justified? A prospective evaluation. J Trauma 67(4):
779–787, 2009.
20. Núñez DB, Jr, Torres-León M, Múnera F: Vascular injuries of the neck
and thoracic inlet: helical CT-angiographic correlation. Radiographics
24(4):1087–1098, Discussion 1099–100, 2004.
21. Steenburg SD, Ravenel JG, Ikonomidis JS, et al: Acute traumatic aortic
injury: imaging evaluation and management. Radiology 248(3):748–762,
2008.
22. Mellnick VM, McDowell C, Lubner M, et al: CT features of blunt abdomi-
nal aortic injury. Emerg Radiol 19(4):301–307, 2012.
23. Pieroni S, Foster BR, Anderson SW, et al: Use of 64-row multidetector
CT angiography in blunt and penetrating trauma of the upper and
lower extremities. Radiographics 29(3):863–876, 2009. doi: 10.1148/
rg.293085517. Review. PubMed PMID: 19448121.
24. Miller-Thomas MM, West OC, Cohen AM: Diagnosing traumatic arterial
injury in the extremities with CT angiography: pearls and pitfalls. Radio-
graphics 25(Suppl 1):S133–S142, 2005.
25. Al-Shakhrah I, Al-Obaidi T: Common artifacts in computerized tomog-
raphy: a review. Appl Radiol 32(8):25–30, 2003.
 Damage Control and
Immediate Resuscitation for
7  Vascular Trauma
TIMOTHY HODGETTS
Introduction
Hemorrhage results from disruption of the blood vessel wall
(i.e., vascular trauma). Early and effective management of this
injury including control of the bleeding and replacement of
blood volume are imperative for survival. The wise surgeon
understands that recent advances in the field make proper
resuscitation every bit as important as any operative maneuver
to expose and control a blood vessel or intricately reconstruct
a vascular injury. Without knowing and adhering to this
modern approach to resuscitation, the patient will be dead or
needlessly compromised.
Hypovolemia from inadequately controlled hemorrhage
has been identified as a leading cause of avoidable death in
both the prehospital and in-hospital civilian settings.1-2 In the
wartime environment, where explosion-related and gunshot
wounds predominate, the extremities are the most commonly
injured body regions.3-5 While death from extremity hemor-
rhage has been a leading cause of death historically, the
modern broad distribution and appropriate use of tourni-
quets and topical hemostatic agents have reversed this trend.
A landmark analysis of cause of death during a decade of war
in Afghanistan and Iraq reported that noncompressible bleed-
ing in the torso (i.e., thorax, abdomen, pelvis) was the most
frequent cause of potentially preventable death (67%), while
mortality from extremity hemorrhage was relatively uncom-
mon (14%).3
As discussed in Chapter 8, the term “potentially prevent-
able” death refers to mortality occurring in those who had no
lethal head or cardiac wounds or body disruption from explo-
sive injury. In effect, such individuals died from uncontrolled
bleeding and unmitigated hemorrhagic shock. The impor-
tance of coagulopathy following vascular trauma and hemor-
rhage has become more apparent and has influenced a
profound change in military medical strategy of when blood
products are first administered, the ratio in which they are
administered, how coagulopathy is dynamically monitored,
and how product replacement is tailored to the need. These
changes, which have substantial potential for strategic impact
on national blood product usage if adopted from military
experience, are highlighted in this chapter.
It is now acknowledged that surgery does not follow resus-
citation but is an intrinsic part of resuscitation.6 This chapter
explains how a trauma team and a hospital can be optimally
configured to facilitate rapid surgical intervention for non-
compressible hemorrhage that causes critical hypovolemia.
This requires working across traditional medical boundaries,
56
whether these boundaries are physical or cultural. Operative
intervention, open or endovascular, is not always required as
part of resuscitation following vascular trauma, particularly
in the setting of blunt trauma and closed injuries (e.g., high-
grade, solid organ injury). In these scenarios initial manage-
ment is more often directed at detailed diagnosis and
nonoperative stabilization. The challenge in the hospital lies
in staff being able to identify those patients who demand rapid
operative intervention and in the facility being flexible to
respond. The UK’s traditional network of district general hos-
pitals (with relatively low trauma workload that is principally
of blunt injury) was a model that responded poorly to the
need for immediate surgical intervention. This structural dis-
advantage has been remedied by emergence of regional major
trauma centers in the United Kingdom, stimulated by evi-
dence of nationwide systemic underperformance in 2007.7
This chapter will focus unapologetically on the trauma
team and hospital approach to vascular trauma and resuscita-
tion. However, the chapter will introduce important and
recent prehospital developments (which will be more com-
pletely described in Chapter 15 by Blackbourne and Butler)
that are targeted at controlling bleeding and minimizing coag-
ulopathy. Resuscitation end points are suggested in this
chapter; these can provide a handrail in a complex clinical
scenario. The ethics of hospital-based resuscitation are also
covered (e.g., when it may not be appropriate to star,
and when it is appropriate to stop), recognizing that these
decisions are more pressing when resources (clinicians,
operating-theater capacity, intensive-trauma-unit [ITU]or
intensive-care-unit [ICU] capacity, blood products) are
constrained.
Definitions
Damage control resuscitation (DCR) is a relatively new term
that reflects advances in combat casualty care made in the wars
in Afghanistan and Iraq. This practice has evolved as an over-
arching concept that draws together all those interventions,
including operative intervention, that aim to reduce bleeding
from vascular disruption, to optimize oxygenation, and to
improve outcome. It therefore starts with first aid measures
(including the use of a tourniquet or topical hemostatic agent)
rendered at the point of injury and finishes with the postop-
erative management of coagulopathy on the intensive care
unit. In this context, damage control resuscitation spans the
spectrum of vascular trauma management. DCR is formally
defined as “a systemic approach to major trauma combining
 7  /  Damage Control and Immediate Resuscitation for Vascular Trauma 56.e1

ABSTRACT
Vascular disruption followed by hemorrhage is a common
cause of early avoidable death following trauma. Damage
control resuscitation (DCR) is an overarching concept that
encompasses all efforts from point of injury through
damage control surgery (DCS) and intensive care. The aims
of DCR are to arrest bleeding, to optimize oxygenation,
and to improve survival. The wise surgeon understands that
knowing and adhering to the principles of DCR after major
vascular trauma is as important as choosing and perform-
ing the best or most-intricate vascular reconstruction. The
concept of DCR has developed in parallel with the advances
in contemporary combat casualty care, now being trans-
ferred into civilian management of vascular trauma. These
advances include a change in the paradigm of initial assess-
ment and treatment (the addition of C or catastrophic
hemorrhage to the traditional ABCs), the introduction of
topical hemostatics to control external bleeding, and pro-
found changes in the use of blood products to manage
coagulopathy. As a precursor to Chapter 8, Noncompress-
ible Torso Hemorrhage by Morrison and DuBose, this
chapter focuses on the hospital approach to resuscitation
following vascular trauma and hemorrhage, drawing out
recent advances in this arena. Resuscitation end-points are
given, where these can provide a handrail in a complex
clinical scenario. The ethics of resuscitation at hospital are
also covered recognizing that these decisions are more
pressing when resources are constrained in the field hospi-
tal or wartime environment.

Key Words:  damage control resuscitation,

hemostatic resuscitation,
horizontal resuscitation,
vertical resuscitation,
2-D resuscitation,
3-D resuscitation,
and ethics of resuscitation
 7  /  Damage Control and Immediate Resuscitation for Vascular Trauma 57
the <C>ABC (catastrophic bleeding, airway, breathing, circu-
lation) paradigm with a series of clinical techniques from
point of wounding to definitive treatment in order to mini-
mize blood loss, maximize tissue oxygenation, and optimize
outcome.”8
Damage control surgery (DCS) therefore fits within DCR.
Specifically, DCS has come to mean a time-limited surgical
procedure (i.e., abbreviated operation) where the imperative
is the minimal intervention to save life and limb before hypo-
thermia, coagulopathy, and acidosis demand intensive care or
result in demise. Specific aspects of damage control surgery as
they relate to the management of vascular trauma are dis-
cussed in Section 4.
In contrast to damage control surgery, it is incorrect to
consider DCR a time-limited, resource-limited, or intervention-
limited phenomenon; in fact, the opposite is true. DCR incor-
porates prehospital intervention (including blood-product
administration), massive transfusion immediately on arrival
at the hospital (see Hemostatic Resuscitation in this chapter)
and consultant-based, multidisciplinary team resuscitation
in the operating theater. (See the discussion on three-
dimensional [3-D] resuscitation later in this chapter.) Initially,
“damage control” was a maritime term that related to the
emergency control of situations that may risk the sinking of a
ship. In this respect, DCR incorporates a patchwork of inter-
ventions that collectively provides an effective plug to blood
loss (mechanically and hematologically), thereby keeping the
patient “afloat.”
Resuscitation Paradigms
The American College of Surgeons’ Committee on Advanced
Trauma Life Support (ATLS) program has provided an inter-
national standard for trauma resuscitation for almost 30
years.9 This is underpinned by the mantra of ABC—airway,
breathing, and circulation—with a strong emphasis on con-
comitant cervical spine control following severe blunt trauma.
Although a raft of parallel specialist resuscitation programs
have been developed (e.g., for burns, children, neonates), the
ABC paradigm has endured.
Historically, medicine advances in war and 21st-century
conflicts in Iraq and Afghanistan have supported this truism,
with particular respect to resuscitation. What has been chal-
lenged is the ABC paradigm; and, for the military, this has
been replaced by <C>ABC, where <C> stands for “catastrophic
hemorrhage” or “control of catastrophic hemorrhage” from
vascular disruption.10 This change concentrates the effort on
stopping external bleeding within the first few minutes of
injury and empowers those at the point of injury with skills
and equipment. This new paradigm has resonated in a change
of approach from first aid through hospital-based resuscita-
tion and has driven incremental amendments to organization,
guidelines, training, and equipment.11 While it is difficult to
evaluate the impact of change at any given level in this chain
of care, there is robust evidence of the systemic impact of these
strategies in reducing preventable death from trauma (i.e.,
producing a cohort of unexpected survivors).12 <C>ABC is
therefore working in the setting of wartime vascular trauma
and hemorrhage to improve outcomes. Furthermore, there is
increasing sentiment and evidence that aspects of these hem-
orrhage control and resuscitation strategies are translating to
care of injured civilians.13
Horizontal Versus Vertical
Resuscitation
The ATLS material teaches a prioritized, linear approach to
resuscitation for the clinician forced to work in isolation:
airway with cervical spine control, then breathing, then circu-
lation. This vertical approach poorly reflects the reality in
most hospitals where resuscitation is team based, that is, where
multiple priorities are managed in parallel or in a horizontal
manner. The patient who needs anesthetic as part of manag-
ing a compromised airway (A) first needs an intravenous
cannula inserted (C) in order to administer the necessary
medication and may well require concomitant preparation for
insertion of a chest drain (B) to treat a pneumothorax that
would otherwise worsen and cause tension physiology once
positive pressure ventilation began.
A horizontal approach to successful resuscitation requires
leadership. In many countries, trauma team leadership is
provided by a surgeon; in the United Kingdom, the norm is
an emergency physician. The background of training is less
important than the required judgment that stems from expe-
rience, the interpersonal skills to coordinate multidisciplinary
team members and the authority to make decisions that
affect how the patient is to be investigated and treated. The
type of leadership will vary with the experience of the team.
An inexperienced team needs to be managed directly with
clear and authoritative instruction, whereas an experienced
team benefits more from a coach or supporter. Rarely, a
team may be so well rehearsed that individuals need no
direction and the team is self-managing: one fairly appropri-
ate analogy is the required coordination of a Formula 1 pit
crew. In some instances the team leader may become more of
a mentor who will step back from the specific steps occurring
within the resuscitation. This scenario is particularly useful
when there are multiple casualties and where the consultant
physician is able to manage competing priorities related to
diagnostic imaging, procedures or interventions, and patient
disposition.
Three-Dimensional Versus
Two-Dimensional Resuscitation
Even though a team-based approach removes the requirement
for a stepwise, linear resuscitation, the overall process for the
management of vascular trauma is often linear or two-
dimensional (2-D). Specifically, there is an initial assessment
and treatment in the emergency department (ED); then
imaging, often in a separate location; followed by operative
intervention (DCS) and stabilization in an intensive care unit.
For the sake of efficiency, casualties should flow in one direc-
tion; but experience demonstrates that, on occasion, patients
return to the ED after imaging to await disposition, be it in
the operating theater, in the intensive care unit, or in the
ward.
Three-dimensional resuscitation is a concept that has been
developed in the deployed military hospital and in select civil-
ian trauma centers. In this scenario, advanced notification
from the field or en route care platform allows the team leader
to identify the small number of patients who will benefit
from direct transfer from the ambulance or helicopter to the
operating theater. In the wartime setting, these patients are
often injured from explosive events, have single or multiple
58 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
amputations or have torso injuries and are in pending cardio-
vascular collapses from hypovolemia. Three-dimensional
resuscitation begins with the trauma team assembling in the
operating theater. Universal donor red cells (O negative) and
plasma (AB positive) are primed for administration to the
patient using a rapid transfusion device with or without a
warming mechanism. Blood-component replacement therapy
is guided by thromboelastography (TEG) undertaken in
the operating theater. Complications of massive transfusion
(hyperkalemia and hypocalcemia) are anticipated, proactively
monitored with a handheld analyzer, and aggressively cor-
rected. Resuscitation starts as soon as the patient arrives and
continues through induction of anesthesia and performance
of procedures to augment resuscitation (i.e., resuscitative
aortic occlusion) and surgical hemostasis. This approach com-
bines ED resuscitation with imaging, surgery, and early inten-
sive care in one location to address vascular disruption,
hemorrhage, shock, and coagulopathy. The configuration of
the British field hospital in Afghanistan, where a critical
patient may turn left into the main resuscitation bay or right
into the adjacent operating theater, has led to this process
being referred to as “right turn resuscitation.”14
Preparation
It is an adage that “prior planning and preparation prevents
poor performance.” A trauma team that has taken time to
prepare will defuse the anxiety during a complex resuscita-
tion and will reduce the direct management needed by the
team leader. Preparation includes assembling the trauma
team, donning protective equipment, assigning roles, draw-
ing up medications, anticipating necessary procedures, and
smoothing the transition to the next stage of treatment.
A list of common pitfalls within preparation—and their
consequences—is provided in Box 7-1.
There is a difference of opinion as to when the trauma team
should be notified before patient arrival. Activation criteria
are generally based on mechanism (e.g., ejection from vehicle),
anatomy of injury (e.g., penetrating torso trauma), and physi-
ological derangement (e.g., tachypnea, tachycardia, hypoten-
sion). Local variations to criteria may need to be developed
taking into account unique patterns of severe injury prone to
be seen at a given medical facility (e.g., “rolled over by horse”
for a hospital close to a racetrack or equestrian event). Team
members may prefer to respond at the last minute to minimize
time waiting for the patient. However, time spent in prepara-
tion is rarely wasted. In the author’s experience, if a significant
injury is suspected, the trauma team should be notified before
or at the time the ambulance (land, air) departs the point of
injury. Group messages that detail injuries and/or time of
arrival allow team members to make a judgment on their
speed of response. However, too much speculation on severity
of injury or a casual response by members may undermine
the team leader’s effective assignment of duties and his or her
ability to establish a good team dynamic (e.g., until the anes-
thetist arrives, someone else must be assigned to manage the
airway).
The first action for trauma team members is to don per-
sonal protective equipment (PPE). Ideally this should be done
at the door to the resuscitation room before entering. Minimal
standards are gloves, a lead gown, and a plastic apron; and eye
protection is desirable. Tabards that identify the functional
Box 7-1 Common Pitfalls in Preparation
1. Failure to call the trauma team early. This leads to
inadequate time to prepare equipment and drugs and adds
avoidable stress within the team dynamic.
2. Failure to assign roles. This causes duplication of effort
and inefficiency in the resuscitation; tasks may be over looked
(e.g., sending blood for crossmatch).
3. Failure to draw up anesthetic medications before the
patient arrives. This distracts the anesthetist from
managing and securing the airway.
4. Failure to order blood products. If there are prehospital
signs of shock, order the universal donor red cells and
plasma. Crystalloid has no oxygen-carrying capacity or
clotting factors!
5. Failure to preload the chest x-ray plate. The resuscitation
will be a scrum, and the radiographer will struggle to position
the CXR plate and the boom of the x-ray machine. The CXR
plate could be positioned before the patient arrives.
6. Failure to don personal protective equipment (PPE).
Most commonly, members fail to wear a lead gown, which
slows performance of radiographs while they race to don this
protection after the fact. This approach also interrupts
performance of necessary procedures.
7. Failure to anticipate. This leads to avoidable stress, but
more importantly it may lead to avoidable critical failure.
8. Failure to stop and listen to MIST (mechanism, injuries
[found and suspected], signs [physiological], treatment). This
is the final step before treatment. The team should pause and
listen to the MIST handover from the paramedic (takes 20
seconds) lest key information be forever lost. The only
exception is when there is catastrophic hemorrhage, airway
obstruction, or cardiopulmonary resuscitation (CPR) in
progress. In these cases, the treatment should be continued
but the paramedic should be asked to wait for the MIST.
role of team members may be especially helpful in centers
where team composition regularly changes. These cards,
posters, or vests can also be color coded (e.g., red for the team
leader).
The trauma team leader should assign roles according to
the competencies of the members. If roles are not assigned,
there will be predictable duplication of effort (e.g., multiple
providers defaulting to attempt to insert an intravenous
cannula). Polytrauma patients with vascular trauma in whom
the full diagnosis has yet to be made are the “sickest” patients
in the hospital at the time of arrival. In these cases it is logical
for the most experienced clinician on duty to play a primary
role. The UK military model is that consultants in every dis-
cipline (emergency medicine, anesthesia, surgery, orthopedics,
and radiology) will undertake the relevant assessment and
intervention to their specialty. Although such a comprehen-
sive initial assessment has proven useful in the deployed
setting, it may rarely be possible in most civilian practices.
Nevertheless, even with a less-experienced team, the anesthe-
tist should be assigned to the airway, an emergency physician
or general surgeon to the primary survey, and an orthopedic
surgeon to the secondary survey of the limbs and pelvis.
To prevent having to repeat the prehospital or history mul-
tiple times to team members who arrive at different stages, it
is advisable to annotate the injury scenario on an information
board for all to see. One format that has been useful to the
author is the abbreviation MIST, which stands for mechanism,
injuries (found and suspected), signs (physiological), treat-
ment. With multiple casualties, patients can be preassigned
 7  /  Damage Control and Immediate Resuscitation for Vascular Trauma 59
treatment bays; and the limited manpower resources can then
be distributed based on the MIST categories.
It is important to note that some medications are required
or can at least be anticipated for nearly all major resuscitations
following vascular trauma with shock. A patient with an iso-
lated head injury and coma will require a computed tomog-
raphy (CT) scan of the brain, and an anesthetic will be needed
to secure the airway before the procedure. When severity of
injury is communicated from the point of injury or the en
route care platform (i.e., 3-D resuscitation), these commonly
used medications can be drawn up and prepared in advance.
This not only speeds the time to anesthesia, CT, and diagnosis,
but it also allows the anesthetist to focus on managing the
airway, rather than being potentially distracted by having to
draw up or prepare medications once the patient arrives. The
same reasoning applies to analgesia and intravenous fluids or
blood component, where nursing time can be saved by pre-
planning during the so called 3-D resuscitation time.
Equipment requirements can also be anticipated. For
example, if the team is expecting a patient with concomitant
facial burns, equipment for intubation can be prepared includ-
ing a smaller than normal, uncut tube with a bougie in antici-
pation of airway edema. In this scenario, equipment for a
surgical airway (i.e., cricothyroidotomy) should be readied;
and the surgeon to perform this procedure, if it is deemed
necessary, should be identified. Smoothing transition follow-
ing immediate resuscitation can also begin in the preparation
phase. When a patient will need CT imaging, the radiologist
can be warned and routine use of the scanner adjusted to
ensure its availability. Similarly, when emergency surgery is
likely (e.g., gunshot wound to the abdomen or severely
mangled extremity) advance notification of the operating
theater should occur.
Techniques and Procedures
An exhaustive description of resuscitation techniques and
procedures is beyond the scope of this chapter. Many of the
prehospital strategies implemented to manage major vascular
trauma including the mangled extremity are addressed more
extensively in Chapter 16 and in Chapter 17. A more in-depth
understanding of resuscitation techniques and procedures can
also be garnered from the recognized modular training courses
(ATLS for core resuscitation skills; Advanced Pediatric Life
Support [APLS] for supplemental understanding and skills
when caring for children; Definitive Surgical Trauma Care
(DSTC) for surgical decision-making and damage control
operative skill in trauma; and Battlefield Advanced Trauma
Life Support (BATLS) for core resuscitation skills in the
combat environment). Those advances in techniques and pro-
cedures that have gained rapid traction in the military setting
yet are still filtering through to civilian practice are important
to pick out. First among these are the first-aid measures to
control external bleeding. Commercial tourniquets are now
issued to uniformed personnel going into a combat environ-
ment for self-application or use on others. Case series dem-
onstrate a life-saving benefit with tourniquets applied in the
setting of traumatic limb amputation following an explosives-
related injury. Evidence also supports the use of a pneumatic
tourniquet rather than a windlass variant; but the cost, sim-
plicity, and robustness of the windlass device means that it is
likely to endure for field tactical use.15-18
Topical hemostatic agents have also developed as a capabil-
ity that can be safely and effectively used as far forward as the
point of wounding. There are substantial market competition
and convincing large animal model evidence of effectiveness
for a range of products.19 The choice of agent is between
industrial minerals (zeolite, kaolin, smectite) and chitosan
from crushed shellfish. The choices of formulation are a loose
powder, a powder contained in a malleable porous bag, or an
impregnated material (square dressing or flexible ribbon). The
British Army adopted the first generation of products (Qui-
kClot, a loose zeolite powder; Hemcon, chitosan in a square
dressing) in parallel with the U.S. military, but they retained
an agile strategy that would allow adaptation to further inno-
vation. The British Army now favors the chitosan impregnated
bandage or ribbon gauze (Celox Gauze). This formulation is
safe, has no exothermic reaction and offers effectiveness to
pack and seal large vessels bleeding in junctional wounds
(groin, axilla). Although these products were designed for
first-aid external use, they have found utility at operation to
assist in hemostatic control.20
As previously noted, the inability to rapidly gain venous
access is a pinch point for resuscitation. In many cases a se-
verely injured patient will not have an airway secured until
intravenous anesthetic medications can be administered (e.g.,
rapid sequence intubation). Although interosseous (IO) access
has been commonly taught as a procedure reserved for chil-
dren younger than 6 years, military experience has demon-
strated the IO route to be effective when peripheral venous
access fails. In adults, IO access can be used for fluids (includ-
ing blood products) and drugs (analgesia and rapid sequence
induction of anesthesia).21 The four principal sites that can be
exploited for IO access follow: (1) upper medial tibia, (2) hu-
meral head, (3) sternum, and (4) iliac crest. Battery-powered
drills (EZ-IO, not for use on the sternum) provide quick and
reliable access, while a mechanical device referred to as the
FAST1 may be used on the sternum and is particularly useful
when there are multiple limb injuries. IO access should be re-
garded as a primary route for resuscitation in traumatic car-
diac arrest because of the speed with which it can be achieved.
ATLS also emphasizes the importance of stabilizing the
cervical spine, which reflects the prevalence of blunt trauma
in setting civilian setting. BATLS deemphasizes the cervical
spine in the military setting where penetrating trauma is much
more common. As an example, it is recommended that, if
there are no neurological symptoms or signs following pene-
trating neck injury, the cervical spine does not be immobi-
lized.22 Pelvic immobilization to control bleeding from a
severe fracture is becoming established as a precautionary pre-
hospital technique.23 Where the mechanism, symptoms or
signs suggest pelvic ring disruption with instability and signs
of bleeding or shock, a commercial binder should be applied
and retained until exclusion of injury with the primary survey
x-ray.
Injured patients with major vascular trauma are prone to
develop hypothermia, which may complicate or compound
coagulopathy.24 Thermal blankets with chemical heat packs
(e.g., Blizzard Blanket) are used in some prehospital settings.
Whether using this or other types of warming devices or blan-
kets, their use should be anticipated as they may take time to
reach optimal temperature. It is also important to be familiar
with the instructions for use as some of these devices should
not be placed in direct contact with the patient’s skin. In the
60 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
hospital, active external rewarming during resuscitation is
commonly achieved with a combination of a heated, insulated
thermal mattress and a warm air paper duvet. Unnecessary or
excessive exposure of the patient during the secondary survey
and serial interventions also leads to loss of heat and should
be avoided.
Fluids and Medications
The most significant advance in trauma resuscitation relates
to reduced or eliminated use of balanced salt solutions or
crystalloids in favor of balanced ratios of blood and blood
products (e.g., platelets, packed red blood cells, plasma). The
effective and balanced use of blood components is particularly
important as patient survival is known to be inversely related
to the presence of coagulopathy.24,25 Imbalance of coagulation
is relatively common in civilian trauma on presentation to the
hospital, yet military trauma is statistically more severe.2-5 The
outcome from military trauma has been shown to be improved
by shortening the ratio of red cells to plasma, which provides
the necessary clotting factors.24,25 Further, in the military
setting, certain types of physician-led medical evacuations
teams can now be sent by rotary wing to or very near to the
point of wounding.26 Many of these en route care capabilities
now carry both red blood cells and plasma for administration
of products at or near the point of injury and in flight. The
forward use of blood components in select cases of vascular
trauma and hemorrhage means that resuscitation begins
earlier and possibly before coagulopathy even develops.26
Platelet replacement has been recommended more recently
to be included in a 1 : 1 : 1 ratio with red cells and plasma.24,25
This cookbook approach to component-based resuscitation
does not necessarily reflect any one patient’s needs, and it
should not be given haphazardly or without consideration.
Thromboelastography (TEG) provides a simple, near–real
time coagulation test that can be performed at point of contact
with the patient in the resuscitation room or operating theater.
TEG results are presented visually as a curve and pattern rec-
ognition allows for immediate or real time interpretation
regarding the need for specific clotting factors (as plasma),
platelets, fibrinogen (as cryoprecipitate), or tranexamic acid
(TXA) (to counter hyperfibrinolysis). A detailed description
of the workings of TEG and its indicators of coagulation
imbalance is beyond the scope of this chapter. TEG and other
types of bedside testing are being developed to allow more
specific or goal or end-point directed resuscitation with spe-
cific components of blood and TXA.27,28
The use of blood component therapy in major vascular
trauma has been termed “hemostatic resuscitation.” Evidence
is now emerging that this strategy results in improved physiol-
ogy at an earlier stage following severe multitrauma and even
improved survival. The practice of hemostatic resuscitation
means that patients who may not have otherwise survived or
may have been too physiologically compromised to have vas-
cular repair are now are now able to have their vascular inju-
ries addressed. Evidence shows that this practice may be
displacing the older dictum of “life over limb” and now may
be allowing for pursuit of life and limb in many cases of
mangled extremity. Improved physiology and survival result-
ing from hemorrhage-control strategies combined with
hemostatic resuscitation may also be responsible for the higher
rate of vascular trauma recorded in the wars in Afghanistan
and Iraq.29,30 The shifting epidemiology of vascular trauma
and the impact of damage control resuscitation on the rates
of this injury pattern are discussed more thoroughly in
Chapter 2.
Massive transfusion has traditionally been defined as 10 or
more units of packed red cells in a 24-hour period (and more
recently as 5 or more units in a 4-hour period). Not surpris-
ingly, the need for this amount of resuscitation in such a short
period of time has predictable life-threatening complications.
Hyperkalemia and hypocalcemia can be detected by electro-
cardiogram (ECG) changes, but more reliably by serial blood
analysis. These electrolyte disturbances are complications of
transfusing stored red cells rather than fresh whole blood (a
technique also used in military practice) to replace volume
following vascular trauma. A technician may need to be
dedicated to monitoring for these complications (e.g., near-
patient blood gas analysis to include potassium and ionized
calcium) and having the appropriate treatments drawn up
(glucose and insulin for hyperkalemia; calcium chloride for
hypocalcemia).
The debate over colloid and crystalloid as an initial resus-
citation fluid before blood is available has raged relentlessly.
In a systematic review of randomized controlled trials com-
paring fluid resuscitation in the critically ill (including ran-
domized controlled trials (RCTs) with trauma patients),
colloids were found to result in an absolute increase in risk of
death.31 Hypertonic saline dextran has been recommended as
a resuscitation fluid. It has additional antiinflammatory prop-
erties and has shown promise in improving outcome follow-
ing penetrating torso injury; but this value has not been
reproducible in animal models of blast injury, thereby under-
mining its military utility.32,33 Crystalloid (normal saline,
Hartmann’s solution) therefore remains the standard fluid of
choice to support initial resuscitation when there is no require-
ment for blood products.34
Analgesia in the conscious trauma patient is a high priority.
Morphine titrated intravenously to effect is perhaps the
benchmark, but it is neither the most potent nor the fastest-
acting drug available. If a painful procedure (e.g., reduction
of a fracture dislocation, chest drain, burns dressing) is to be
undertaken, then the medication ketamine should be used.
Ketamine is a rapid, potent, and short-acting anesthetic.
Although the analgesic dose is stated to be 0.5mg/kg to 1 mg/
kg, the author’s experience suggests that starting with the
slightly lower dose of 0.25 mg/kg is wise. The therapeutic
window is relatively narrow, with a total anesthetic dose being
2 mg/kg. Simultaneous resuscitation of multiple casualties can
be aided by prepared standardized drug boxes assigned to each
treatment bay containing analgesia, anesthetic agents, and
predictable prophylactic antibiotics. This assists providers
who may be unfamiliar with the emergency department in
having rapid access to the medications when nursing staff
capacity is stretched. This practice also encourages a standard
approach to the use of medications in this complex setting
(e.g., to the use of antibiotics) and also provides a relatively
easy way within the resuscitation bay to keep a tally of medica-
tions given.
Imaging
Imaging assists clinical decision making during resuscitation
from vascular trauma and shock. There are three traditional
 7  /  Damage Control and Immediate Resuscitation for Vascular Trauma 61
primary survey radiographs: chest, pelvis and cervical spine.
The most pressing is the chest x-ray as it commonly dictates
whether a drain needs to be placed in the thorax and will
provide information about the position of the endotracheal
tube. The chest x-ray can be performed during the primary
survey and is an extension of the physical examination. Good
preparation will have placed the plate within the resuscitation
trolley before the patient arrives. With the team gowned in
lead and with judicious prepositioning of the x-ray boom (or
gantry), the image can be taken as soon as the chest examina-
tion is complete. Venous access and blood sampling is likely
to continue in parallel. Direct digital radiography (DDR) gen-
erates an image for immediate viewing, rather than waiting
minutes to process a wet film. In the best case, the chest radio-
graph is an adjunct to the stethoscope, which in the noise of
the resuscitation room can be a fairly blunt diagnostic instru-
ment. In this modernized and efficient resuscitation, the ATLS
dictum that “an x-ray of tension pneumothorax should never
be seen” is not necessarily true.
A plain image of the pelvis is useful to identify instability,
to confirm or direct the need for a splint if not already applied,
and to account for signs of hypovolemia. It often raises the
requirement to progress to pelvic CT, with or without angiog-
raphy, to identify arterial bleeding. For patients with persistent
hemodynamic instability, the pelvic x-ray may be the first
indicator that arteriography and pelvic embolization may be
needed. Where there is concomitant intraabdominal bleeding
(detected by ultrasound) the decision to proceed to laparot-
omy will be based on the team leader’s determination of
patient trajectory. A grossly unstable pelvic fracture patient
who does not have the reserve to undergo confirmatory CT
may be better off undergoing combined laparotomy and
extraperitoneal packing (EPP) to tamponade bleeding, with
either the in situ pelvic sling or coapplied external fixation
providing a degree of integrity to the disrupted pelvic ring.
A plain image of the lateral cervical spine does little to alter
the initial approach in the resuscitation room where injury is
presumed following blunt trauma. A poor image (in the mus-
cular or obese) can lead to repeated unsatisfactory images in
an attempt to see as far as the C7-T1 junction, which can delay
further progress in critical cases. If a CT is being ordered,
particularly for associated head injury, it has become increas-
ingly accepted practice to defer imaging of the cervical spine
until a CT scan can be performed. In some countries, c
(LODOX) is used to generate a full body topogram as a screen-
ing tool in the resuscitation room to identify pneumothoraces,
long-bone or pelvic fractures and foreign bodies (e.g., ballistic
rounds). This idea arose from the screening of workers in the
diamond mines of South Africa to detect illicit smuggling.
Four-quadrant ultrasound (focused abdominal sonogra-
phy in trauma [FAST]) is used to determine the presence of
free fluid in the abdomen, pelvis, and pericardium. Following
trauma, this is presumed to be blood. This is a safe and rapid
technique that can be repeated serially if required and is easily
performed within the resuscitation room. A gross positive for
abdominal free fluid can be used as a triage tool to indicate
the need for an immediate laparotomy. In the case of a grossly
positive FAST, the temptation to take the hemodynamically
unstable patient to CT imaging for detailed antemortem diag-
nosis should be avoided! FAST replaces unreliable clinical
examination (a soft abdomen does not exclude hemoperito-
neum) and invasive diagnostic peritoneal lavage. FAST should
be regarded as a minimum standard of investigation in all
hospitals receiving major trauma. Reliability is operator
dependent, but in trained hands it is highly sensitive (>90%).
Importantly, the skill can be mastered quickly.
The increasing availability of CT continues to influence the
early assessment and management of vascular trauma. Guide-
lines for CT following head injury have serially lowered the
threshold, but the priority remains for those with low or low-
ering conscious level where timely intervention for acute
extradural or subdural hematoma will impact morbidity and
mortality. CT of the chest will often identify small pneumo-
thoraces or hemothoraces that are missed on supine plain
films; and this is important for planning surgical treatment
for complex facial, spinal, and pelvic fractures. In children,
where a conservative approach is more common to abdominal
solid organ and hollow viscus injury, a detailed understanding
of the anatomical injury is important in determining the need
for operation. As long as the patient remains hemodynami-
cally normal, most instances of low to mid-grade solid organ
injury can be can be carefully monitored without the need for
open operation. Some injuries are elusive to investigation. A
child who was riding in the center of the rear seat of a crashed
car, who was wearing a lap belt, and who has an imprint bruise
on the abdominal wall should be considered at high risk of a
perforated hollow viscus. Free air under the diaphragm and/
or bowel wall edema on CT is also be a telltale sign of hollow
viscus injury.
Resuscitation End Points
There are physiologic, hematologic, biochemical, and proce-
dural end points or targets of immediate resuscitation follow-
ing major vascular trauma. If a patient with blunt abdominal
trauma has tachycardia and hypotension that responds to
initial fluid resuscitation and has a negative FAST examina-
tion, it is safe to obtain CT imaging rather than to move to
emergency surgery. The same patient who is not responding
and has intraabdominal fluid on FAST requires an immediate
laparotomy. It is incorrect to regard hemodynamically unsta-
ble patients as inadequately resuscitated and therefore unfit
for an open operation. In these scenarios, it is an operation
with hemorrhage and contamination control above all else
that may be lifesaving. For example, a labile blood pressure
(i.e., intermittently responsive to fluid resuscitation) may be a
good indicator of vascular disruption within the hilum of a
solid organ (i.e., liver, kidney, spleen) with a persistent low
level of bleeding.
The concept or practice of hypotensive resuscitation builds
on evidence of poor outcome in an urban trauma setting
where fluids are started prehospital or in the ED for patients
with penetrating torso injury.35 The teleological explanation is
that aggressive fluid resuscitation may dislodge any clot that
has been formed leading to worsening of bleeding. Conse-
quently, limited fluid resuscitation has been recommended
with a target of maintaining a radial pulse (equating to a sys-
tolic blood pressure of c.90 mm Hg). However, a swine blast
model has identified that when hypotensive resuscitation is
sustained for more than 2 hours then the acidosis is
irretrievable.35-37 The British military approach is therefore
one of novel hybrid resuscitation—when evacuation is delayed,
maintain the radial pulse for the first hour, then switch to
normotensive resuscitation.37
62 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
For most vital signs there is no absolute target number to
be achieved during the resuscitation, but instead improve-
ment or stabilization of trends. A mildly reduced Glasgow
Coma Scale (13-14/15) will require investigation, but it
becomes a pressing concern if the GCS starts to decrease
further. The respiratory rate is a highly sensitive indicator of
physiological compromise, although nonspecific as it may rise
with airway obstruction, inadequate ventilatory capacity
(chest wall, lung or neurological injury), or hypovolemia.38
The trend in the respiratory rate is also useful evidence of the
success of resuscitation interventions.
The patient’s core temperature is also a very important end
point to consider during resuscitation from major vascular
trauma. Although a good target to keep in mind is maintain-
ing core temperature above 35° C, one also desires to achieve
a positive trend toward normothermia during DCR. The evi-
dence for neuroprotection using therapeutic hypothermia
may be regarded to be in conflict with the desire to maintain
normothermia in major trauma, but the balance of opinion is
that hypothermia aggravates coagulopathy and that this is the
primary concern following major vascular trauma.
Hematologic targets should be placed secondary to the
overall clinical response of the vascular trauma patient during
DCR. As a general guide, packed red blood cells are trans-
fused to keep the hemoglobin at or above 10 g/dL and the
hematocrit at or above 35. Plasma is given to bring the inter-
national normalized ratio (INR) below 1.5 and platelets given
to increase the count above 100 × 109/L (each bag of platelets
raises the count by 30-40 × 109/L). Cryoprecipitate is given to
increase the fibrinogen level to above 1 g/L (the lower limit of
normal is 1.5 g/L). Again, these are general guidelines, and
the overall condition of the patient during DCR should guide
the administration of blood and blood components. Bio-
chemical targets during DCR include normalization of the
serum potassium, ionized calcium, and base excess, an indi-
cator of tissue perfusion. Induced hypocapnia following
closed head injury can cause harm and should be strictly
limited to the treatment of life-threatening intracranial
hypertension pending definitive measures or to facilitate
intraoperative neurosurgery. When it is used, the PaCO2
should be normalized as soon as is feasible.38
There is a danger that serial procedures performed in the
emergency department can delay progress to the next location
of care be that an imaging suite, the operating theater, or the
intensive care unit. The trauma team leader must balance the
perceived benefit of further interventions in the resuscitation
room with the need to move the patient on to advanced levels
of monitoring and care. In this capacity, the trauma team
leader must discern which procedures are necessary to save
life, to reduce morbidity, and to improve comfort and which
can be safely deferred. As an example, a judgment needs to be
made regarding the patient with vascular trauma and a closed
head injury and the time taken to place arterial and/or central
venous lines before transfer for CT imaging
Resuscitation Ethics
Putting aside the requirement to treat all patients within the
law as an assumption, the ethics of resuscitation following
major vascular trauma and hemorrhagic shock presents a
series of choices and challenges. Many of these are brought
into sharp focus when working in the resource-constrained
environment of a field hospital. Consider the following
scenarios:
1. When there are multiple patients with serious injury,
how do you determine which to treat first?
2. When a patient is brought to the hospital in cardiac
arrest following trauma, it is easy to continue; but when
is it appropriate to stop?
3. If a patient requires massive transfusion, how much
blood product is enough or is there no ceiling?
4. Are there some injuries, such as 100% burns or qua-
druple amputation following explosive injury, where the
severity of injury means that resuscitation will be hope-
less and should not be started?
There are no absolute answers to these vexing cases. Treat-
ment priorities in multiple casualty situations are guided by
experience and triage algorithms. Such algorithms assign pri-
orities based on physiological signs, but they can and should
be tempered with clinical experience. Emotion inevitably
plays a part; and there is opportunity to overtriage children,
particularly if the algorithm is not adjusted for pediatric vital
sign norms.
The outcome from arrest following vascular trauma and
cardiovascular collapse has been universally poor. The best
civilian results achieve a survival of 7% (physician-led London
Helicopter Emergency Medical Service).39 Results from the
British military have been more encouraging, demonstrating
a 24% survival in a select group of injured in whom the domi-
nant cause of cardiac arrest was hypovolemia.14 The decision
regarding how aggressively to treat traumatic cardiac arrest
will therefore be influenced by the context of the injury and
the expectations for success. Blood products are finite
resources, and even more so in a field hospital. Were they not,
it might easier to justify resuscitation of asystolic patients.
However, when resources constrain treatment, it may be nec-
essary to set resuscitation boundaries.
Further complexity is present in a deployed field hospital.
As an example, what is the ethical choice in considering treat-
ment of enemy combatants alongside one’s own injured
service personnel? If one has limited capacity, can he or she
turn away injured civilians who present with vascular trauma
in order to retain the ability to treat service personnel? When
there is no hospital to which to refer ventilated civilian casual-
ties, what is the threshold for sustaining these patients; and
can the standard be ethically any different to the best peace-
time practice? Although these questions will not be answered
in this textbook, it is appropriate for those who manage major
vascular trauma to consider these questions. The point is to
think about and discuss the challenges in advance and to set
organizational norms, which will be based on expectations
that will inevitably vary among societies and various settings
of trauma practice.
REFERENCES
1. Humphrey PW, Nichols WK, Silver D: Rural vascular trauma: a twenty-
year review. Ann Vasc Surg 8:179–185, 1994.
2. Anderson ID, Woodford M, de Dombal FT, et al: Retrospective study of
1000 deaths from injury in England and Wales. Br Med J (Clin Res Ed)
296:1305–1308, 1988.
3. Eastridge BJ, Mabry RL, Seguin P, et al: Death on the battlefield (2001–
2011): implications for the future of combat casualty care. J Trauma Acute
Care Surg 73(6 Suppl5):S431–S437, 2012.
4. Hodgetts TJ, Davies S, Russell R, et al: Benchmarking the UK military
deployed trauma system. J R Army Med Corps 153(4):237–238, 2007.
 7  /  Damage Control and Immediate Resuscitation for Vascular Trauma 63
5. Champion HR, Bellamy R, Roberts P, et al: A profile of combat injury.
J Trauma 53:S13–S19, 2003.
6. Hodgetts T, Gunning K, Deane S: Trauma rules, London, 1997, BMJ
Publishing.
7. National Confidential Enquiry into Patient Outcome and Death: Trauma:
Who Cares? November 2007.
8. Hodgetts T, Mahoney P, Kirkman E, et al: Damage control resuscitation.
J R Army Med Corps 153(4):299–300, 2007.
9. American College of Surgeons: Advanced Trauma Life Support (8e),
Chicago, 2008, ACS.
10. Hodgetts T, Mahoney P, Russell M, et al: ABC to <C>ABC: redefining the
military trauma paradigm. Emerg Med J 23:745–746, 2006.
11. National Association of Emergency Medical Technicians (US): Pre-
Hospital Trauma Life Support Committee, and American College of Sur-
geons. Committee on Trauma, PHTLS: basic and advanced prehospital
trauma life support, 2004, Mosby Inc.
12. Kotwal RS, Montgomery HR, Kotwal BM, et al: Eliminating preventable
death on the battlefield. Arch Surg 146(12):1350, 2011.
13. Elster EA, Butler FK, Rasmussen TE: Implications of combat casualty care
for mass casualty events. JAMA 310(5):475–476, 2013.
14. Russell R, Hodgetts T, McLeod J, et al: The role of trauma scoring in devel-
oping trauma clinical governance in the Defence Medical Services. Philos
Trans R Soc Lond B 366(1562):171–191, 2011.
15. Hettiaratchy S, Tai N, Mahoney P, et al: UK’s NHS trauma systems:
lessons from military experience. Lancet 376(9736):149–151, 2010.
16. Brodie S, Hodgetts TJ, Lambert P, et al: Tourniquet use in combat trauma:
UK military experience. J R Army Med Corps 153(4):310–313, 2007.
17. Kragh JF, Walters TJ, Baer DG, et al: Survival with emergency tourniquet
use to stop bleeding in major limb trauma. Ann Surg 249:1–7, 2009.
18. Parker P: Consensus statement on decision making in junctional trauma
care. J R Army Med Corps 157(3 Suppl 1):S293–S296, 2011.
19. Sondeen JL, Pusateri AE, Coppes VG, et al: Comparison of 10 different
hemostatic dressings in an aortic injury. J Trauma 54:280–285, 2003.
20. Rhee P, Brown C, Martin M, et al: QuikClot use in trauma for hemor-
rhage control: case series of 103 documented uses. J Trauma 64:1093–
1099, 2008.
21. Cooper B, Mahoney P, Hodgetts T, et al: Intra-osseous access for resusci-
tation: UK military combat experience. J R Army Med Corps 153(4):266–
268, 2007.
22. Mahoney PF, Steinbruner D, Mazur R, et al: Cervical spine protection in
a combat zone. Injury 38(10):1220–1222, 2007.
23. Lee C, Porter K: The pre-hospital management of pelvic fractures. Emerg
Med J 24(2):130–133, 2007.
24. Brohi KJ, Singh M, Heron T: Coats. Acute traumatic coagulopathy.
J Trauma 54:1127–1130, 2003.
25. Borgman M, Spinella PC, Perkins JG, et al: The ratio of blood products
transfused affects mortality in patients receiving massive transfusions at
a combat support hospital. J Trauma 63:805–813, 2007.
26. Morrison JJ, Oh J, DuBose JJ, et al: En-route care capability from point
of injury impacts mortality following severe wartime injury. Ann Surg
257(2):330–334, 2013.
27. Morrison JJ, Dubose J, Rasmussen TE, et al: Military application of
tranexamic acid in trauma emergency resuscitation (MATTERs) study.
Arch Surg 147(2):113–119, 2012. [Epub 2011 Oct 17].
28. Morrison JJ, Ross JD, DuBose JJ, et al: Association of cryoprecipitate and
tranexamic acid with improved survival following wartime injury: find-
ings from the MATTERs II study. Arch Surg 148(3):218–225, 2013.
29. White JM, Stannard A, Burkhardt GE, et al: The epidemiology of vascular
injury in the wars in Iraq and Afghanistan. Ann Surg 253(6):1184–1189,
2011.
30. Stannard A, Brown K, Benson C, et al: Outcome after vascular trauma in
a deployed military trauma system. Br J Surg 98:228–234, 2011.
31. Schierhout G, Roberts I: Fluid resuscitation with colloid or crystalloid in
critically ill patients: a systematic review of randomised trials. Br Med J
316:961–964, 1998.
32. Wade CE, Grady J, Kramer GC: Efficacy of hypertonic saline dextran fluid
resuscitation for patients with hypotension from penetrating trauma.
J Trauma 54:S144–S148, 2003.
33. Sawdon M, Kirkman E, Ohnishi M, et al: Hypertonic saline-dextran is
ineffective after thoracic blast and hemorrhage. Br J Surg 87:961, 2000.
34. Kirkman E, Watts S, Hodgetts T, et al: A proactive approach to the coagu-
lopathy of trauma: the rationale and guidelines for treatment. J R Army
Med Corps 153(4):302–306, 2007.
35. Bickell W, Wall M, Pepe P, et al: Immediate versus delayed fluid resuscita-
tion for hypotensive patients with penetrating torso injuries. N Engl J
Med 331:1105–1109, 1994.
36. Garner J, Watts S, Parry C, et al: Prolonged permissive hypotensive resus-
citation is associated with poor outcome in primary injury with con-
trolled hemorrhage. Ann Surg 251:1131–1139, 2010.
37. Jacobs N, Watts S, Doran C, et al: Novel resuscitation strategy is superior
to hypotensive strategy for delayed evacuation of casualties after explo-
sion. Br J Surg 97:190–191, 2010.
38. Curley G, Kavanagh BP, Laffey JG: Hypocapnia and the injured brain:
more harm than benefit. Crit Care Med 38(5):1348–1359, 2010.
39. Lockey D, Crewdson K, Davies G: Trauma cardiac arrest: who are the
survivors? Ann Emerg Med 48(3):240–244, 2006.
 Vascular Disruption and
Noncompressible Torso
8  Hemorrhage
JONATHAN J. MORRISON AND JOSEPH J. DUBOSE
Introduction
Vascular disruption with hemorrhage remains a leading cause
of death in both civilian1,2 and wartime trauma.3,4 In the civil-
ian setting, hemorrhage is present in 15% to 25% of admis-
sions; and studies from the wars in Afghanistan and Iraq show
that the rate of vascular injury in combat is approximately
10%.4-6 Hemorrhage can be broadly considered as originating
from either extremity or torso vessels, a distinction of signifi-
cant clinical importance. Extremity hemorrhage is generally
compressible, meaning those bleeding vessels can be amenable
to immediate control with manual pressure or tourniquet
application. This is in contrast to torso hemorrhage which is
usually noncompressible meaning vessels that are not amenable
to control with direct pressure and generally require surgical
control of the hemorrhage (Fig. 8-1).5
Although extremity hemorrhage is a more common injury
in trauma practice, noncompressible torso hemorrhage
(NCTH) carries a far greater burden of mortality. Civilian
studies demonstrating that NCTH accounts for 60% to 70%
of mortality following otherwise survivable injuries (i.e., no
lethal head or cardiac wounds) clearly emphasizes the lethality
of this injury pattern.1,2 Hemorrhage is also a significant
problem in the wartime setting, accounting for up to 60% of
deaths in potentially survivable-injury scenarios.7,8 Studies on
those killed in action in Afghanistan and Iraq have shown that
of deaths occurring in the setting of otherwise survivable inju-
ries,3 80% were a result of bleeding from disruption of vascu-
lar structures within the torso.4,5
The distinction between compressible extremity hemor-
rhage and NCTH is notable as there has been a demonstrable
reduction in mortality with a better understanding of the
epidemiology of extremity injury and the need to rapidly
control hemorrhage with tourniquets and/or topical hemo-
static agents.8 There has been no such reduction in mortality
in the setting of NCTH.
The Military and Civilian
Epidemiology of Torso Hemorrhage
One of the first studies to recognize the importance of vascu-
lar disruption and uncontrolled truncal hemorrhage was by
Holcomb et al, who reviewed autopsy findings of special oper-
ations forces personnel killed early in the wars in Afghanistan
64
and Iraq.5 A panel of experts reviewed the records of 82 fatali-
ties and judged them as nonsurvivable (e.g., lethal head or
cardiac wounds) or potentially salvageable. This was one of
the first studies to specifically use the term “noncompressible
truncal hemorrhage,” although it was not specifically defined.
NCTH was found to be the cause of death in 50% of patients
judged to have sustained potentially survivable injuries. Kelly
at al used a similar methodology to analyze 997 U.S. military
deaths that occurred within two time periods: 2003-2004 and
2006.4 Hemorrhage was the leading cause of death in those
with otherwise survivable injuries and accounted for 87% and
83% of deaths during these respective periods. Airway prob-
lems, head injury, and sepsis constituted the remaining causes
of death.
Within the hemorrhage group, 50% were due to NCTH
and 33% to extremity hemorrhage (amenable to tourniquet
application). This study also introduced hemorrhage from
another distinct anatomic and clinically important location–
from junctional areas between the torso and the extremities.
Junctional vascular trauma or hemorrhage from the proximal
femoral or axillobrachial vessels often is not amenable to
direct pressure or application of a tourniquet and therefore
poses an especially difficult problem. In the study by Kelly,
20% of deaths from hemorrhage occurred from injuries to
these junctional zones. Again, in these early studies from the
war, NCTH was not explicitly defined but encompassed dis-
ruption of any torso vascular structure that resulted in
bleeding.4
Interestingly, these figures remained unchanged when East-
ridge et al, expanded this analysis to all U.S. military personnel
who died of wounds between 2001 and 2009.6 While lethal
head injury was the dominant pattern of trauma in the non-
survivable cases, hemorrhage again accounted for 80% of
potentially survivable deaths. Truncal hemorrhage accounted
for 48% deaths in this cohort of these casualties. Publication
of these studies provided an important characterization of
battlefield injury and illustrated the high and early lethality of
NCTH in those who could have otherwise survived their inju-
ries. In parallel with postmortem studies, several clinical
studies have examined the incidence of hemorrhage in specific
organ systems.
In a study using the U.S. Joint Theater Trauma Registry
(JTTR), White and colleagues reported the incidence of vas-
cular injury in U.S. troops between 2002 and 2009.9 The
 8  /  Vascular Disruption and Noncompressible Torso Hemorrhage 64.e1

ABSTRACT
Trauma resulting in hemorrhage from vascular disruption
within the torso is a challenging scenario. The source of
bleeding may be from structures within the thorax,
abdomen, or pelvis and may not be amenable to tourni-
quet application or manual pressure. As such, this scenario
has a propensity to being lethal in the earliest stages after
initial trauma. Although the injury pattern and its serious-
ness are not new, the term “noncompressible torso hemor-
rhage” was only recently coined as part of contemporary
studies describing the epidemiology of wounding during
the wars in Afghanistan and Iraq. The burden of injury from
these wars and the particular emphasis on the early mortal-
ity associated with noncompressible torso hemorrhage
have led to a reappraisal of this injury pattern. This chapter
provides a contemporary review of noncompressible torso
hemorrhage, including a unifying definition to promote
future study. Additionally, this appraisal provides a descrip-
tion of resuscitative and operative management strategies
that can be utilized in this setting; and it highlights oppor-
tunities for additional research that may be required to
further mitigate the risk of mortality following this morbid
injury pattern.

Key Words:  noncompressible torso hemorrhage,

trauma surgery,
military surgery,
damage control surgery,
damage control resuscitation
 8  /  Vascular Disruption and Noncompressible Torso Hemorrhage 65
FIGURE 8-1  The shaded area denotes the region where noncom-
pressible torso hemorrhage is anatomically located. (From: Blackbourne
LH, Czarnik J, Mabry R, et al: Decreasing killed in action and died of
wounds rates in combat wounded. J Trauma 69[1]:1–4, 2010.)
authors of this study observed a specific vascular injury rate
of 12% (1570 of 13,075), which was 5 times higher than that
described in previous in wartime reports. Named large vessel
injury accounted for 12% of the torso vascular injuries in
White’s study, with iliac, aortic and subclavian vessels being
the most commonly injured. In a separate study also using the
JTTR, Propper et al examined wartime thoracic injury between
2002 and 2009. In this report, the authors found that thoracic
injury of any type occurred in 5% of wartime casualties. In
this cohort, the mean Injury Severity Score (ISS) was 15 and
the crude mortality was 12%.10 The most common thoracic
injury pattern in Propper’s study was pulmonary contusion
(32%), followed by hemopneumothorax (19%).
A report by Morrison and co-workers, from a single combat
support hospital in Afghanistan, analyzed 12 months of con-
secutive episodes of abdominal trauma. Over half (65 patients,
52.0%) required immediate laparotomy, with hemorrhage
from solid organs identified in 46 patients (70.8%).11 There
were 15 deaths (23%) in patients undergoing immediate lapa-
rotomy with a median New Injury Severity Score (NISS) of 29
and range of 1-67.
Despite the value of these studies, they do not specifically
emphasize the potential lethality from vascular disruption
resulting in NCTH. In this context, given the undeniable asso-
ciation of NCTH with early mortality in those with otherwise
survivable injuries, military researchers and civilian collabora-
tors have aggressively sought to establish a unifying definition
of this pattern of vascular trauma. Table 8-1 illustrates the
initial definition of NCTH, which was developed at the U.S.
Army’s Institute of Surgical Research and is based on the pre-
viously mentioned anatomic categories of vascular disruption
linked to either a physiologic or a procedural criterion. A
procedure in this definition is defined as an emergent lapa-
Table 8-1 Noncompressible Torso
Hemorrhage (NCTH)
Hemodynamic/
Anatomic Criteria Procedural Criteria
1) Thoracic cavity, including the lung
2) Solid organ injury ≥ grade 4; liver, Hemorrhagic shock*
kidney, spleen or the need for
immediate operation
3) Named axial torso vessel
4) Pelvic fracture with ring disruption
*Hemorrhagic shock is defined as a systolic blood pressure
< 90 mm Hg.
rotomy, a thoracotomy, or a procedure undertaken to control
bleeding from a complex pelvic injury.
Defining Noncompressible
Torso Hemorrhage
These observations have resulted in a thrust within the combat
casualty care research community to better define and classify
locations and patterns of NCTH. Despite its obvious signifi-
cance, a consensus definition of NCTH was lacking until the
wars in Afghanistan and Iraq. Reports have emerged recently
from the military’s Joint Trauma System (JTS) and select civil-
ian institutions proposing a unifying classification of this
injury pattern. It has been the aim of these studies to establish
a cohesive definition allowing for study of the epidemiology
of this problem and allowing for comparison of management
strategies with the hope of mortality reduction. Until these
recent reports, studies of injuries within the torso focused on
specific organ injuries (e.g., a series of liver injuries), or they
fell along specialty boundaries (e.g., a vascular surgeon’s
approach to iliac artery repair).
The wartime perspective on NCTH works from the premise
that vascular disruption with bleeding can arise from an array
of anatomic sites, as follows:
• Large axial vessels
• Solid organ injuries
• Pulmonary parenchymal injuries
• Complex pelvic fractures
As such, the contemporary definition of NCTH begins
with the presence of vascular disruption from one or more of
four anatomic categories listed in Table 8-1. Cardiac wounds
are not included within this definition because of their high
mortality.
In order to identify only patients with active hemorrhage
from these anatomic categories, the definition of NCTH
includes the presence of physiologic measures or operative
procedures that reflect hemodynamic instability and/or the
need for urgent hemorrhage control. These include hypoten-
sion or shock and the need for emergent laparotomy, thora-
cotomy, or a procedure to manage bleeding from a complex
pelvic fracture. Without the physiologic or procedural inclu-
sion criteria, the definition of NCTH would be prone to
include injuries within the at-risk anatomic category that does
not include active bleeding. The following sections will review
the military and civilian experience with noncompressible
torso hemorrhage and will provide an overview of surgical
and resuscitative strategies.
66 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
Epidemiology of Noncompressible
Torso Hemorrhage
A recent study of the U.S. JTTR presented at the American
Association for the Surgery of Trauma in 2011 used the defini-
tion presented in Table 8-1 to characterize the epidemiology
of NCTH in patients injured in Iraq and Afghanistan between
2002 and 2010. Using the injury pattern criteria alone, 1936
patients were identified as each having an injury putting them
at risk for NCTH, which was nearly 13% of battle-related
casualties. When the physiological and procedural inclusion
criteria were applied to this cohort, 331 patients with a mean
ISS ± standard deviation (SD) of 30 ± 13 were identified as
having NCTH. The most common pattern of hemorrhage was
pulmonary parenchyma (32%) followed by bleeding from a
named, large vessel within the torso (20%). High-grade solid
organ injury (grade IV or V liver, kidney, spleen) also consti-
tuted 20% of cases, and pelvic fracture with vascular disrup-
tion accounted for 15%. The most lethal injury pattern in this
study (odds ratio: 95% CI) was injury to a named large vessel
within the torso (3.42; 1.91-6.10), followed by injury to the
pulmonary parenchyma (1.89; 1.08-3.33) and complex pelvic
fracture with vessel disruption (0.80; 0.36-1.80).
The same authors applied this definition to British troops
injured in Iraq and Afghanistan from 2001 to 2010 using the
UK Trauma Registry. This analysis included patients who died
before receiving treatment at a military surgical hospital (i.e.,
killed in action [KIA]) and thus did not apply the physiologic
or procedural inclusion criteria. This report identified 234
patients with the anatomical injury profile at risk for NCTH,
which was 13% of UK battle-related injuries—a number
nearly identical to the incidence of this injury pattern in the
U.S. JTTR. The overall case fatality rate of UK patients with
NCTH was 83% compared to 25% for any battle-related
injury, underscoring the significant mortality burden posed by
vascular disruption of any type within the torso.
The civilian experience with NCTH carries a similar
message, albeit with a different injury pattern. Specifically,
vascular injury or disruption within the torso in the civilian
population consists predominantly of blunt rather than pen-
etrating or explosive mechanisms.2 Hemorrhage remains the
leading cause of potentially preventable death in civilian set-
tings accounting for 30% to 40% of mortality, with 33% to
56% of such deaths occurring in the prehospital phase of
injury.1 Tien and co-workers examined 558 consecutive
trauma deaths at a Canadian Level I trauma center.12 While
the most numerous causes of death related to CNS injury, 15%
were due to hemorrhage, with 16% of such deaths judged to
be preventable. Delay in identifying the bleeding source was
cited as the most common preventable reason, with pelvic
hemorrhage being the most common source. These findings
were confirmed and extended by investigators at Los Angeles
County and University of Southern California Medical Center,
who identified delayed pelvic hemorrhage control as the most
frequent cause of preventable deaths from hemorrhage.13
Clinical Management Strategies in
Torso Hemorrhage Control
The aim of this section is to complement the forthcoming
chapters on the definitive management of specific vessel inju-
ries by introducing strategic surgical concepts within the
context of the current literature. The surgical management of
the “nontraditional” vascular injuries—pulmonary parenchy-
mal, solid organ, and pelvic hemorrhage—is also discussed in
order to provide a holistic view of torso hemorrhage control.
Throughout these chapters, the fundamental tenants of vas-
cular surgery remain: proximal control and distal control are
essential when managing any suspected vascular injury.
Damage Control Surgery and
Damage Control Resuscitation
Damage control surgery (DCS) is a strategy originally
described in the context of exsanguinating abdominal trauma,
where the completeness of operative repair is sacrificed in
order to limit physiologic deterioration.14,15 This technique has
been extended to include other body regions.16 Definitive
operative repair is then completed in a staged fashion follow-
ing resuscitation and warming in the intensive care unit. DCS
is an extreme surgical strategy that should be selectively
applied because infection, intraabdominal abscess, wound
dehiscence, incisional hernia, and enterocutaneous fistulae are
common with its use.17-19
Military experience in Iraq identified a survival benefit in
patients receiving a higher ratio of packed red blood cells
(PRBCs) to fresh frozen plasma (FFP) and found that they
had a significantly lower mortality than patients receiving
the lower ratio (19% vs. 65%; p < 0.001).20 This finding has
brought about the concept of a balanced or hemostatic resus-
citation, where major trauma patients are resuscitated with a
unit ratio of around 1 : 1 PRBC to FFP. This concept has
evolved into a coherent strategy incorporating additional
hemorrhage control adjuncts and is termed “damage control
resuscitation (DCR).”21 Most DCR protocols incorporate
techniques such as permissive hypotension, minimal use of
crystalloid, aggressive warming, and novel infusible hemo-
static drugs such as tranexamic acid paired with damage
control surgery for early hemorrhage control.22
Importantly, damage control surgery (DCS) should be con-
sidered a tool within DCR, which may be utilized in circum-
stances of extreme physiology or significant anatomical injury
burden.23 The evidence thus far suggests that the adoption of
DCR confers a survival advantage, and is associated with a
reduction in the use of DCS techniques.18,24,25 However, while
DCR demonstrates significant promise, it does liberally utilize
precious resources exposing patients to the risks associated
with blood products. Work is being undertaken on product
ratios26,27 and the use of novel compounds to reduce this reli-
ance, such as lyophilized fibrinogen and platelets.28
Resuscitative Surgical Maneuvers
A proportion of patients with vascular trauma resulting in
noncompressible torso hemorrhage (NCTH) have circulatory
collapse, either profound hypotension or cardiac arrest. With
the burden of injury resulting from the wars in Iraq and
Afghanistan, the management of these patients has been
extensively studied.29-32 The current civilian standard in this
setting is to perform a resuscitative thoracotomy (RT) to
enable release of cardiac tamponade, to enable control of a
massive air leak, to obtain thoracic hemostasis, and to accom-
plish thoracic aortic occlusion.33 The latter maneuver is
undoubtedly the most practiced because aortic control has
 8  /  Vascular Disruption and Noncompressible Torso Hemorrhage 67
several beneficial effects in hypovolemia—namely, to enhance
cerebral and myocardial perfusion. While RT is typically per-
formed for thoracic wounding, it has been explored for use in
patients with a tense hemoperitoneum in physiological dis-
tress.34,35 The aim is to obtain control of the vascular inflow of
the abdomen, while enhancing central pressure, before lapa-
rotomy and abdominal hemostasis. This approach is now
being challenged due to the poor survival rate, although the
physiological principle of aortic occlusion supporting central
pressure remains.
Resuscitative techniques where proximal control is remote
to the site of injury should not be used liberally, as direct
vascular control, where possible, results in a lesser ischemic
burden. A recent animal study that examined thoracic clamp-
ing versus aortic clamping versus direct control of an iliac
arterial injury identified a significantly reduced burden of
global ischemia with direct control.36
Resuscitative aortic occlusion can also be achieved by use
of a compliant endovascular balloon as demonstrated by the
use of percutaneous devices to control inflow to abdominal
aortic aneurysms during endovascular repair.37,38 This tech-
nique enables the physiological benefit to be realized without
the additional burden of entering the abdomen or thorax.
Such a technique was utilized in trauma as early as the Korean
War39 and has been utilized since.40 It has not been used widely
or been evaluated systematically. However, with recent im-
provements in endovascular devices and overall resuscitation
strategy, there is a renewed interest in this approach that has
been termed “resuscitative endovascular balloon occlusion of
the aorta (REBOA).”41
Recent animal work has characterized the reduced physi-
ological burden of REBOA compared to RT.42 Animals in Class
IV shock were allocated to aortic occlusion by a balloon or
clamp via thoracotomy. The balloon group demonstrated the
same improvement in mean aortic pressure as the clamp
group, but with a lower lactate, base excess, and pH measure-
ments post intervention. A different group has identified 40
Phrenic nerve
Pericardial sac
FIGURE 8-2  Anterolateral thoracotomy through the 4th intercostal space permitting access to the left hemi-thorax, aorta, and cardiac structures.
(From: Hirshberg A, Mattox KL: The no-nonsense trauma thoracotomy. In Top Knife, Shrewsbury, UK, 2005, TFM Publish Limited, p 160.)
minutes as the optimum time for aortic balloon occlusion in
hypovolemic animals using similar end points.43
Operative Exposures and Control
of Nontraditional Vascular Trauma
and Hemorrhage
Thoracic Exposure and Control of
Pulmonary Parenchymal Hemorrhage
For hemorrhage control within the thoracic cavity, access to
the ipsilateral side is most expeditiously achieved via an
anterolateral thoracotomy, through the 4th intercostal space,
with the patient in the supine position, tilted up on a roll (Fig.
8-2). This approach will also allow extension of this incision
across the sternum into the right hemithorax or the “clam-
shell” incision, permitting access to either of the other two
compartments in the chest (mediastinum and contralateral
thoracic cavity) if required (Fig. 8-3). Importantly, a surgeon
performing this maneuver must also have the ability to con-
comitantly explore the abdomen, so this must be included
when preparing the surgical field.
Once within the chest, hemorrhage control is the highest
priority. Pulmonary bleeding can be controlled using several
techniques depending on the location. Injury to the periphery
of the lung can be stapled off in a nonanatomical fashion
using a linear stapler. Bleeding from within a wound tract is
effectively managed following tractotomy where a linear
stapler or clamp is introduced down the length of the wound
tract and then deployed. This opens the tract permitting direct
oversewing of disrupted vessels using 3-0 or 4-0 polypropyl-
ene sutures on a larger noncutting needle (i.e., SH) or con-
trolled with a stapling device.
If hemorrhage from the lung is from the deeper hilar struc-
tures, the lung itself (after mobilization) can be compressed
or even twisted on itself to occlude the hilar vessel. Because
the hilar twist creates the same physiological burden and
Left
lung
68 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
Right
lung
FIGURE 8-3  Extension of the anterolateral thoracotomy across the sternum into the right intercostal space, facilitating access to the mediasti-
num and the right hemithorax. (From Hirshberg A, Mattox KL: The no-nonsense trauma thoracotomy. In Top Knife, Shrewsbury, UK, 2005, TFM
Publish Limited, p 161.)
outflow obstruction as a trauma pneumonectomy, it should
be performed only as a last resort. In cases where the injury
significantly compromises a patient’s pulmonary reserve,
extracorporeal membrane oxygenation may also be a useful
adjunct.44
Abdominal Exposure and the Control of
Splenic, Hepatic, and Renal Hemorrhage
The abdomen should be opened through a midline incision
from the xiphoid process to the pubic symphysis to permit
access to all four quadrants. Initial packing remains the best
method of initial hemostasis, allowing for the resuscitation to
restore the circulating volume. An additional useful adjunct
for patients in extremis is resuscitative aortic occlusion of the
aorta at the diaphragmatic hiatus. The next key step is sequen-
tial evaluation of the abdomen and a decision regarding local
control of hemorrhage and contamination.
Hemorrhage from vascular structures in the hilum or
parenchyma solid organs (i.e., liver, kidney, spleen) within the
abdomen is managed differently depending on the organ in
question. Exposure and removal of the spleen is fairly straight-
forward and well tolerated by the patient, and thus splenec-
tomy is the favored maneuver for the hemorrhaging spleen. In
contrast, hemorrhage from the liver necessitates packing in
most instances to control bleeding. Control of the porta
hepatis at the gastrohepatic ligament and application of the
Pringle maneuver are often used as adjuncts to liver packing
to control inflow to the organ. Depending on the nature of
the wound and the location of the hepatic bleeding, the liver
can be mobilized by dividing the coronary and triangular liga-
ments and allowing the left and right lobes to be drawn or
compressed together. If this maneuver is successful, Vicryl
mesh can be used to wrap the liver and maintain apposition
of the lobes for hemostasis. If the bleeding liver wound is a
defined tract, a tractotomy can be performed to allow expo-
sure and ligation of specific vessels deeper within the wound
or a Penrose drain can be tied over a nasogastric tube to allow
inflation of the Penrose within the tract and application of a
Sternum Left
(cut) lung
Pericardial
sac
balloon tamponade. These are only a minority of the tech-
niques that can be employed to achieve liver hemostasis,45 but
it is beyond the scope of this chapter to go further.
The kidneys are located within zone II of the retroperito-
neum and can be accessed by mobilizing the overlying colon.
Renal trauma should generally be managed conservatively in
blunt trauma, provided there is no expansion of the surround-
ing hematoma and the patient is hemodynamically stable.
Penetrating trauma requires a different approach, with an
emphasis on exploration and repair of the kidney, if possible,
or nephrectomy. If there is concern of injury to or violation
of the collecting system, drains should be left in the perineph-
ric or retroperitoneal space.
Pelvic Access and Control  
of Pelvic Hemorrhage
The pelvis is a complex compartment containing both ana-
tomic and specialty junctional structures (e.g., urologic,
orthopedic, vascular, general, colorectal surgery). Operative
exposure of the pelvic space can be achieved using an intra-
peritoneal route at the time of laparotomy or with an extra-
peritoneal approach which can be accomplished through a
midline or a Pfannenstiel incision. The former is the quicker
approach enabling access to both the abdomen and the pelvis
permitting access to the aorta and distal vascular along with
the hollow viscera within that region. The extraperitoneal
approach permits access to the external iliac vasculature for
suprainguinal arterial control and for packing of the preperi-
toneal space but limits access to other abdominal structures
that may be injured (Fig. 8-4).
The presentation of pelvic hemorrhage can range from
gross hemodynamic instability associated with obvious ana-
tomical deformity to the operative discovery of a zone III
retroperitoneal hematoma (RPH). Pelvic hematomas can be
extensive, tracking all the way up to the supracolic compart-
ment. In blunt trauma, these are generally best managed con-
servatively and opening them should be avoided. However,
when circumstances dictate, as in patients with refractory
 8  /  Vascular Disruption and Noncompressible Torso Hemorrhage 69

A B

C D
FIGURE 8-4  A, The sequence of preperitoneal pelvic packing is a lower midline incision down to the peritoneum; B, a blunt dissection of
preperitoneal space; C, a packing of the preperitoneal space; D, and a representative CT scan demonstrating the packs in situ. (Figures A-C from
Cothren CC, Osborn PM, Moore EE, et al: J Trauma 62[4]:834–839, 2007. Figure D from Totterman A, Madsen J, Skaga NO, et al: Extraperitoneal
pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. J Trauma 62[4]:843–852, 2007.)

shock, the preperitoneal space can be packed to achieve
control of venous bleeding. The latter is a useful adjunct to
managing venous bleeding in complex pelvic fractures once
bony stabilization has been achieved. In penetrating trauma,
vascular control is vital, especially if a direct vessel injury is
suspected. This control may require mobilization of the ter-
minal aorta.
Arterial bleeding from the pelvis is most commonly
managed with endovascular techniques such as coil emboliza-
tion in cases of complex pelvic fracture. In rare instances of
pelvic fracture or open fragmentation or gunshot wounds to
the pelvis, ligation of the internal iliac artery is necessary as a
hemorrhage control maneuver. Because of cross filling from
the contralateral internal iliac artery, ligation of one side must
typically be accompanied by packing with or without topical
hemostatic agents in order to achieve hemostasis. Ligation of
both internal iliac arteries is rarely necessary and is associated
with very poor outcomes related to both the complex nature
of the wound and the subsequent pelvic, buttock, and pero-
neal ischemia.46
Summary
Vascular disruption with concomitant hemorrhage is the
leading cause of potentially preventable death in both civilian
and military trauma. Noncompressible torso hemorrhage is a
particularly vexing scenario that, despite being an intuitive
concept, has until recently lacked a formal definition. Manage-
ment of vascular trauma and hemorrhage within the torso
requires rapid decision making, aggressive resuscitation, and
surgery with an emphasis on early hemostasis. Despite the
emergence of damage control resuscitation and adjuncts such
as endovascular surgery, the principles of proximal and distal
control remain. The use of a novel and inclusive definition of
NCTH based on anatomic and physiologic criteria should
enable better identification of this important patient popula-
tion and should enable comparisons of treatment modalities
in the future.
REFERENCES
1. Kauvar D, Lefering R: Impact of hemorrhage on trauma outcome: an
overview of epidemiology, clinical presentations, and therapeutic consid-
erations. J Trauma 60:3–11, 2006.
2. Kauvar DS, Wade CE: The epidemiology and modern management of
traumatic hemorrhage: U.S. and international perspectives. Crit Care 9:
S1–S9, 2005.
3. Martin M, Oh J, Currier H, et al: An analysis of in-hospital deaths at a
modern combat support hospital. J Trauma 66:S51–S61, 2009.
4. Kelly JF, Ritenour AE, McLaughlin DF, et al: Injury severity and causes of
death from Operation Iraqi Freedom and Operation Enduring Freedom:
2003–2004 versus 2006. J Trauma 64:11–15, 2008.
5. Holcomb JB, McMullin NR, Pearse L, et al: Causes of death in U.S. Special
Operations Forces in the global war on terrorism: 2001–2004. Ann Surg
245:986–991, 2007.
6. Eastridge BJ, Hardin M, Cantrell J, et al: Died of Wounds on the battle-
field: causation and implications for improving combat casualty care.
J Trauma 71:4–8, 2011.
7. Kotwal R, Montgomery H, Kotwal B, et al: Eliminating preventable death
on the battlefield. Arch Surg 146:1350–1358, 2011.
8. Kragh JF, Walters TJ, Baer DG, et al: Survival with emergency tourniquet
use to stop bleeding in major limb trauma. Ann Surg 249:1–7, 2009.
70 SECTION 2  /  DIAGNOSIS AND EARLY MANAGEMENT
9. White JM, Stannard A, Burkhardt GE, et al: The epidemiology of vascular
injury in the wars in Iraq and Afghanistan. Ann Surg 253:1184–1189,
2011.
10. Propper BW, Gifford SM, Calhoon JH, et al: Wartime thoracic injury:
perspectives in modern warfare. Ann Thorac Surg 89:1032–1035, 2010.
11. Morrison JJ, Clasper JC, Gibb I, et al: Management of penetrating
abdominal trauma in the conflict environment: the role of computed
tomography scanning. World J Surg 35:27–33, 2011.
12. Tien H, Spencer F, Tremblay L, et al: Preventable deaths from hemorrhage
at a level I Canadian trauma center. J Trauma 62:142–146, 2007.
13. Teixeira P, Inaba K, Hadjizacharia P, et al: Preventable or potentially pre-
ventable mortality at a mature trauma center. J Trauma 63:1338–1347,
2007.
14. Rotondo MF, Zonies DH: The damage control sequence and underlying
logic. Surg Clinics North Am 77:761–777, 1997.
15. Shapiro MB, Jenkins DH, Schwab CW, et al: Damage control: collective
review. J Trauma 49:969–978, 2000.
16. Loveland JA, Boffard KD: Damage control in the abdomen and beyond.
Brit J Surg 91:1095–1101, 2004.
17. Hatch QM, Osterhout LM, Podbielski J, et al: Impact of closure at the first
take back: complication burden and potential overutilization of damage
control laparotomy. J Trauma 71:1503–1511, 2011.
18. Higa G, Friese R, O’Keeffe T, et al: Damage control laparotomy: a vital
tool once overused. J Trauma 69:53–59, 2010.
19. Miller RS, Morris JA, Diaz JJ, et al: Complications after 344 damage-
control open celiotomies. J Trauma 59:1365–1374, 2005.
20. Borgman MA, Spinella PC, Perkins JG, et al: The ratio of blood products
transfused affects mortality in patients receiving massive transfusions at
a combat support hospital. J Trauma 63:805–813, 2007.
21. Duchesne JC, McSwain NE, Cotton BA, et al: Damage control resuscita-
tion: the new face of damage control. J Trauma 69:976–990, 2010.
22. Hodgetts TJ: Damage control resuscitation. J R Army Med Corps 153:
299–300, 2008.
23. Midwinter MJ: Damage control surgery in the era of damage control
resuscitation. J R Army Med Corps 155:323–326, 2009.
24. Duchesne JC, Kimonis K, Marr AB, et al: Damage control resuscitation
in combination with damage control laparotomy: a survival advantage.
J Trauma 69:46–52, 2010.
25. Cotton BA, Reddy N, Hatch QM, et al: Damage control resuscitation is
associated with a reduction in resuscitation volumes and improvement
in survival in 390 damage control laparotomy patients. Ann Surg 254:
598–605, 2011.
26. Davenport R, Curry N, Manson J: Hemostatic effects of fresh frozen
plasma may be maximal at red cell ratios of 1 : 2. J Trauma 70:90–96, 2011.
27. Holcomb JB, Zarzabal LA, Michalek JE, et al: Increased platelet : RBC
ratios are associated with improved survival after massive transfusion.
J Trauma 71:S318–S328, 2011.
28. Duchesne JC: Lyophilized fibrinogen for hemorrhage after trauma.
J Trauma 70:S50–S52, 2011.
29. Edens JW, Beekley AC, Chung KK, et al: Longterm outcomes after combat
casualty emergency department thoracotomy. J Am Coll Surg 209:188–
197, 2009.
30. Frezza E, Mezghebe H: Is 30 minutes the golden period to perform emer-
gency room thoratomy (ERT) in penetrating chest injuries? J Cardiovasc
Surg (Torino) 40:147–151, 1999.
31. Moore EE, Knudson MM, Burlew CC, et al: Defining the limits of resus-
citative emergency department. J Trauma 70:334–339, 2011.
32. Passos EM, Engels PT, Doyle JD, et al: Societal costs of inappropriate
emergency department thoracotomy. J Am Coll Surg 214:18–25, 2012.
33. Asensio J, Wall M, Minei J: Practice management guidelines for emer-
gency department thoracotomy. J Am Coll Surg 193:303–309, 2001.
34. Ledgerwood A, Kazmers M, Lucas C: The role of thoracic aortic occlusion
for massive hemoperitoneum. J Trauma 16:610–615, 1976.
35. Seamon MJ, Pathak AS, Bradley KM, et al: Emergency department tho-
racotomy: still useful after abdominal exsanguination? J Trauma 64:1–7,
2008.
36. White JM, Cannon JW, Stannard A, et al: Direct vascular control results
in less physiologic derangement than proximal aortic clamping in a
porcine model of noncompressible extrathoracic torso hemorrhage.
J Trauma 71:1278–1287, 2011.
37. Arthurs Z, Starnes B, See C, et al: Clamp before you cut: proximal control
of ruptured abdominal aortic aneurysms using endovascular balloon
occlusion. Vasc Endovasc Surg 40:149–155, 2006.
38. Assar A, Zarins C: Endovascular proximal control of ruptured abdominal
aortic aneurysms: the internal aortic clamp. J Cardiovasc Surg 50:381–
385, 2009.
39. Hughes C: Use of an intra-aortic balloon catheter tamponade for control-
ling intra-abdominal hemorrhage in man. Surgery 36:65–68, 1954.
40. Gupta BK, Khaneja SC, Flores L, et al: The role of intra-aortic balloon
occlusion in penetrating abdominal trauma. J Trauma 29:861–865, 1989.
41. Stannard A, Eliason JL, Rasmussen TE: Resuscitative endovascular
balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic
shock. J Trauma 71:1869–1872, 2011.
42. White J, Cannon J, Stannard A, et al: Endovascular balloon occlusion of
the aorta is superior to resuscitative thoracotomy with aortic clamping in
a porcine model of hemorrhagic shock. Surgery 150:400–409, 2011.
43. Avaro JP, Mardelle V, Roch A, et al: Forty-minute endovascular aortic
occlusion increases survival in an experimental model of uncontrolled
hemorrhagic shock caused by abdominal trauma. J Trauma 71:720–725,
2011.
44. Arlt M, Philipp A, Voelkel S, et al: Extracorporeal membrane oxygenation
in severe trauma patients with bleeding shock. Resuscitation 81:804–809,
2010.
45. Morrison JJ, Bramley K, Rizzo A: Liver trauma—operative management.
J R Army Med Corps 157:136–144, 2011.
46. DuBose J, Inaba K, Barmparas G, et al: Bilateral internal iliac artery liga-
tion as a damage control approach in massive retroperitoneal bleeding
after pelvic fracture. J Trauma 69:1507–1514, 2010.
 SECTION 3

Definitive
Management
Cardiac, Great Vessel, and
Pulmonary Injuries
DAVID V. FELICIANO
Introduction
Penetrating injuries to the heart and great vessels result in
significant prehospital mortality (50% to 70% for cardiac
wounds), so the numbers of patients undergoing operations
for such injuries are small even in the busiest civilian centers
or wartime hospitals. The same is true for penetrating wounds
to the nonhilar vessels of the lung parenchyma. With a systolic
pressure of 25 mm Hg in the pulmonary artery and its
branches, bleeding from injury to these vessels requires a tho-
racotomy in only 5% to 10% of cases. After blunt thoracic
trauma, the majority of injuries involve the chest wall (i.e.,
fractured ribs) or lung (i.e., pneumothorax, hemothorax). As
such, only 7% to 8% of patients with this injury pattern
require thoracotomy or median sternotomy. The most
common indications for thoracotomy are hemorrhage from
the lung; major arterial injury (i.e., blunt aortic injury; Chapter
10); rupture of the tracheobronchial tree or, rarely, blunt
cardiac rupture. There is a limited number of civilian or
military surgeons with extensive experience with the life-
threatening injuries described in this chapter.
Evaluation and Management in the
Emergency Center
Mechanism of Injury
Penetrating wounds that injure the heart, the thoracic great
vessels, or the hilum of the lung are often in a location referred
to as the “cardiac box,” which is the area between the nipples
from the sternal notch to the xyphoid process. Other penetrat-
ing wounds that increase the likelihood of injuries to these
structures are those that traverse the mediastinum (i.e., trans-
mediastinal wounds) and those to the thoracic outlet.
With blunt trauma to the chest, particularly from motor-
vehicle crashes, significant injuries to the heart and great
vessels (and occasionally the lung) may occur whether or not
the victim is restrained. Unrestrained victims with frontal or
lateral impact can sustain all of the previously described decel-
eration or direct blunt injuries to the chest wall or intratho-
racic structures. The most classic example of a deceleration
injury is when the forward motion of the victim’s thorax stops
abruptly on contact with the hub of the steering wheel. This
mechanism may cause varying degrees of traumatic disrup-
tion of the descending thoracic aorta most commonly at the
level of the ligamentum arteriosum (Chapter 10). Depending
9 
on the position of any shoulder-harness restraint and the
direction of impact, the innominate, carotid, subclavian, or
vertebral arteries may be prone to blunt injury. Blunt thoracic
vascular injury has also been reported as a result of air-bag
inflation and is more prone to occur in women of small stature
or in children. Recognition of air-bag inflation as a mecha-
nism of blunt thoracic injury is what prompted the National
Transportation Safety Administration’s decision to allow
selective deactivation of front passenger seat air bags in
1997.1
Advanced Trauma Life Support: Primary
Survey and Initial Resuscitation
Profoundly hypotensive patients with external hemorrhage at
or near the thoracic outlet, those with hemorrhage into the
pericardial sac or pleural cavity, or those with cardiac tampon-
ade (diagnosis by ultrasound) should undergo rapid sequence
or emergent endotracheal intubation in the emergency depart-
ment. Awake patients with more normal hemodynamics with
intrapleural blood or a pneumothorax, with or without ten-
sion physiology, should have a thoracostomy tube inserted in
the 5th intercostal space, midaxillary line. If this maneuver
drains 1000 mL or more of blood in the first 15 minutes after
tube insertion, the patient should be moved emergently to the
operating room (OR). In this scenario, the patient should be
placed on the operating table in the supine position with the
anesthesiologist and operating team present. If another
200 mL of blood drains out of the thoracostomy tube in the
next 15 minutes, the patient should be intubated.
The decision as to whether the incision should be an
anterolateral thoracotomy or a median sternotomy will
depend on the entrance location and the trajectory of any
penetrating wound, the results of the thoracic and pericardial
ultrasound, and the hemodynamic condition of the patient. If
the amount of bloody drainage stops before 1200 mL and the
patient has normal or near-normal hemodynamics, he or she
should be moved to the intensive care unit (ICU) for close
observation. Resumption of bleeding from the tube thoracos-
tomy at a rate of 100mL to 200 mL per hour over the next 2
to 4 hours should prompt urgent thoracotomy or median
sternotomy.
Any patient who is hypotensive from a pneumothorax, a
hemorrhage, or a cardiac tamponade requires large-bore
intravenous access for resuscitation, including placement of
either 14-gauge extremity vein catheters, large-bore 7.5 Fr
central venous catheter(s), or both. If there is concern about
73
 9  /  Cardiac, Great Vessel, and Pulmonary Injuries 73.e1

ABSTRACT
Patients with trauma to the heart, great vessels, or lungs
often die in the prehospital setting. As such, patients with
one or more of these injuries who arrive at the emergency
department (ED) have a chance of survival if rapid diagno-
sis and treatment are rendered. Resuscitative thoracotomy
is occasionally indicated in patients with penetrating tho-
racic injury, including those in extremis or those with recent
cardiac arrest.
Penetrating cardiac injury with tamponade is diagnosed
with ultrasound while intrapleural bleeding is evident on
chest x-ray or on placement of a tube thoracostomy. A
sternotomy or an anterolateral thoracotomy is used for
cardiac and great vessel injury exposure, and a variety of
techniques are available to control hemorrhage until suture
repair can be accomplished. Blunt cardiac trauma is uncom-
mon, is diagnosed with electrocardiogram, and mandates
admission with monitored intensive care.
Great vessel repair follows standard principles; and, in
the case of occlusion or contained disruption (i.e., pseu-
doaneurysm), a contrast-enhanced computed tomography
(CT) scan may be afforded to confirm extent and location
of injury. Patients who are hemodynamically normal may
also be candidates for conventional arteriography with or
without endovascular stent graft repair.
Fewer than 10% of patients with lung injury require
thoracotomy for hemorrhage control because most are
successfully managed with tube drainage. When thora-
cotomy is necessary, most injuries are successfully treated
with suture pneumonorrhaphy, stapled wedge resection,
or pulmonotomy (i.e., pulmonary tractotomy). Lobectomy
or pneumonectomy are rare and are reserved for hilar
injuries or extensive parenchymal injuries involving more
than 75% of a lobe.

Key Words:  cardiac injury,

cardiac tamponade,
great vessel injury,
endovascular stent graft,
lung injury,
pulmonary tractotomy
74 SECTION 3  /  DEFINITIVE MANAGEMENT
the original wounding mechanism having injured one of the
subclavian veins, the contralateral upper extremity or subcla-
vian should be used for venous access. Thoracic wounds in the
cardiac box or those with a transmediastinal trajectory that
might have injured the superior vena cava should prompt
placement of resuscitation lines into the common femoral
veins.
While the resuscitation fluid for patients with thoracic
trauma was lactated Ringer’s solution for 50 years, hypotensive
patients (systolic blood pressure <70 mm Hg) are now
managed with a strategy referred to as “damage control resus-
citation” (DCR).2 In essence, this protocol involves avoiding
administration of any fluid if the patient is mentating and has
a recordable blood pressure. Initial application of this hypo-
tensive resuscitation strategy allots for the fact that needless
administration of any fluid aimed at achieving an arbitrary
systolic blood pressure may lead to or worsen bleeding that
had otherwise nearly stopped (i.e., “pop the clot” phenome-
non). Avoidance of crystalloids such as normal saline or Ring-
er’s lactate also stems from recognition that even small
amounts of these fluids may dilute clotting factors and may
lead to a condition referred to as dilutional coagulopathy.
Damage control resuscitation is based on the early and bal-
anced use of thawed plasma, packed red blood cells (pRBC)
and platelets. Studies initiated from the wars in Iraq and
Afghanistan demonstrated that the balanced use of plasma,
pRBC, and platelets in a 1 : 1 : 1 ratio as part of a DCR strategy
conveyed a mortality benefit to severely injured patients.
Recent military studies have reported a mortality benefit with
the use of the antifibrinolytic medication tranexamic acid
(TXA), as well as administration of supplemental cryoprecipi-
tate as part of the DCR strategy.
Emergency center thoracotomy for resuscitation and
control of hemorrhage is indicated in a highly selected group
of patients. This maneuver also referred to as resuscitative
thoracotomy is performed in hospitals that do not have an
operating room in or immediately adjacent to the emergency
department. Reasonable indications to perform an emergency
center thoracotomy are as follows3,4:
1. Penetrating thoracic wound with agonal physiology or
recent cardiac arrest
2. Deteriorating shock or cardiac arrest after care has been
initiated in the emergency center.
3. Uncontrolled hemorrhage from the thoracic inlet or
emanating from a tube thoracostomy tube
4. Suspected subclavian vessel injury with intrapleural
exsanguination
5. Need for open cardiac massage or occlusion of the
descending thoracic aorta before laparotomy in the
operating room
6. Need for open cardiac massage or clamping of thoracic
aorta when countershock or closed chest cardiac massage
is ineffective (i.e., cardiopulmonary arrest)
Relative indications include a recent cardiac arrest associ-
ated with a flail or other chest wall abnormality, a blunt
trauma, or a pregnancy. Strong contraindications for the use
of resuscitative thoracotomy include penetrating trauma with
no signs of life in the field and blunt trauma with no signs of
life on arrival in the emergency center.5
A left anterolateral thoracotomy at the lower edge of the
male nipple is performed when a penetrating left thoracic
wound is present. When a penetrating right thoracic wound
is present and the patient is agonal on arrival, a bilateral
anterolateral thoracotomy (i.e., clamshell thoracotomy) is
performed. If intrapleural exsanguination from a suspected
injury to a subclavian vessel is believed to be present, an
anterolateral thoracotomy at a higher intercostal space is
appropriate. The primary goal of either a unilateral anterolat-
eral or bilateral anterolateral thoracotomy is to control hem-
orrhage from a wound to the heart, to a great vessel, or to the
lung or to release a cardiac tamponade. Whether suture repair
of the injured organ or vessel is appropriate in the emergency
department will depend on the following factors: (1) the mag-
nitude of the injury; (2) the success of temporary hemorrhage
control maneuvers; (3) the quality of lighting, and (4) the
availability of instruments and sutures.
An additional and important goal of resuscitative thora-
cotomy is to cross-clamp the descending thoracic aorta to
maintain any remaining central aortic pressure and perfusion
to the coronary and carotid arteries. One must be mindful in
these scenarios that applying a cross-clamp to the descending
thoracic aorta is more difficult through the higher left-sided
thoracotomy incisions. Thoracic aortic clamping is performed
by first lifting the posterolateral edge of the left lung out of
the hemithorax. Once the mediastinal pleura over the descend-
ing thoracic aorta and vertebral bodies is visualized, it is
opened with scissors. Next, the descending thoracic aorta is
encircled with the surgeon’s left index finger before the cross
clamp is applied. Subsequent maneuvers for cardiac massage
or repair include longitudinal pericardiotomy above the left
phrenic nerve; exposure of the cardiac wound or rupture; and
the use of fingers, staples, sutures, or balloons for control of
hemorrhage (Figs. 9-1 to 9-4).
Because of the cost and low survivability of emergency
center thoracotomy, the technique has been used more selec-
tively in recent years. The overall reported survival rate of 7%
to 10% is somewhat deceptive as it includes patients with
penetrating cardiac wounds who have a significantly better
outcome.6 In a report by Ivatury and colleagues, 16 of 22
patients with penetrating cardiac injury who arrived in the
emergency center without “detectable vital signs, cardiac
activity, or spontaneous respirations” were able to have resto-
ration of cardiac function with resuscitative thoracotomy.7 In
this same report, 8 patients (36%) survived without neuro-
logic sequelae. A more recent report on 283 patients undergo-
ing emergency department thoracotomy for penetrating
injury to the heart and great vessels documented worse out-
comes including a survival rate of 24% in patients with stab
wounds and only 3% in those with gunshot wounds.8 The
injury scenario with the highest survival rate following emer-
gency center thoracotomy is cardiac tamponade from an iso-
lated, anterior cardiac stab wound presenting with measurable
vital signs following a short prehospital transport.
For patients with penetrating wound(s) that may involve
the heart, arch, or great vessels who are hemodynamically
normal, it is appropriate to image the thorax to better char-
acterize the presence and location of injury. This can be
accomplished with a chest x-ray, which may demonstrate
hematoma in the superior mediastinum or in the supracla-
vicular area, or a contrast-enhanced CT scan. Standard trans-
femoral digital subtraction aortography may also be useful
and augmented with retrograde angiography of the axillary
and subclavian vessels via brachial artery or basilica vein
access in the upper extremity.
 9  /  Cardiac, Great Vessel, and Pulmonary Injuries 75

Phrenic nerve

Pericardial sac

Left
A lung

Sternum Left
Right (cut) lung
lung

Pericardial
B sac
FIGURE 9-1  A, A left anterolateral thoracotomy incision is made at the inferior edge of the male left nipple. In women, the left breast is
retracted superiorly and the incision is made at the midaspect of the left hemithorax. The Finochietto retractor is placed with the handle facing
the left side of the patient. B, Bilateral anterolateral thoracotomy.

The Injured Heart Incidence

History
Asensio and colleagues have reviewed the unsuccessful
attempts at cardiac repair by Cappelen in Norway and Farina
in Italy that preceded Ludwig Rehn’s successful repair of a
wound to the right ventricle in 1896.9,10 L.L. Hill of Montgom-
ery, Alabama, is credited with the first successful delayed repair
of a stab wound to the left ventricle in the United States in
1902.9,10 In the modern era, the vast majority of cardiac inju-
ries are from penetrating wounds and are treated in urban
trauma centers.11 Blunt cardiac injuries occur mostly after
head-on motor-vehicle crashes, can be caused by air bags, and
have a significant mortality that is often related to a delay in
diagnosis.12
Penetrating Trauma
Patients with penetrating cardiac injuries, especially from
gunshot wounds, have a 50% to 75% mortality rate at the
scene or on arrival at the hospital.13 This is secondary to acute
cardiac tamponade if the lateral walls of the pericardial sac are
intact or to exsanguination when there is communication with
a pleural cavity. Only rapid transport to a trauma center or
acute care hospital will save the lives of patients with repair-
able cardiac injuries and signs of life in the field. This is
because therapeutic procedures such as pericardiocentesis, an
open pericardial window, or an emergent anterolateral thora-
cotomy are not performed in the prehospital setting in the
United States or during military conflicts. To gain insight into
76 SECTION 3  /  DEFINITIVE MANAGEMENT

Left lung
Phrenic nerve
Aorta
Pericardial sac

FIGURE 9-2  In a patient with profound hypotension (or who has
suffered a cardiac arrest), the left lung is lifted out of the left chest by
the left hand of the surgeon or by an assistant on the other side of
the table. Having used the tip of an aortic clamp to spread the pleura
above and below the mid-descending thoracic aorta, the surgeon is
using the left index finger to encircle the aorta and pull it to the left
so that the clamp can be applied to under direct vision. (Adapted from
Copyright, Baylor College of Medicine, Houston, 1980.)
Left
lung
FIGURE 9-3  In the patient with a wound through the pericardial sac,
with blood underneath the pericardium, or with asystole, a left lon-
gitudinal pericardiotomy is made 1 cm to 2 cm above the left phrenic
nerve from the great vessels superiorly to the left hemidiaphragm
inferiorly. (Adapted from Copyright, Baylor College of Medicine, Houston,
1980.)

Swing heart into

left chest

Repair 1

Cardiac
massage

Repair 2

B Repair 3 C
FIGURE 9-4  A, After the left pericardiotomy, the heart is swung into the left chest. B, Atrial wounds are repaired over a Satinsky clamp, while
ventricular wounds are repaired by sewing under a finger and under adjacent coronary arteries. C, Patients with profound hypotension, elec-
tromechanical dissociation, or asystole undergo two-handed internal cardiac massage. (Adapted from Copyright, Baylor College of Medicine,
Houston, 1980.)

how uncommon these injuries are, one busy urban trauma
center in the United States that has a 30% incidence of
penetrating trauma treated 271 patients with cardiac injuries
from 1975 to 2010 (7.5 per year).14 During an earlier and
more violent era, another busy urban trauma center in the
United States treated 18 cardiac injuries per year for a 30-year
period.11
Blunt Trauma
In a recent review from the American College of Surgeons
National Trauma Data Bank, blunt cardiac rupture had an
incidence of 1/2400 admissions and occurred most commonly
after motor-vehicle crashes (73%) followed by automobile–
pedestrian accidents (16%). In this study, blunt cardiac injury
was determined to have an overall mortality of 89%.12
Presentation
Penetrating Trauma
Patients with stab wounds to the heart may present with
cardiac tamponade (60% to 90%), intrapleural hemorrhage
(10% to 40%), or both. In contrast, patients with gunshot
wounds present with cardiac tamponade (20%), intrapleural
hemorrhage (80%), or both. Cardiac tamponade is caused by
blood in an intact pericardial sac, which compresses the atria
and impairs venous return.15 The cardiovascular response to
decreased cardiac output is progressive tachycardia to com-
pensate for a decreased stroke volume. Pulsus paradoxus is
present in essentially all patients as well. While blood pressure
decreases by as much as 10 mm Hg with inspiration second-
ary to a decrease in left ventricular stroke volume, this decrease
may be 15 mm Hg or more in the setting of cardiac tampon-
ade. In the setting of tamponade there is a simultaneous
progressive rise in central venous pressure secondary to the
impaired venous return. In this scenario, patients often present
with a dusky or deathlike appearance that is noticeable regard-
less of race. Alert patients express extreme anxiety (“Am I
going to die?”) and frequently complain of a “heaviness” or
pressure in the chest.
If the diagnosis of cardiac tamponade is delayed, myocar-
dial ischemia and continuing decreases in cardiac output
occur. This spiral leads to cardiovascular collapse and cardiac
arrest in minutes in patients with wounds or ruptures of the
ventricles. In patients with wounds or ruptures of the atria,
compression of the hole by the extravasated blood in the peri-
cardium may stop further hemorrhage and progressive tam-
ponade. The main hemodynamic finding in such patients is a
progressive rise in central venous pressure to 20 mm Hg to
30 mm Hg with profound hypotension or a cardiac arrest as
the terminal event. The diagnosis of a compressed atrial
wound may go undiagnosed for 12 or more hours until clini-
cal suspicion prompts a pericardial ultrasound, a pericardial
window, a sternotomy, or a thoracotomy. In most reports, the
classic Beck’s triad of hypotension, distended cervical veins,
and muffled heart sounds is present in less than 10% of
patients with tamponade. The incidence of Kussmaul’s sign or
jugular venous distension with inspiration is difficult to deter-
mine. Hemorrhage from the injured heart into a pleural cavity
most often results from a gunshot wound in the cardiac box
or one with a transmediastinal trajectory. In this scenario, the
classic signs of hypovolemic shock are typically present.
Depending on the hemodynamic status of the patient, an early
9  /  Cardiac, Great Vessel, and Pulmonary Injuries 77
resuscitative thoracotomy, and not diagnostic tests, will be
necessary.
Blunt Trauma
Blunt cardiac injury (BCI) encompasses a spectrum of trauma
including myocardial bruising (myocardial contusion), trans-
mural infarction, or a rupture of the free wall or septum. This
spectrum of cardiac injury has been described in the Ameri-
can Association for the Surgery of Trauma’s Organ Injury
Scale reported in 1994.16 Clinical manifestations that the
trauma team must treat in rare patients include unexplained
hypotension, new-onset arrhythmias, or cardiac tamponade.
Diagnosis
Penetrating Trauma
Other than physical diagnosis, diagnostic options for patients
with penetrating injuries (or blunt ruptures) with secondary
tamponade include (1) measurement of central venous pres-
sure, (2) pericardiocentesis, (3) subxyphoid pericardial win-
dow, (4) transthoracic or transesophageal ultrasound, and (5)
transthoracic ultrasound (part of a FAST [focused assessment
with sonography for trauma] examination). Measurement of
central venous pressure is invasive, time consuming, and may
not confirm the diagnosis of cardiac tamponade immediately.
It is appropriate to use when there is no desire to anesthetize
the stable patient to perform a diagnostic subxyphoid pericar-
dial window or when the ultrasound machine is broken or
unavailable. Any 10 mm Hg increase in central venous pres-
sure over time in the relaxed supine patient receiving only
maintenance intravenous fluids should prompt a median ster-
notomy or thoracotomy.
A pericardiocentesis has a therapeutic effect in the patient
with cardiac tamponade and hemodynamic instability.
However, the diagnostic sensitivity of this maneuver in the
stable patient with a small tamponade has always been ques-
tioned.17 To rule out aspiration of intracardiac blood mistaken
as an early tamponade, the long spinal needle used to for the
pericardiocentesis should be attached to a monitor lead to rule
out a current of injury as the cardiac wall is penetrated.
An open surgical subxyphoid pericardial window is per-
formed under general anesthesia and mandates a bloodless
operative approach.18 It is most helpful during an emergency
laparotomy after a gunshot or stab wound when the track of
the missile or knife appears to be in proximity to or appears
to penetrate the pericardial sac. Also, it is used in many centers
around the world when nonsurgeon or surgeon-performed
ultrasound is unavailable or when there is not acceptable
accuracy. The operative approach is through a 5 cm to 10 cm
midline incision starting on the xyphoid process, which may
be excised as needed for exposure. The linea alba is divided,
and extraperitoneal dissection is performed bluntly in a supe-
rior direction toward the pericardium.
Exposure is enhanced by lifting the xiphoid process (if still
in place) and the lower sternum up with one medium Rich-
ardson retractor or two Army-Navy retractors. Once cardiac
pulsations are palpated, the inferior pericardial sac is grasped
with two long Allis clamps, and a 2-cm vertical pericardiot-
omy is made between the clamps. If this maneuver results in
the release of blood from the pericardial sac, most centers
transition immediately to a median sternotomy followed by a
longitudinal pericardiotomy, evacuation of the tamponade,
78 SECTION 3  /  DEFINITIVE MANAGEMENT
Liver
Blood
Heart Vena cava
FIGURE 9-5  Cardiac tamponade detected on surgeon-performed
ultrasound using a 3.5 mHz transducer.
and control of bleeding. Patients who manifest progressive
hemodynamic deterioration during the subxyphoid pericar-
dial window should undergo left anterolateral thoracotomy
and opening of the pericardium through that approach. Some
centers choose to wash blood out of the pericardial sac after
a positive window in the reasonably stable patient and to
observe for further bleeding without opening the pericardial
sac further. The rationale for this approach is that pericardial
wounds only or wounds that injure the cardiac wall superfi-
cially (epicardium and outer myocardium) may have stopped
bleeding by the time the pericardial window has been per-
formed.19 Should there be no further bleeding during a period
of intraoperative observation with the pericardial sac open, a
few groups around the world close the incision without per-
forming a median sternotomy or anterolateral thoracotomy.19-22
A formal transthoracic or transesophageal ultrasound per-
formed by a cardiologist or anesthesiologist is an accurate
technique to detect cardiac tamponade. This maneuver can
also diagnose intracardiac lesions such as septal defects or
valvular injuries and can also calculate an ejection fraction.
Unfortunately, the majority of penetrating cardiac injuries
come to the emergency department on weeknights or week-
ends when the specialists who perform formal transthoracic
or transesophageal ultrasounds are not available. Additionally,
the sedation required to properly perform transesophageal
echocardiography would be contraindicated in the unstable
patient with this injury scenario.
Over the past 15 years, reports have been documented that
transthoracic echocardiography performed in the emergency
center by surgeons or specialists in emergency medicine using
a 3.5 MHz general access transducer is the diagnostic test
of choice23-25 (Fig. 9-5) (Table 9-1). The FAST examination
begins with a pericardial view in patients with either penetrat-
ing or blunt trauma. During the FAST, the probe is placed in
a longitudinal direction in the subxyphoid area at an angle of
30 degrees off the epigastrium with firm pressure. This usually
results in a clear view of the apex of the heart, the pericardium,
and the left lobe of the liver. The beating heart in this real-time
ultrasound approach should lie immediately adjacent to the
liver. Should tamponade be present, a black stripe will separate
the beating heart from the liver. The black or anechoic stripe
Table 9-1 Accuracy of Transthoracic
Ultrasound in Diagnosing Cardiac
Tamponade
Number of True-
Author Patients Positives Accuracy
23
Rozycki et al, 1996 236 10 100%
Rozycki et al, 199824 313 22 99.4%*
Rozycki et al, 199925 261 29 97.3%†
*2 false-positives, no false-negatives.
†
7 false-positives, no false-negatives.
with an ultrasound density that is the same as blood in the
inferior vena cava represents blood outside the heart or rep-
resents a tamponade. Failure to visualize an adequate sagittal
view through the subxyphoid window is often secondary to
the patient’s complaining about pain or discomfort. This
cardiac window may also be diminished in obese patients.
The ultrasound probe is next placed in a horizontal direc-
tion in the 4th or 5th left parasternal space to obtain a coronal
view of the same cardiac structures. In the study by Rozycki
et al, 246 patients with penetrating thoracic wounds were
evaluated by surgeon-performed ultrasound.23 There were 236
true-negative results and 10 true-positive results. In the latter
group, the mean time from ultrasound to operation was 12
minutes. In this study, all patients survived after repair of their
cardiac wounds. A follow-up study by Rozycki et al in 313
patients with penetrating precordial or transthoracic wounds
resulted in 289 true-negative examinations, two false-positive
examinations, and 22 true-positive examinations.24 In the
latter group, all patients survived when surgery was immedi-
ately performed by the surgeon-sonographer. Finally, Rozycki
et al completed a multicenter study in which emergency peri-
cardial sonograms were performed by ultrasound technicians,
cardiologists, or surgeons.25 In a series of 261 patients with
penetrating precordial or transthoracic wounds evaluated at
five Level I trauma centers, 29 (11%) had true-positive studies,
and 28 survived after emergency cardiac repair. The accuracy
(97%), specificity (97%), and sensitivity (100%) were equiva-
lent to those reported in the previous study from Grady
Memorial Hospital.23
Blunt Trauma
As previously noted, 90% of blunt cardiac injuries are caused
by precordial trauma sustained during motor-vehicle or
automobile–pedestrian crashes. Arrhythmias such as sinus
tachycardia, premature atrial or ventricular contractions, and
heart block are the most common manifestations of blunt
cardiac injury.26 For this reason, admission electrocardiogram
(ECG) is the most logical diagnostic technique of choice. The
usefulness of an ECG is often discounted by studies advocat-
ing radioisotope scanning, transthoracic echocardiography
(TTE), and transesophageal echocardiography (TEE) as diag-
nostic modalities for blunt cardiac injury. However, multiple
reports have documented that an ECG is an excellent initial
test when evaluating patients with blunt thoracic trauma.27,28
In essence, these studies have shown that a normal ECG in the
emergency department effectively excludes significant blunt
cardiac injury.
There has been renewed interest in using a measure of
serum cardiac troponin I (TnI) in addition to the admission

ECG to detect blunt cardiac injury. In one study from Los
Angeles County Hospital, 27 of 80 patients (34%) with an
abnormal ECG and TnI level after blunt chest trauma devel-
oped significant BCI.29 Blunt cardiac injury in this and other
studies is defined as arrhythmias requiring treatment, cardio-
genic shock, or cardiac structural injury. The authors con-
cluded that a normal ECG and serum TnI on admission and
8 hours after injury excluded blunt cardiac injury. Transtho-
racic or transesophageal echocardiography may be used as an
adjunct in patients with persistent ECG abnormalities or with
hypotension after blunt chest trauma.
Nonoperative Management of Blunt Trauma
Admission to the hospital for a possible or likely blunt cardiac
injury is justified when the following are present after signifi-
cant chest trauma: (1) history of cardiac disease (i.e., angina
pectoris, myocardial infarction, arrhythmias, coronary revas-
cularization); (2) unexplained hypotension; and (3) new onset
arrhythmia or conduction disturbance on an admission ECG.
A patient with blunt chest trauma and a history of cardiac
disease or the presence of non–life-threatening arrhythmias
such as sinus tachycardia or atrial fibrillation should be admit-
ted to a telemetry unit for monitoring and observation. When
hypotension is present or when the ECG change is potentially
lethal (i.e., ventricular tachycardia, ventricular fibrillation,
third-degree heart block) treatment is initiated in the emer-
gency center before transfer to the intensive care unit.
When an operation for another injury is indicated in a
patient with blunt cardiac injury, not including cardiac
rupture, the prognosis is generally excellent. In the report by
Flancbaum et al, 19 patients with blunt cardiac injury had an
emergency operation, including 15 on the day of admission.30
Pulmonary artery catheters were placed in 12 patients, and
inotropes were used in 11. The duration of anesthesia was 6
hours, and there were no cardiac-related complications or
deaths.
Operative Management in the Emergency
Department and Operating Room
Incisions
As previously noted, left or bilateral anterolateral thoracotomy
(i.e., clamshell thoracotomy) is performed in the emergency
department for release of tamponade, for control of cardiac
hemorrhage, and for resuscitation. The same incision(s)
would be used in the operating room for agonal patients or
for those having gone into cardiac arrest particularly following
transmediastinal gunshot wounds. These incisions allow for
expedited control of hemorrhage from cardiac perforation(s)
and for cross-clamping of the descending thoracic aorta. The
anterolateral thoracotomy approach may also be kept separate
from any abdominal midline incision needed to address
intraabdominal injury. The median sternotomy is performed
in the operating room in patients who are more hemodynami-
cally stable and who have solitary anterior stab wounds. In
such patients, multiple cardiac perforations are unlikely and
cross-clamping of the descending thoracic aorta is usually not
needed.
Pericardiotomy
Opening of the left chest via an anterolateral thoracotomy
requires a Finochietto retractor after which a longitudinal left
9  /  Cardiac, Great Vessel, and Pulmonary Injuries 79
lateral pericardiotomy can be performed anterior to the left
phrenic nerve. In obese patients where fat obscures the phrenic
nerve, the accompanying pericardial-phrenic vessels mark the
location. Even if the pericardium is difficult to grab with a
forceps secondary to distention of the sac with blood, the
surgeon should resist performing a pericardiotomy with a
scalpel. This is a particularly dangerous as right-sided tam-
ponade from a wound to the atrium or ventricle may push the
heart to the left so that it lies immediately underneath or abuts
the left pericardial sac. In this position, the left anterior
descending coronary artery is at risk of injury if a scalpel is
passed too deep while opening the pericardium. A better tech-
nique is to lift the pericardium with a toothed forceps and to
open the sac with the tip of a straight Mayo scissors. Once it
has been opened, the pericardium generally lifts away from
the surface of the heart allowing the incision to be extended
in a superior direction until the pericardial fold on the great
vessels is reached. The longitudinal left pericardiotomy is
completed in an inferior direction until the left hemidia-
phragm is reached. Exposure of the injured heart is enhanced
by making a transverse opening as well. This pericardial inci-
sion is made at a right angle to the left lateral pericardiotomy
and extends to 1 cm anterior to the right phrenic nerve.
In patients undergoing a bilateral anterolateral thoracot-
omy, either the pericardiotomy described above or the midline
pericardiotomy described below can be used. After a median
sternotomy and insertion of a Finochietto retractor, the epi-
cardial fat and the anterior extensions of the parietal pleura
are swept laterally with the fingers over laparotomy pads. This
maneuver exposes the anterior surface of the pericardial
sac which is grasped with toothed forceps and opened in a
midline longitudinal direction from the great vessels to the
diaphragm.
Control of Hemorrhage from the Heart (Table 9-2)
After the pericardiotomy is performed, blood and thrombus
are removed from the pericardial sac manually and with irri-
gation and suction. A rapid inspection of the anterior surface
of the heart and great vessels is performed. If no anterior
perforation or blunt rupture is noted, the surgeon should note
the patient’s blood pressure on the monitor. A profoundly
hypotensive patient may not tolerate inspection of the poste-
rior aspect of the heart, which requires elevation of the apex.
Lifting the heart to inspect the underside compresses or kinks
the vena cava, restricting right-sided filling. This maneuver
also carries with it a risk of sucking air into an open
Table 9-2 Techniques for the General Surgeon
to Control Hemorrhage from a
Cardiac Perforation or Rupture
Finger Atrium/ventricle
Stapler Atrium/ventricle
Satinsky vascular clamp Atrium
Row of Allis clamps Lateral atrium adjacent to
pericardium or atrium
adjacent to ventricle
Foley balloon catheter Atrium/ventricle
Crossed mattress sutures Ventricle
Inflow (superior vena cava/ Large ventricular hole or
inferior vena cava) occlusion multiple chamber wounds
3-mg intravenous adenosine to induce 10 to 20 seconds asystole.
80 SECTION 3  /  DEFINITIVE MANAGEMENT
hypovolemic ventricle. With left ventricular perforation, air
has the potential to rapidly move into the coronary arteries
causing an air embolism and cardiac arrest. As such, manual
palpation of the posterior surface of the heart without eleva-
tion of the apex is all that is advised until the patient is resus-
citated with a relatively normal blood pressure. Palpation of a
posterior defect or jet of blood as a ventricle contracts man-
dates leaving the finger in place for control of hemorrhage
until the aforementioned status can be reached.
Once the patient has been stabilized and the surgeon is
ready to lift the apex of the heart to inspect the posterior
aspect, he or she should notify the anesthesia team so that they
are aware and can assist in managing any associated hypoten-
sion. If there is bleeding from this posterior aspect of the heart
that will require prolonged elevation and/or suturing, the
surgeon should consider placing a cross-clamp on the descend-
ing thoracic aorta to preserve central pressure and cerebral
circulation.
A finger or compression with fingers will control hemor-
rhage from cardiac perforation or cardiac rupture in 95% to
96% of patients. This is because patients with larger defects
die at the scene or in transit and are generally not alive to
undergo operation. Suture repair of a ventricular wound can
be performed under the occluding finger. When a finger is not
successful in controlling bleeding or when more definitive
control is needed, the techniques in Table 9-2 may be applied.
Disposable skin staplers with long rotating heads have been
used to quickly close atrial or ventricular defects for over 2
decades.31-33 Whether staple repair lines placed in the emer-
gency department should be buttressed or replaced with
sutures in the operating room is controversial. The safest
policy is to buttress any ventricular repair with Teflon pledgets
in the operating room in patients who stabilize after the initial
hemorrhage control and resuscitation maneuvers.
Elevation of an atrial wound with the fingers, forceps, or
Allis clamps will frequently allow placement of a Satinsky
vascular clamp under the perforation. Suture repair of the
laceration can then be performed in a bloodless field. Atrial
wounds or ruptures in the lateral aspect adjacent to the peri-
cardium or anteriorly or posteriorly adjacent to the ventricle
cannot be controlled with a Satinsky. With these injuries, Allis
clamps grabbing both sides of the defect are placed in a row
similar to the method described for wounds to the vena cava
for the past 100 years. Use of a Foley balloon catheter to
control hemorrhage from a difficult cardiac location after a
penetrating wound was first described in 1966.34 Insertion of
the tip and balloon of the catheter into the defect is followed
by inflation of the balloon and gentle traction on the end of
the catheter hanging out of the heart.
On rare occasions, the length of a ventricular laceration
will lead to exsanguinating hemorrhage that will preclude the
use of the stapler or the balloon catheter. With manual com-
pression of the defect, a horizontal mattress suture is rapidly
placed on either side of the defect, the two ends on each side
are placed in the hands, and the hands holding the suture ends
are crossed. This should prevent exsanguination as a continu-
ous over-and-over suture row or a row of staples is placed. A
temporary closure as described would then be buttressed with
Teflon pledgets in the operating room.
Because few trauma surgeons are familiar with the biman-
ual technique for control of hemorrhage from the heart
described over a century ago by Ernst Ferdinand Sauerbruch
(1875-1951), the related technique of inflow occlusion is used
occasionally to control major hemorrhage from the heart.
Inflow occlusion was popularized during World War II by the
late Dwight E. Harken (1910-1983) as a technique to slow the
heart and to allow for removal of intracardiac foreign bodies.35
With difficult-to-visualize cardiac wounds or with large ven-
tricular wounds, as described above, application of vascular
clamps to the superior and inferior vena cavae is appropriate.
This maneuver decreases hemorrhage from the injured heart
and rapidly causes a profound bradycardia. The decreased
blood in the operative field and a low heart rate will allow for
clamp or suture control of hemorrhage from complex cardiac
wounds. Prior to tying down the last suture of a ventricular
repair, the clamps on the cavae are removed to allow for refill-
ing of the ventricle. Evacuation of ventricular air is accom-
plished by elevation of the apex of the heart as refilling occurs
and before the final suture of the repair is tied down. The exact
time limit on inflow occlusion is unknown, but 1 to 2 minutes
will usually allow for a restoration of a cardiac rhythm after
the repair has been completed.
There have been several reports about the administration
of 3 mg of adenosine intravenously to aid in the repair of
cardiac injuries.36,37 Approximately 20 seconds after adminis-
tration of adenosine, the heart will stop beating (i.e., induced
asystole) for 10 to 25 seconds allowing for initiation of a rapid
suture repair. Further intravenous doses are given to complete
the repair as needed. The annoying side effects associated with
adenosine use, including facial flushing, thoracic discomfort,
dyspnea, and headache, are not noticeable under general
anesthesia.
Restoring a Cardiac Rhythm
After hemorrhage has been controlled, patients with preter-
minal bradycardia or new onset asystole need immediate
cardiac resuscitation. If the heart feels empty, the descending
thoracic aorta should be cross-clamped if this has not been
performed previously. If a median sternotomy was the original
approach, a left anterolateral thoracotomy will have to be per-
formed to complete this maneuver. Cardiac resuscitation
should also be aided with administration of blood compo-
nents as part of DCR, along with bimanual cardiac massage
to perfuse the coronary and carotid arteries. It is critical
not to lift the apex of the heart because this may cause
impingement of the vena cavae or the previously described
air embolism from the partially empty cardiac chamber with
perforation.
When the heart does not respond to the infusion of volume
and internal cardiac massage, cardioactive medications should
be administered. These include 1 mg intravenous atropine for
bradycardia, 1 mg to 3 mg intravenous epinephrine for bra-
dycardia and hypotension, or 1 mg to 3 mg of intracardiac
(into left ventricle) epinephrine for profound bradycardia or
asystole. The onset of ventricular fibrillation is treated with
internal electrical defibrillation using two paddles in contact
with the heart anteriorly and posteriorly and 20 Ws as the
initial electrical charge. After restoration of a satisfactory
cardiac rhythm and blood pressure, suture repair of the
cardiac perforation may be performed.
Suturing Techniques
Suturing of the injured heart is often complicated by tachy-
cardia and the side-to-side motion of the heart in the

pericardial sac. A most helpful maneuver to stabilize the
beating heart as repair is being performed is “clamp control
of the right ventricular angle” as described at Temple Univer-
sity.38 To accomplish this maneuver, a Satinsky clamp is applied
to the apex of the right ventricle, and an assistant holding on
to this clamp will eliminate much of the side-to-side motion
of the beating heart.
Repair of an atrial perforation or rupture above a Satinsky
is performed with a pursestring or continuous 4-0 or 5-0
polypropylene suture. An alternate approach to a hole in the
atrial appendage is to place a 2-0 silk tie under the Satinsky
clamp much like in performing a decannulation maneuver
following cardiopulmonary bypass. As noted, Allis clamps are
used to control hemorrhage from atrial wounds in the lateral
aspect adjacent to the pericardium or in those adjacent to the
ventricle. Repair is accomplished with a continuous or inter-
rupted mattress technique using 4-0 polypropylene suture
passed under the row of Allis clamps.
With a wound of the ventricle being controlled by the
surgeon or the assistant’s finger, horizontal mattress 3-0 or
4-0 polypropylene sutures can be placed under the finger and
tied.39 When a Foley balloon catheter has been used to control
hemorrhage from a ventricle, the surgeon must be mindful
that placement of the sutures for the cardiac repair can rupture
the underlying balloon. Therefore, as the continuous 3-0 or
4-0 polypropylene sutures are placed around the controlled
defect, the balloon must be temporarily pushed down into
the ventricle with each passage of the needle. Hemorrhage
will occur with this maneuver, but rupture of the balloon is
prevented.
Teflon pledgets are used to buttress ventricular repairs
performed with sutures alone in the emergency department
and any repairs performed in the operating room. Commer-
cially available pledgets or pledgets cut from Teflon strips
may be used. When synthetic pledgets are not available, pieces
of the pericardium may be used. The technique is to first pass
the two needles of a 4-0 polypropylene suture through a
pledget 6 mm to 10 mm long and 3 mm to 5 mm wide. The
same needles are separately passed through both sides of the
ventricular perforation under the surgeon or assistant’s finger
as described above. The two needles are then passed through
another Teflon pledget of similar size and then cut off. As the
two ends are pulled up tight, the second pledget is moved
down to its side of the ventricular wound aided by ample
irrigation on the monofilament sutures. Tying the polypro-
pylene suture with appropriate tension will bring the Teflon
pledgets in apposition, will seal the cardiac perforation, and
will prevent the sutures from tearing through edematous
myocardium.
One technique for a cardiac surgeon to repair a wound is
the use of a sutureless patch and bioglue. This technique
appears to be most useful for small wounds in difficult-to-
repair areas of the heart, such as the coronary sinus.40 Cardiac
wounds adjacent to a coronary artery are repaired with pled-
gets as described above, but the needles are passed through
both sides of the ventricular perforation and under the adja-
cent coronary artery. Even with this modified technique, tying
the pledgets together to once again control hemorrhage may
cause compression of the coronary artery and ischemia of the
distal myocardium. A direct, but limited, laceration of a proxi-
mal coronary artery may be repaired with interrupted single
6-0 or 7-0 polypropylene sutures on rare occasions. In
9  /  Cardiac, Great Vessel, and Pulmonary Injuries 81
contrast, a laceration of a distal coronary artery near the apex
of the heart is treated with ligation and a 15-minute period of
observation to assess myocardial ischemia.
Acute Need for Cardiopulmonary Bypass
The majority of patients who reach the hospital with signs of
life despite a cardiac perforation or rupture have a limited
injury that can be repaired by a general surgeon or by a senior
surgical resident. Approximately 3% to 4% of such patients
have a more complex injury that can only be repaired by a
cardiac surgeon using cardiopulmonary bypass (Table 9-3).
Only 0.5% to 2% of cardiac injuries will require the use of
cardiopulmonary bypass14,41 (Fig. 9-6).
Treatment in the Operating Room
After Cardiorrhaphy
If a left anterolateral or bilateral anterolateral thoracotomy has
been performed, the superior and inferior transected ends of
the internal mammary arteries should be clamped and ligated
with 3-0 silk ties. As the heart is usually edematous after a
repair, the pericardial sac is not closed if a median sternotomy
and midline pericardiotomy have been used for exposure. On
Table 9-3 Indications for Cardiopulmonary
Bypass for Cardiac Injuries
Acute
Unable to complete repair because of size and location
Repair fails after blood pressure stabilizes or inotropes are
administered
Injury to proximal coronary artery treated by ligation (off
pump bypass appropriate in certain patients)
Delayed
Injury to cardiac valve, papillary muscle, chordae tendinae, or
atrial or ventricular septum
Intracardiac fistula
Late pseudoaneurysm of ventricular repair
Left anterior
descending
coronary artery
Emergency
aortocoronary
bypass
Left
Left lung
ventricular
stab wound
repair
FIGURE 9-6 Repair of left ventricular stab wound compressed the
adjacent left anterior descending coronary artery and prompted an
emergency aortocoronary bypass to restore perfusion.
82 SECTION 3  /  DEFINITIVE MANAGEMENT
occasion, there may appear to be a risk of postoperative
cardiac herniation through a left lateral pericardiotomy per-
formed through a left anterolateral thoracotomy. Closure of
this lateral defect with interrupted 2-0 silk sutures would then
be appropriate. The pericardial sac is drained with a right-
angle 36 Fr thoracostomy tube inserted through the epigastric
area of the abdominal wall. A second 36 Fr thoracostomy tube
is placed anterior to the heart. If either pleural cavity has been
opened, one or two 36 Fr thoracostomy tubes are placed
through the 5th intercostal space between the ipsilateral ante-
rior and middle axillary lines.
On occasion, epicardial pacing wires may have to be sewn
to the heart when arrhythmias continue despite cardiac repair
and resuscitation. An unstable patient who is not fully respon-
sive to continuing resuscitation and inotropes may benefit
from the transfemoral insertion of an intraaortic balloon
pump before transfer to the intensive care unit. Certain
patients will not tolerate wire closure of the sternum after a
cardiac repair, presumably due to compression of the edema-
tous heart. A plastic silo (a genitourinary irrigation bag opened
on three seams) should be sewn to the skin edges of the
median sternotomy with continuous sutures of 2-0 nylon as
a temporary closure maneuver. As the patient enters the
diuretic phase of recovery in the subsequent 48 to 72 hours,
the silo is removed; and the sternum is closed at a
reoperation.
Major Complications
Cardiac Failure
Cardiac failure after repair of a traumatic injury may require
the use of inotropic medications and/or an intraaortic balloon
pump. Possible causes of cardiac failure in these cases are as
follows: (1) tamponade from a coagulopathy, hemorrhage
from the repair, or hemorrhage from missed injury; (2) cardiac
compression from closure of the sternum; (3) posttraumatic
acute myocardial infarction without injury to a coronary
artery42; (4) posttraumatic acute myocardial infarction with
injury to a coronary artery; and (5) undiagnosed injury to a
cardiac valve, a papillary muscle, the chordae tendinae, or the
atrial or ventricular septum. An immediate ECG, transtho-
racic ultrasound, and TTE assist in making this diagnosis and
the diagnoses of scenarios 1, 3, 4, and 5 listed above. Cardiac
compression from closure of the sternum is unusual and
remains the diagnosis of exclusion.
Delayed Diagnosis of Intracardiac Lesions
For more than 55 years, it has been recognized that patients
who survive acute repair of a wound or rupture of the atrium
or ventricle may also have an internal cardiac injury.43 Post-
operative cardiac failure or the presence of a murmur on
auscultation in a previously healthy patient are clinical signs
of such an internal injury. Other patients, particularly those
with internal fistulas (i.e., right atrium to left ventricle) may
be asymptomatic in the postoperative period.44 While some
disagree, most centers study all surviving patients with trans-
thoracic echocardiography before discharge. Abnormal or
inconclusive studies are then followed by a TEE or a cardiac
catheterization. In a recent study of 109 patients who survived
penetrating cardiac injury at Los Angeles County Hospital,
17% were found to have abnormalities on TTE (Table 9-4).45
Of interest, none of these patients required a reoperation for
Table 9-4 Abnormalities on Postoperative TTE
on 19 of 109 Patients (17.4%) Who
Each Survived a Penetrating
Cardiac Injury at Los Angeles
County Hospital, 2000-2010
Abnormality Number of Patients
Pericardial effusion 9
Abnormal wall motion 8
Ejection fraction <45% 8
Intramural thrombus 4
Valve injury 4
Cardiac enlargement 2
Conduction abnormality 2
Pseudoaneurysm 1
Aneurysm 1
Septal defect 1
Adapted from Tang AL, Inaba K, Branco B, et al: Postdischarge com-
plications after penetrating cardiac injury: a survivable injury with a
high postdischarge complication rate. Arch Surg 146: 1061–1066,
2011.
these findings. Patients with hemodynamically significant
injuries, particularly those to a valve, a papillary muscle, the
chordae tendinae, or the septum should have delayed repair
on cardiopulmonary bypass40,44,46 (Table 9-3). When consider-
ing all patients who require cardiopulmonary bypass for
repair of cardiac trauma those requiring its use in the delayed
setting account for 85% to 90% of cases.
Survival
Survival after penetrating cardiac trauma depends on the
mechanism of injury (stab versus gunshot), the number of
signs of life on admission (cardiovascular and respiratory
components of trauma score), the location of the thoracot-
omy (emergency department versus operating room), the
cardiac rhythm at time of the pericardiotomy (rhythm versus
asystole), the number of chambers injured, and the associated
injuries.9,14,47 Survival rates from a large series over the past
decade are listed in Table 9-5.
Injuries to the Great Vessels
Definition/Classification
The great vessels in the chest and thoracic outlet are variously
defined, but most consider this category to include the large
vessels originating from the aortic arch and those in what is
traditionally considered zone I of the neck. In this context, the
terminology may also include the ascending, transverse, and
proximal descending aorta as well as the innominate (brachi-
cephalic), common carotid and the subclavian arteries.
Because of their sizes and proximal locations, the innominate
and central jugular veins may also be included as great vessels
of the chest. Table 9-6 provides The American Association for
the Surgery of Trauma Thoracic Vascular Organ Injury Scale
for vascular trauma in this region.16
History
Several authors have cited the repair of a stab wound of the
ascending aorta in 1922 by Dfhanelidze in Russia as one of the
 9  /  Cardiac, Great Vessel, and Pulmonary Injuries 83

Table 9-5 Survival Rates After Penetrating Table 9-6 Thoracic Vascular Organ Injury
Cardiac Injuries Scale
Asensio Grade* Injury Description† ICD-9 AIS-90
et al* Morse et at†
I Intercostal artery/vein 901.81 2-3
1994- 1975- 1986- 1996- Internal mammary artery /vein 901.82 2-3
1996 1985 1996 2010 Bronchial artery/vein 901.89 2-3
Esophageal artery/vein 901.9 2-3
Patients 105 113 79 79 Hemiazygos vein 901.89 2-3
SW/GSW 37/68 77/36 53/26 34/45 Unnamed artery/vein 901.9 2-3
Survival SW 24/37 59/77 47/53 26/34 II Azygous vein 901.89 2-3
(65%) (77%) (89%) (76%) Internal jugular vein 900.1 2-3
Survival GSW 11/68 23/36 15/26 20/45 Subclavian vein 901.3 3-4
(16%) (64%) (58%) (44%) Innominate vein 901.3 3-4
Survival Overall 35/105 82/113 62/79 46/79 III Carotid artery 900.01 3-5
(33%) (73%) (78%) (58%) Innominate artery 901.1 3-4
Subclavian artery 901.1 3-4
Survival EDT 10/71 2/23 13/28 9/16
(14%) (9%) (46%) (56%) IV Thoracic aorta, descending 901.0 4-5
Inferior vena cava (intrathoracic) 902.10 3-4
EDT, Emergency department thoracotomy. Pulmonary artery, primary 901.41 3
*Data from Asensio JA, Berne JD, Demetriades D, et al: One hundred intra-parenchymal branch
five penetrating cardiac injuries: a 2-year prospective evaluation. Pulmonary vein, primary 901.42 3
J Trauma 144:1073–1082, 1998. intra-parenchymal branch
†
Data from Morse BC, Carr JS, Dente CJ, et al: Penetrating cardiac V Thoracic aorta, ascending and 901.0 5
injuries: a 36-year perspective at an urban, level I trauma center. arch
J Trauma Acute Care Surg. Publication pending. Superior vena cava 901.2 3-4
Pulmonary artery, main trunk 901.41 4
Pulmonary vein, main trunk 901.42 4
earliest examples of a repair of a great vessel injury.48,49 Emer- VI Uncontained total transection of 901.0 5
thoracic aorta or pulmonary 901.41 4
gency ligation of injured great vessels and delayed repair of hilum 901.42
aneurysms and arteriovenous fistulas of the same were
described in reports after World War II.50-52 The earliest civil- From Moore EE, Malangoni MA, Cogbill TH, et al: Organ injury scaling
ian reports on techniques of exposure and repair of great IV. Thoracic vascular, lung, cardiac, and diaphragm. J Trauma
36:299–300, 1994.
vessel trauma (exclusive of blunt rupture of the thoracic aorta) *Increase one grade for multiple grade III or IV injuries if >50% cir-
were from Johns Hopkins and Baylor College of Medicine.53-55 cumference. Decrease one grade for grade IV and V injuries if <25%
circumference.
†
Based on most accurate assessment at autopsy, operation, or radio-
Incidence logic study.
Penetrating Trauma
If wounds to the heart and coronary arteries (#553) are
excluded from the 30-year review of 5760 cardiovascular inju- trauma center have been 1 blunt injury to the innominate
ries at Ben Taub Hospital in Houston, injuries to the great artery and 3 to 5 blunt injuries to a subclavian artery per 1 or
vessels account for approximately 10% of cases.11 The mecha- 2 years.
nism of these injuries is overwhelmingly penetrating (90%).
Of patients who underwent emergent thoracotomy after pen- Etiology
etrating thoracic injury, less than one third had great vessel
injury as the cause of hemorrhage. Penetrating Trauma
A gunshot wound to the chest has less than a 5% chance of
Blunt Trauma injuring a thoracic great vessel.49 This low incidence in patients
Blunt injuries to the great vessels (exclusive of the descending arriving at trauma centers reflects the lethal nature of pene-
thoracic aorta, which will be described in Chapter 10) are very trating wounds in this region. Stab wounds are also uncom-
uncommon. When they do occur, these injuries almost always mon and are reported to injure a great vessel in only 2% of
involve the proximal innominate or subclavian artery. In an instances.49 This low percentage reflects the fact that in order
older series describing 43 patients with injury to the innomi- for a stab wound to cause this pattern of vascular trauma it
nate artery from 1960-1992, a blunt mechanism was the cause must fall within a limited parasternal, thoracic outlet or a
in 17% of patients.56 Another even-older series reported on 93 supraclavicular region any of which is associated with high
patients with subclavian vascular trauma from 1955-1978 and lethality of wounding.
described that only 2% of patients had blunt mechanism of
injury.57 However, it should be noted that both of these reviews Blunt Trauma
included periods of time when shoulder-harness restraints Blunt injuries to the innominate and subclavian arteries most
either were not available on passenger vehicles or were not commonly occur in individuals wearing shoulder-harness
commonly used. In this author’s experience in a trauma center restraints in frontal motor-vehicle crashes. The proposed
admitting 3400 to 3600 patients per year, great vessel injuries mechanism for this injury is direct compression to the
remain uncommon even in this era of widespread seat-belt upper sternum into the artery itself with partial or complete
and shoulder-harness use. The recent numbers from this avulsion off the aortic arch. Another mechanism involves
84 SECTION 3  /  DEFINITIVE MANAGEMENT

FIGURE 9-7  Shoulder-harness restraint caused proximal occlusion of

the right subclavian artery.

hyperflexion, hypertension, and lateral rotation of the cervical

spine away from the side of the shoulder harness. This mecha-
nism occurs as the victim slides under the shoulder harness
and may cause stretching and avulsion of the innominate FIGURE 9-8  An arteriogram that was performed in an asymptomatic
artery. Either mechanism may lead to disruption of the intima patient with a stab wound to the thoracic outlet demonstrated a 5-cm
with or without injury to part or all of the media and adven- traumatic false aneurysm of the right common carotid artery (arrows).
titia. Similar mechanisms are proposed to explain blunt injury
to the carotid and vertebral arteries in recent years. Disruptive
injuries to cervical vertebrae contribute to select patterns of
zone I vascular trauma as well.
The etiology of blunt injury to either subclavian artery is
slightly different and more likely related to deceleration of the
vessel in relation to the first rib and the supraclavicular area
fixated under the shoulder-harness restraint itself. Shoulder
harness notwithstanding, a sudden posterior movement of the
shoulder from blunt trauma may cause disruption of the
intima and all or part of the media of this relatively fragile
artery. The most common manifestation of the subclavian
artery trauma is thrombosis within 3 cm to 5 cm of its origin
(Fig. 9-7).

Presentation
Penetrating Trauma
There are 3 different clinical scenarios with which patients
with penetrating wounds to the thoracic outlet and superior
mediastinum will present. Some patients will be asymptom-
atic with normal vital signs and with a normal chest x-ray.
These patients may have proximity of the penetrating
wound only to zone I of the neck and to the great vessels (Fig.
9-8). Secondly, some patients will be asymptomatic with a
normal blood pressure but will have a contained hematoma
in the suprasternal, mediastinal or supraclavicular area. This
otherwise-asymptomatic hematoma may be seen on physical
examination, chest x-ray, or both (Fig. 9-9). The third group
of patients will have proximity of penetrating wound to zone
I structures with hard signs of vascular trauma such as exter-
nal bleeding, expanding hematoma, or hemorrhagic shock.
These patients may also have an effusion indicating hemotho-
rax or a lung outlined by blood or a hematoma visible on chest
x-ray (Fig. 9-10). In the latter two groups, patients will com-
monly have a difference in blood pressure between arms with
FIGURE 9-9  A patient with a transmediastinal gunshot wound was
stabilized with crystalloid infusion. The aortogram demonstrated a
through-and-through wound (arrow) of the descending thoracic
aorta. (From Feliciano DV: Trauma to the aorta and great vessels. Chest
Surgery Clinics of North America 7:305–323, 1997. With permission.)
the effected side notably less than the unaffected side. Exten-
sive collateral flow around the subclavian and axillary arteries
makes it such that a patient with proximal thrombosis of the
subclavian artery may still have a palpable pulse in the arm
(Figs. 9-11 and 9-12). However, measurement of blood pres-
sure using either a stethoscope or the continuous wave Doppler
machine has a great enough sensitivity for the thorough clini-
cian to identify this injury.
 9  /  Cardiac, Great Vessel, and Pulmonary Injuries 85

FIGURE 9-10  A profoundly hypotensive patient with superior medi-

astinal hematoma from a gunshot wound to posterior transverse aortic
arch and the left common carotid artery was taken to the operating
room directly. (From Feliciano DV: Vascular Injuries. In Maull KI, Cleve-
FIGURE 9-11  A patient with thrombosis of the proximal left subcla-
land HC, Strauch GO, et al, editors: Advances in Trauma, Vol. 2, Chicago,
vian artery on arteriogram after sustaining a gunshot wound to the
1987, Mosby-Year Book, pp 179–206. With permission.)
lateral left arm. (From Graham JM, Feliciano DV, Mattox KL: Combined
brachial, axillary, and subclavian artery injuries of the same extremity.
J Trauma 20:899–901, 1980. With permission.)
Blunt Trauma
Most patients with blunt injury to the innominate or subcla-
vian arteries will have been in a motor-vehicle crash. The mark
of a shoulder-harness restraint at the lateral aspect of the
lower neck may be present as a physical examination finding.
If the victim was not wearing a restraint and there was no
air-bag deployment, sternal contusions indicate risk for blunt
injury of the descending thoracic aorta.
Patients with avulsion of the innominate artery from the
aortic arch will present with hypotension, with diminished or
absent pulses at the right arm, and with a large hematoma in
the superior mediastinum on a chest x-ray. Other less-severe
injuries include an intimal tear of the innominate or subcla-
vian artery without thrombosis. Depending on the extent of
the arterial-wall injury and the flow-limiting nature of the
intimal abnormality there may be a finding of disparate blood
pressures in the arms. Therefore, it is external markers of
mediastinal injury, asymmetric arm pressures, and/or an
abnormal chest x-ray that should prompt additional, more-
detailed diagnostic studies. As will be discussed in Chapter 10,
widening of the superior mediastinum on chest x-ray is a
marker for blunt injury to the descending thoracic aorta.
Finally, some patients with innominate artery injury and
hematoma have a particular pointed appearance to the right
side of the superior mediastinum on chest x-ray (Fig. 9-13).
Blunt injuries to the proximal subclavian artery typically
cause flow-limiting intimal abnormalities or even thrombosis
(Fig. 9-7). As noted, the patient with blood pressure discrep-
ancies between arms should be suspected of having a subcla- FIGURE 9-12  The same patient as in Figure 10-11. Delayed film
vian or axillary artery injury. While most blunt injuries to the demonstrates reconstitution of the left axillary artery in this patient
with an intermittently normal left radial pulse. (From Graham JM,
carotid artery occur in the cervical location or zone II of the Feliciano DV, Mattox KL: Combined brachial, axillary, and subclavian
neck, more proximal common carotid artery injuries (i.e., artery injuries of the same extremity. J Trauma 20:899–901, 1980. With
zone I) can occur. Indicators of such an injury include an permission.)
86 SECTION 3  /  DEFINITIVE MANAGEMENT
FIGURE 9-13  A patient with a pointed appearance of the right side
of the widened superior mediastinum had blunt rupture of the innom-
inate artery on a CT arteriogram. (From Feliciano DV, Burch JM, Graham
JM: Vascular injuries of the chest and abdomen. In Rutherford RB, editor:
Vascular Surgery, ed 3, Philadelphia, 1989, WB Saunders, pp 588–603.
With permission.)
external mark of trauma such as a shoulder-harness restraint
on the lower neck or supraclavicular area. Also carotid artery
injury should be suspected in patients who present with
abnormal neurological findings with a normal head CT scan.
In cases of proximal (zone I of the neck) common carotid
artery injury, the patient may also manifest a widened supe-
rior aspect of the mediastinum on the initial chest x-ray. Other
classic findings associated with blunt cerebrovascular injury
include cervical spine fracture, LeFort II or III facial fractures,
Horner syndrome, and skull-base fracture. The presence of
one or more of these findings should heighten the trauma
team’s suspicion of the presence of a great vessel injury and
specifically blunt carotid artery trauma.
Diagnosis
Penetrating Trauma
In the first two groups noted earlier (i.e., normotensive patient
with proximity of wound and normotensive or hypotensive
patient with hematoma on examination or on chest x-ray),
further radiologic studies are necessary. Patients in the hypo-
tensive group will require judicious resuscitation in the emer-
gency department before further imaging studies. Depending
on the degree of hypotension, the resuscitation should be
limited to maintain the patient’s mentation and urine output
and not a specific normal blood pressure. Judicious and even
hypotensive resuscitation in patients with penetrating vascu-
lar trauma may avoid restarting bleeding that had stopped or
may avoid exacerbating ongoing bleeding.
The purpose of additional imaging studies in this scenario
is to verify and localize the aortic or arterial injury and to help
determine the best management approach. In the past, the
diagnostic study that was most commonly used was trans-
femoral digital subtraction aortography by interventional
radiology. Transbrachial retrograde arteriography with a
blood pressure cuff inflated to 300 mm Hg on the side of the
injury has also been used in a few centers for the past 40 years
to evaluate the subclavian artery.58 CT arteriography with a
64- or 128-slice machine is gradually replacing the aforemen-
tioned studies because of convenience, speed, and improved
accuracy. Should CT arteriogram be compromised by scatter
from metallic bullet fragments, a transfemoral digital subtrac-
tion aortogram is performed.
Regardless of chest x-ray findings, no additional diagnostic
studies are indicated in the third group of patients with pro-
found hypotension. Instead, patients with this injury pattern
and clinical presentation should have manual compression of
any bleeding from the suprasternal or supraclavicular area and
initiation of blood component–based resuscitation. Hypoten-
sive patients with active bleeding should be transported
directly to the OR for operative treatment. Patients with a
systolic blood pressure less than 70 mm Hg or with a recent
cardiac arrest should have preliminary operative management
in the emergency department as described in previous
sections.
Blunt Trauma
Diagnosis of blunt common carotid artery injury proceeds in
much the same manner as with patients who have a penetrat-
ing injury. Initial chest x-ray is useful as a general screening
test to assess for the presence of hemothorax and/or a widened
mediastinum indicative of hematoma. CT angiography is very
useful in determining the presence and extent of proximal
great vessel injury in patients who are hemodynamically
normal and can tolerate additional time in the CT imaging
suite. As indicated earlier, patients with blunt proximal
common carotid artery injury often have a clinical presenting
sign of contusion or a physical finding of discrepant upper
extremity blood pressure measurements.
Endovascular Management
Patients who are hemodynamically normal and who have
CT-angiographic evidence of an intimal flap, a contained pul-
satile hematoma (traumatic false aneurysm), or an arteriove-
nous fistula may be preferentially treated with a covered
endovascular stent or stent graft. The large diameter of the
innominate, subclavian, and proximal common carotid arter-
ies and the absence of atherosclerosis in most younger patients
make endovascular repair particularly appealing for this injury
pattern (Fig. 9-14).59-62 At this time there are no long-term
follow-up data after use of stents or stent grafts in these great
vessels.
Operative Management in the Emergency
Department and Operating Room
Finger Control of External Hemorrhage
On rare occasions, external hemorrhage from either the
suprasternal notch or the supraclavicular fossa may be the sole
manifestation of a major thoracic vascular injury from a stab
wound or gunshot wound. If no pleural connection is present,
insertion of a finger or pack into the stab-wound or gunshot-
wound site may control hemorrhage temporarily until the
patient can be transferred to the operating room.63
Incisions
The emergent approach to a patient who is profoundly hypo-
tensive or who has had a recent cardiac arrest from a wound
to a great vessel is a unilateral or bilateral anterolateral

FIGURE 9-14  A patient with blunt trauma to the chest had a trau-
matic false aneurysm of the innominate artery on an arteriogram.
thoracotomy. The only change that may be needed from the
previously described approach is to place the thoracic incision
or incisions above the male nipple if there is an obvious
wound, a pulsating hematoma, or external bleeding in prox-
imity to the subclavian vessels. While it is more difficult to
spread the ribs at this level, it does allow for rapid insertion
of a finger or pack to control intrapleural hemorrhage from
an injury to a subclavian vessel. After the bilateral anterolateral
thoracotomy is performed, bimanual dissection is performed
to separate the upper chest flap and sternum from the under-
lying thymus and pericardium. Finochietto retractors are
placed bilaterally, and a finger or clamp is used to control
hemorrhage.
A median sternotomy is performed in the OR in patients
who are more stable when the track of a stab wound or
gunshot wound is in proximity to the superior mediastinum
(i.e., supraclavicular notch or zone I of the neck). The same
incision is used when the initial chest x-ray documents a
hematoma in the superior mediastinum. Median sternotomy
provides excellent exposure to the innominate artery and
veins, the first portion of the right subclavian artery, and the
proximal right common carotid artery. Although relatively
posterior along the aortic arch and therefore challenging to
manipulate through this approach, the proximal left common
carotid artery should be approached via a median sternotomy.
A high left anterolateral thoracotomy is the preferred approach
to a documented injury to the first (intrathoracic) portion of
the left subclavian artery (Fig. 9-15).
Injury to the second portion of either subclavian artery
(posterior to the scalenus anticus muscle) is approached via a
supraclavicular incision. Exposure of the injured subclavian
artery (or vein) may be improved by an ipsilateral infracla-
vicular incision and by isolation of the proximal most axillary
artery (or vein). If the injury is directly behind the clavicle or
at its midpoint, claviculotomy, or a resection of the middle
9  /  Cardiac, Great Vessel, and Pulmonary Injuries 87
Compressed
subclavian
artery
Clamped
subclavian
artery
Chest
incision
FIGURE 9-15  A high left anterolateral thoracotomy, cross-clamping
of the first portion of the left subclavian artery, and external compres-
sion to control exsanguinating hemorrhage from the second portion.
(From Feliciano DV, Graham JM: Major thoracic vascular injury. In Cham-
pion HR, Robb JV, Trunkey DD, editors: Robb & Smith’s Operative Surgery,
London, 1989, Butterworth & Co. With permission.)
one third of the clavicle may be useful in facilitating control
and repair (Fig. 9-16). Before claviculotomy or resection of
the clavicle is performed, circumferential stripping of the peri-
osteum is performed to separate away the often tightly adher-
ent subclavian vein. At the completion of the vascular repair,
the claviculotomy may be repaired by drilling holes in an
anteroposterior direction in the ends. With this maneuver, a
sternal wire is curved into the letter “U,” and is placed postero-
anterior; and the two ends are twisted to align or approximate
the divided ends of the bone. Another technique of repair is
use of a dynamic compression plate across the anterior aspect
of the fracture. When a segment of clavicle has been removed,
inserting a sternal wire across each “fracture” site is the quick-
est repair. Repair of the divided clavicle is should be per-
formed in patients who are hemodynamically well. This is
especially important because most patients with this injury
pattern are young and active.
Should there be a need to expose the junction of the first
and second portions of the subclavian artery on the right side,
it may be necessary to perform a median sternotomy con-
nected to a right supraclavicular incision (Fig. 9-17). On the
left side, a high left anterolateral thoracotomy, a left supracla-
vicular incision, and a connecting partial upper median ster-
notomy will need to be performed (Fig. 9-17). This rarely used
“book thoracotomy” will, of course, not open like a book.
Rather, it slides open once a Finochietto retractor is inserted.
The disadvantages of this incision include multiple sharp
bony ends that catch the gloves of the surgical team and sig-
nificant postoperative pain for the patient.
Injury to the third portion of either subclavian artery
(lateral edge of scalenus anticus muscle to anterior edge of first
88 SECTION 3  /  DEFINITIVE MANAGEMENT
Subclavian
artery
FIGURE 9-16  Subperiosteal resection of the middle one third of the clavicle improves exposure of the second portion of the subclavian artery
and of the adjacent subclavian vein. (Copyright, Baylor College of Medicine, Houston, 1985.)
FIGURE 9-17  Multiple incisions used for wounds to the great vessels.
Exposure of the first portion of right subclavian artery may require a
median sternotomy and right supraclavicular incision. Exposure of the
junction of the first and second portions of the left subclavian artery
may require a high left anterolateral thoracotomy, a partial upper
median sternotomy, and a left supraclavicular incision—the so called
“book thoracotomy.” (Copyright Baylor College of Medicine 1980. With
permission.)
rib) cannot always be approached through the standard supra-
clavicular incision. An infraclavicular incision may also need
to be performed adjacent to the proximal portion of the lateral
1/3 of the clavicle, as well. Connecting the supra- and infra-
clavicular incisions and dividing the clavicle, if necessary, will
allow for distal control of the first portion of the axillary
artery.
Clavicle (cut)
Control of Hemorrhage/Vascular Repair
Penetrating Wound of the Ascending or Transverse
Aortic Arch
After opening the pericardium, pulsatile hemorrhage from the
thoracic aorta is controlled with a finger or a Satinsky or a
large Wiley “J” clamp.64 These two large clamps may be placed
as partial occlusion clamps isolating the vascular injury for
débridement and repair. Aortorrhaphy is performed with a
continuous or interrupted row of 4-0 polypropylene sutures
placed under the surgeon’s finger or above the Satinsky clamp.
During these maneuvers it is useful to reduce the patient’s
blood pressure and stroke volume to avoid dislodgment of the
clamp and tearing of the sutures. The use of Dacron or Teflon
pledgets as previously described may also assist in repairing
arterial injuries in this location.
Repair of Penetrating Wound of the
Innominate Artery
After performing a pericardiotomy, the crossover left innomi-
nate vein is rapidly mobilized and elevated superiorly or infe-
riorly with a Silastic vessel loop. This vein may be ligated if
necessary because it has been injured or is obstructing expo-
sure of the injured artery. Finger control on a perforation of
the artery is maintained until proximal and distal vascular
clamps (e.g., Satinsky or Wiley J) are applied. A wound near
the distal bifurcation of the innominate artery may be difficult
to visualize through a standard median sternotomy. In these
cases, the median sternotomy may be extended cephalad with
a longitudinal cervical incision or laterally with a supracla-
vicular incision. These extensions of the median sternotomy
will allow for distal control of the common carotid and right
subclavian arteries, respectively.
Dissection around the proximal right subclavian artery
should be done with care as the right recurrent laryngeal nerve
loops around this vessel within 1.5 cm to 3.0 cm of its origin.
Once control has been obtained, an effort should be made to
convert clamping of the right subclavian and common carotid

arteries to just the distal innominate artery if there is room.
This maneuver allows for perfusion of the right upper extrem-
ity via backflow through the right common carotid artery
from the circle of Willis in the brain.
If a short segmental resection of the innominate artery is
necessary for a through-and-through gunshot wound, an end-
to-end and often pledgeted, anastomosis is performed with
5-0 polypropylene suture. A longer segmental resection man-
dates the insertion of an 8-mm or 10-mm polytetrafluoroeth-
ylene (PTFE) or knitted Dacron interposition graft. As
previously noted, temporary vascular shunts are not usually
inserted during end-to-end anastomoses or insertion of inter-
position grafts because there is almost always adequate cere-
bral crossover flow in young patients.
As the end-to-end anastomosis or suture line on the distal
graft is completed, proximal and distal flushings of air are
necessary before the final sutures are tied. The proximal clamp
and a clamp on the right common carotid artery are then
reapplied as backflow from the right subclavian artery com-
pletes the evacuation of air. Antegrade flow is first established
into the right subclavian artery by removing the clamp on the
innominate artery. Flow into the right common carotid artery
is established 10 seconds later by removing the clamp on this
vessel. Depending on the location of an interposition graft, the
proximal suture line may lie on top of the trachea. An effort
should be made to interpose thymic tissue or pericardial fat
between these two structures as this may prevent the later
development of a tracheoinnominate artery fistula.
Repair of Blunt Tear of the Innominate Artery
at Its Origin
The proximal ascending aorta is first exposed, and an 8-mm
knitted Dacron graft is sewn to it using a partial occlusion
clamp (Statinsky or Wiley J) and a 4-0 polypropylene suture
(Fig. 9-18). The hematoma (true or false traumatic aneurysm)
around the proximal innominate artery is not entered until
FIGURE 9-18  Operative technique of
bypass grafting for repair of blunt injury
to proximal innominate artery. (Copyright,
Baylor College of Medicine, Houston, 1981.)
9  /  Cardiac, Great Vessel, and Pulmonary Injuries 89
the aortic arch at the origin of the artery and its bifurcation
in the right superior mediastinum have been dissected free. At
this point a partial occlusion clamp is again placed on the arch,
this time around the origin of the innominate artery. Another
vascular clamp is placed around the distal artery, or the right
subclavian and common carotid arteries are clamped indi-
vidually. The hematoma is then entered, and the distal innom-
inate artery is transected.
At this juncture, the previously inserted PTFE or Dacron
graft, which has been cut longer than necessary, is sewn end-
to-end to the distal innominate artery (see Fig. 9-18) using 4-0
or 5-0 polypropylene or polyester suture. No shunt is used, as
occlusion of the right carotid circulation is well tolerated for
the few minutes it takes to complete the distal anastomosis.
Most of these patients are young, and removal of the right
carotid artery clamp at any time before completion of the
anastomosis will result in significant back-bleeding. On rare
occasions, profound intraoperative hypotension may force the
surgeon to use a temporary intraluminal shunt inserted
through the proximal graft anastomosis and withdrawn before
completion of the distal anastomosis. Systemic doses of intra-
venous heparin are not generally used in patients with this
pattern of vascular trauma, especially those who have suffered
blunt injuries. The final step in this reconstructive approach
is the oversewing of the proximal innominate artery over the
partial occlusion clamp on the aortic arch. This suture line is
easily visualized by moving the somewhat redundant Dacron
graft away from the arch.
Repair of Blunt Tear of the Left Common Carotid
Artery at Its Origin
After performing a pericardiotomy, the crossover left innomi-
nate vein is mobilized and elevated superiorly or inferiorly
with a Silastic vessel loop. As stated previously this vein may
be ligated if it has been injured or is obstructing an otherwise
challenging dissection. A Statinsky or Wiley J vascular clamp
90 SECTION 3  /  DEFINITIVE MANAGEMENT
is applied in a longitudinal direction to the transverse aortic
arch just under the origin of the left common carotid artery.
The type of repair will depend on the amount of local disrup-
tion of the intima and media at the junction of the left
common carotid artery and transverse aortic arch. An obvious
extensive disruption of the origin of the left common carotid
artery is repaired as described for proximal blunt disruption
of the innominate artery using a separate inflow site for an
interposition graft.
Right and Left Subclavian Vessels
When penetrating wounds of the subclavian vessels commu-
nicate with the corresponding pleural cavity, rapid exsangui-
nation will occur. In such patients, a high anterolateral
thoracotomy at the level of the 3rd or 4th intercostal space
above the nipple should be performed. Finger or pack control
in the right pleural cavity through the high right thoracotomy
coupled with manual pressure on the right supraclavicular
fossa will tamponade almost all major subclavian hemorrhage
until vascular control can be obtained in the operating room.
As the proximal left subclavian artery is an intrathoracic
structure (in contrast to the mediastinal course of the proxi-
mal right subclavian artery), it can be visualized and directly
clamped through a high thoracotomy incision. If back-
bleeding from the distal artery or concomitant hemorrhage
from the left subclavian vein continues, finger or pack pressure
through the thoracotomy incision should be combined with
supraclavicular pressure, as described for the right side.
Proximal and distal control of the subclavian artery is
obtained after mobilizing the phrenic nerve away and after
dividing the scalenus anticus muscle. Depending on the loca-
tion of the injury, it may be necessary to ligate and divide the
thyrocervical trunk and, on occasion, the vertebral artery. For
future cardiac surgery, it is always worthwhile to preserve the
ipsilateral internal mammary artery if possible. Experienced
trauma vascular surgeons know that the subclavian artery is
fragile and that tension on an end-to-end anastomosis or graft
anastomosis will lead to partial or complete disruption of the
suture line when flow is reestablished. If an end-to-end anas-
tomosis cannot be performed after a segmental resection, an
8-mm PTFE or knitted Dacron interposition graft should be
used as the method of reconstruction.
Proximity and adherence of the subclavian vein to the
clavicle and the many venous branches in this area make
obtaining venous control and a satisfactory vein repair chal-
lenging. If control of the subclavian vein is too difficult or if
repair results in extensive narrowing, ligation may be a better
choice. After ligation has been performed, the pressure should
be measured in the superficial volar compartment of the ipsi-
lateral forearm. A compartment pressure >35 mm Hg is fol-
lowed by fasciotomies of the mobile wad, superficial and deep
volar compartments through a volar–ulnar incision.63 The
pressure is then measured in the dorsal compartment of the
forearm to see if a fasciotomy is needed there, as well. If a
claviculotomy or partial clavicular resection has been per-
formed for exposure, care must be taken to ensure that the
tips of the screws used for a bony repair do not protrude
posteriorly near the artery, vein, or repair.
Superior or Inferior Vena Cava
After performing a pericardiotomy, DeBakey forceps are used
to elevate the perforated edges of the lacerated vein. A Satinsky
clamp is then placed under the perforation. As previously
noted, a row of Allis clamps may also be used to control hem-
orrhage and to elevate the edges of a long anterior, medial, or
lateral laceration. A through–and-through wound to the cava
mandates clamp control around the lacerations and repair of
the posterior perforation through the anterior opening, fol-
lowed by repair of the anterior wall injury. Venorrhaphy using
either 4-0 or 5-0 polypropylene in a running or continuous
fashion is the favored method of repair for the vena cava.
When clamp control of an extensive posterior perforation
of the inferior vena cava is impossible, the patient will need
to be placed on cardiopulmonary bypass. In this scenario, the
inferior cannula is placed in the inferior vena cava in the
abdomen via the femoral vein; and a balloon catheter occludes
the inferior vena cava beyond the injury.49 Posterior repair
with 4-0 or 5-0 polypropylene suture is completed through a
right atriotomy.
Crossover Left Innominate Vein
After performing a pericardiotomy, vascular clamps are placed
around any perforation in the left innominate vein. Either a
lateral venorrhaphy or end-to-end anastomosis is performed
with a suture of 5-0 polypropylene. Ligation may be per-
formed with more extensive injuries or as an expedited damage
control maneuver. If the vein has been ligated, the pressure is
then measured in the superficial volar compartment of the
forearm as previously described. In these instances, it may be
useful to place the left upper extremity in a stockingette
to facilitate intermittent elevation of the arm to reduce
swelling.
Major Complications
Cardiac Compression with Sternal Closure
A major vascular injury in the mediastinum or thoracic outlet
accompanied by hemorrhage and massive transfusion often
leads to significant edema of the heart and the mediastinal
structures. To avoid compression of these structures at the
completion of an operation, one may opt for a temporary
sternal closure. As previously noted, this can be accomplished
by sewing a plastic silo to the skin edges of an anterolateral
thoracotomy or median sternotomy. Once the patient’s physi-
ology improves and diuresis occurs, the silo is removed and
the sternum closed at a reoperation.
Cerebral Ischemia
Cross-clamping of the innominate or left common carotid
artery in the hypotensive patient has the risk of leading to
cerebral ischemia and stroke. Fortunately, this complication is
uncommon if control of hemorrhage, carotid clamp time, and
vascular repair are performed quickly. Brief carotid occlusion
times are generally tolerated in younger trauma patients
because they have a patent or normal circle of Willis, which
allows cerebral perfusion from the contralateral carotid artery.
If a patient has a persistently depressed Glasgow Coma Score
in the intensive care unit after carotid artery injury repair, he
or she should undergo a CT of the brain. Ipsilateral cerebral
ischemia on the CT scan is treated with the avoidance of
hypotension and hypoxia. Secondary cerebral edema is
managed with elevation of the patient’s head, with intrave-
nous mannitol (1 g/Kg), with drainage of cerebrospinal fluid,
and on rare occasion with pentobarbital coma.
 9  /  Cardiac, Great Vessel, and Pulmonary Injuries 91

Associated Neurological Deficits Table 9-7 Survival Rates After Injuries to the
The proximity of the brachial plexus to the supraclavicular Great Vessels
area explains the fairly high incidence of neurological deficits
Survival
associated with subclavian vascular trauma. Transected trunks, Injuries Rates
divisions, or cords noted at the time of operation should be
tagged with long 0 or 2-0 polypropylene sutures to allow for Stab wound or small gunshot wound to 50%
ascending aorta or transverse aortic arch with
identification at a subsequent operation. A careful neurologi- vital signs present65
cal examination should be performed and documented in the Injury to innominate vessels, 1955-1980 86%
patient’s record once swelling and pain from the acute injury (penetrating 34/blunt 8)66
and operation have resolved. Persistent and severe deficits in Injury to innominate artery, 1964-1992
the ipsilateral upper extremity mandate referral to a neurosur- (penetrating 34/blunt 7/other 2)56
geon with experience in neural grafting. If this is not possible,   Gunshot/stab 72%
  Blunt 86%
referral of the patient to an upper extremity or hand surgeon
Injury to subclavian vessels, 1955-1978
for possible tendon transfers in the forearm is appropriate. (penetrating 91/blunt 2)57
  Overall 88%
Survival   Without resuscitative thoracotomy 96%
Much as with cardiac injuries, survival after injuries to the Penetrating injury to subclavian artery, 1991-2001
great vessels depends on multiple factors. These include mech- (gunshot 46/stab 5/shotgun 3)67
anism of injury (penetrating versus blunt), number of signs   Gunshot 73%
  Stab 80%
of life on admission, location of thoracotomy, presentation   Shotgun 80%
(hemorrhage versus hematoma), number of vessels injured, Penetrating injury to subclavian artery, 1997-2007
and number of associated injuries. Survival figures in large (stab 53/gunshot 4)60—all stent graft
series over the past 5 decades are listed in Table 9-7.   Survival 98% (#56)
  Early occlusion 5% (#3)
  Late occlusion 5% (#3)
  Late stenosis 9% (#5)
Injuries to the Lungs Injury to subclavian artery, 2004-2005 (gunshot
7/fall 2/shotgun 1)61
Classification   No treatment (minor) 20% (#2)
Injuries to the lungs are classified according to the American   Stent graft 40% (#4)
Association for the Surgery of Trauma Lung Organ Injury   Survival 50% (2/4)
  Balloon occlusion 10% (#1)
Scale described in 1994 (Table 9-8).16   Survival 0% (0/1)
  Operation 30% (#3)
History   Survival 67% (2/3)
Asensio et al have comprehensively reviewed the history of the
management of pulmonary injuries.68 After the introduction

Table 9-8 Lung Organ Injury Scale

Grade* Injury Type Injury Description† ICD-9 AIS-90
I Contusion Unilateral, <1 lobe 861.12/861.31 3
II Contusion Unilateral, single lobe 861.20/861.30 3
Laceration Simple pneumothorax 860.0/1 3
860.4/5
III Contusion Unilateral >1 lobe 861.20/861.30 3
Laceration Persistent (>72 hours), air leak from distal airway 860.0/1 3-4
860.4/5
862.0/861.30
Hematoma Nonexpanding intraparenchymal
IV Laceration Major (segmental or lobar) airway leak 862.21/861.31 4-5
Hematoma Expanding intraparenchymal
Vascular Primary branch intrapulmonary vessel disruption 901.40 3-5
V Vascular Hilar vessel disruption 901.41/901.42 4
VI Vascular Total, uncontained transaction of pulmonary hilum 901.41/901.42 4

From Moore EE, Malangoni MA, Cogbill TH, et al: Organ injury scaling IV. Thoracic vascular, lung, cardiac, and diaphragm. J Trauma 36:299–300,
1994.
*Advance one grade for bilateral injuries; hemothorax is graded according to the thoracic vascular OIS.
†
Based on most accurate assessment at autopsy, operation, or radiologic study.
92 SECTION 3  /  DEFINITIVE MANAGEMENT
of median sternotomy by Duval in 1897 and left anterolateral
thoracotomy by Spangaro in 1906, it was American surgeons
who developed operative repair of major injuries to the lung
during World War I. The overwhelming number of penetrat-
ing thoracic wounds in World War II prompted continued use
of drainage with thoracostomy tubes as primary treatment.69,70
This continues today with more extensive thoracoscopy or
thoracotomy reserved for a selected group of patients to be
described.
Incidence
Penetrating Trauma
Penetrating injury, 70% to 75% of which is gunshot related,
accounts for 75% to 88% of thoracotomies performed for
trauma to the thorax in the United States.68,71,72 When all
patients with penetrating wounds to the chest are considered,
only 5% to 10% have hemorrhage from the lung as the indica-
tion for a thoracotomy.
Blunt Trauma
Only 12% to 25% of patients undergoing a thoracotomy for
trauma to the lung have a blunt mechanism of injury.68
Etiology
Penetrating Trauma
Gunshot and/or stab wounds are prone to lacerate the pulmo-
nary parenchyma of the lung. Exsanguinating hemorrhage
from a lung injury is uncommon especially if the wound is in
the periphery of a lobe. As noted previously in this chapter,
the relatively low incidence of bleeding from pulmonary
parenchymal injury may be a reflection of the relatively low
systolic blood pressure in the branches of the pulmonary
artery. The uncommon nature of pulmonary parenchymal
hemorrhage may also relate to a tamponade effect as the vis-
ceral and parietal pleura come into contact with one another
after insertion of a thoracostomy tube.
Penetrating wounds that injure the more central, hilar area
of a lobe or the lung are much more likely to cause life-
threatening hemorrhage. The obvious reason relates to the
larger size of the more central vessels as well as the increased
likelihood that branches of both the pulmonary artery and
vein will be injured. It is also true that more central vessels are
extraparenchymal making them more prone to open or free
bleeding if they are lacerated.
Blunt Trauma
It is unusual for an adult to have an injury to the lung with
an associated pneumothorax or hemothorax without an
injury to the overlying ribs. In other words most blunt pul-
monary injuries in adults are associated with rib fractures. The
same is not true for children, who are more susceptible to
blunt pulmonary injury without rib fracture. In addition to
the mechanism of direct laceration from the end of a fractured
rib, there are two other proposed mechanisms for blunt injury
to the lung. The second is the valsalva-compression scenario
in which a patient inspires and holds their breath just before
compression occurs during a motor-vehicle crash. This phe-
nomenon is thought to be associated with rupture of the
pulmonary parenchyma and pneumothorax. The third mech-
anism relates to the differential deceleration of the fixed
(hilum and inferior pulmonary ligament) versus the mobile
(peripheral parenchyma and lobes) aspects of the lung in
frontal deceleration or lateral impact. In these scenarios, it is
the pulmonary vasculature at these junction points that is
prone to tearing or disruption.
Presentation
Pneumothorax
Either penetrating or blunt trauma to the chest can cause a
simple, tension, or open pneumothorax. A patient with a
simple pneumothorax (does not expand with inspiration) is
likely to present with pain from an associated rib fracture and
with shortness of breath. The severity of the shortness of
breath is related to the size of the pneumothorax and the
extent of the injury to the underlying lung. Trainees have
historically underestimated the three-dimensional magnitude
of a pneumothorax with a collapsed lung. For example, should
the radius of an injured lung decrease from 10 cm to 8 cm
secondary to a pneumothorax, the volume of the lung as a
sphere (πr3) would decrease by 50%. If the physician prefers
to consider the injured lung as a cylinder (πr2h), a decrease in
the radius of 10 cm to 8 cm in a structure 30 cm in height
would decrease volume by 36%.
A patient with an open pneumothorax or what is some-
times referred to as a “sucking chest wound” has an opening
in the chest wall and pleura that is larger than the opening
in the glottis. In this scenario, when the patient takes a
breath, air will enter the pleural space around the lung
rather than enter into the lung through the tracheobronchial
tree (i.e., breathing through the chest wall). Such a patient
will present with the sound of air movement through the
chest wall defect, with shortness of breath, and possibly with
hypotension related to tension physiology including medias-
tinal shift.
A patient with a true tension pneumothorax is rare in the
emergency department presumably because of the lethality of
such an injury. In the modern era, most patients with this
entity are in the intensive care unit on a volume ventilator and
often with ventilator-associated pneumonia that predisposes
to rupture of the lung. Tension pneumothorax leads to anxiety
and a sense of doom, to absent breath sounds, to hyperreso-
nant percussion on the affected side, and to deviation of the
trachea away from the pneumothorax. Cyanosis is an ominous
sign often manifest shortly before cardiovascular collapse sec-
ondary to tension physiology.
Hemothorax
Hemothorax or blood in the plural cavity results from injury
to a vessel in the pulmonary circulation, a vessel in the
systemic circulation (including an intercostal or internal
mammary vessel), or an injury to the heart. In all three
instances, symptoms from hemothorax will be related to its
size or volume and whether any bleeding is sustained (i.e.,
ongoing). As such, both respiratory (e.g., shortness of breath)
and hemodynamic compromise (e.g., hypotension) may
occur.
Diagnosis
A patient with significant thoracic trauma, shortness of breath,
and decreased or absent breath sounds over one hemithorax
has a presumed pneumo- or hemothorax. In the presence of

all three factors, no further diagnostic study is indicated before
treatment in the form of tube thoracostomy is instituted. In a
patient with an altered sensorium, traumatic brain injury, or
multiple injuries or one in whom bilateral breath sounds are
difficult to assess, a surgeon-performed transthoracic ultra-
sound of the lungs should be performed. This extended FAST
examination (EFAST) is accomplished with a 3.5 mHz general
transducer probe positioned over the lateral thorax, superior
to the 10th and 11th intercostal spaces. This technique can be
used to quickly determine the presence of a pneumo- and/or
hemothorax.73-75
Blood in the thoracic cavity appears as a V-shaped stripe
that is isoechoic compared to the blood in the inferior vena
cava and often results in a “fluttering” partial collapse of the
lower lobe.73 Pneumothorax results in loss of a finding referred
to as the lung “sliding sign” which is a hyperechoic line with
to-and-fro movement between lung and chest wall. Pneumo-
thorax may also result in an ultrasound finding referred to as
a “comet-tail artifact” which is related to the partially com-
pressed visceral pleura. Similar to examination of the pericar-
dial sac and heart in the standard FAST, pleural ultrasound
looking for an effusion or pneumothorax can be performed
quickly and is highly accurate.73-75
An anteroposterior chest x-ray performed with the patient
in the supine or semirecumbent position in the trauma room
remains the acute standard for diagnosis in many trauma
centers. While gross intraparenchymal and pleural abnormali-
ties are readily seen, small pneumothoraces may be missed
with this basic technique. The incidence of missed injuries
can be reduced by performing a posteroanterior chest x-ray
in the upright position or by repeating the film with the
patient having fully expelled his or her lung volume (i.e.,
expiration).
It has long been recognized that a small percentage of
pneumothoraces will develop in a delayed fashion hours after
an injury to the chest or lung. This fact prompted initiation
of a “6-hour rule” in many emergency departments, which
called for a second or repeat chest x-ray at that time before
allowing patients to leave the hospital.76 Subsequent studies
documented that repeating a chest x-ray at 3 hours (i.e., “a
3-hour rule”) was as effective in diagnosing the delayed pneu-
mothorax as waiting 6 hours to repeat the film.77 While much
has been written about the benefits of CT scanning patients
with suspected thoracic trauma, many of the injuries detected
with this sensitive imaging modality do not require treatment.
Examples include incidentally discovered fractured rib(s),
asymptomatic pulmonary contusion, and small pneumo- or
hemothoraces.78 The major advantage of chest CT is in the
diagnosis of blunt aortic injury.
Nonoperative Management
Tube Thoracostomy
Adult patients with a pneumo- or hemothorax who have a
systolic blood pressure of 90 mm Hg or greater have tradi-
tionally been treated with insertion of a 36 or 38 Fr tube
thoracostomy. The chest tube is placed in the ipsilateral
midaxillary line in the 4th or 5th intercostal space under sterile
conditions and with local infiltrative anesthesia. It has recently
been documented that 28 to 32 Fr tubes have the same success
rates as larger tubes in treating traumatic pneumo- and hemo-
thoraces.79 More recently, 14 Fr pigtail catheters have been
9  /  Cardiac, Great Vessel, and Pulmonary Injuries 93
shown to have reasonable success rates in treating traumatic
pneumothoraces.80 The role of prophylactic antibiotics in con-
junction with tube thoracostomy is controversial. However, if
given, a first generation cephalosporin is the antibiotic of
choice and should be administered intravenously before the
incision to insert the tube.
Analgesia
Pain control following rib fracture(s) is extremely important
and allows patients to cough, to use an incentive spirometer,
and to reduce the risk of atelectasis and pneumonia. The
options for local and regional analgesia in this scenario
include:
1. Lidoderm (Lidocaine Patch 5%, Endo Pharmaceuticals,
Chadds Ford, PA)—three 10 × 14 cm patches applied
for up to 12 hours
2. Intercostal nerve block with 3 mL to 5 mL 0.25% bupi-
vacaine per rib
3. Continuous intercostal nerve block
4. Intrapleural regional analgesia with 20 mL 0.25%
bupivacaine
5. Continuous epidural analgesia
6. Open, operative rib fixation with metal or absorbable
plates
Supportive Care After Pulmonary Contusion
The presence of blood in alveoli after penetrating or blunt
chest trauma causes a ventilation/perfusion mismatch and
secondary hypoxia. Oxygen by a nasal cannula or by a close-
fitting mask with judicious administration of maintenance
fluids based on hemodynamic status are the mainstays of
treatment in patients without early onset respiratory failure.
Placement of a central venous catheter to measure central
venous pressure may be useful in older patients with signifi-
cant pulmonary contusion. Signs of respiratory failure (e.g.,
pO2 less than 70 torr on oxygen, pCO2 greater than 55, respira-
tory rate of greater than 25, poor negative inspiratory force or
worsening chest x-ray) mandate intubation. Significant pul-
monary contusion can progress in a short period of time to
become every bit as serious as other forms of acute lung injury
and adult respiratory distress syndrome (ARDS).
Thoracoscopy Evacuation of Retained Hemothorax
It has long been recognized that hemodynamically normal
patients with retained hemothorax despite tube thoracostomy
will benefit from early evacuation (24 to 48 hours) of the
blood.81 Video-assisted thoracoscopic surgery (VATS) per-
formed under general anesthesia with 2 or 3 trocars has been
shown to provide excellent results in evacuating retained
blood in these types of cases. If the length of time from injury
to thoracoscopy exceeds 10 days, the failure rate for the pro-
cedure including the need to convert to open thoracotomy is
as high as 20%.
Operative Management in the Emergency
Department and Operative Room
Indications
The indications for emergent or resuscitative thoracotomy
with or without aortic clamping have been discussed else-
where in this chapter and are also provided in Box 9-1
(Fig. 9-19).
94 SECTION 3  /  DEFINITIVE MANAGEMENT
Box 9-1 Indications for Emergency or Urgent
Thoracotomy in Patients With Trauma
to the Lung
• 1200 mL to 1500 mL of blood evacuated through
thoracostomy tube in the first 15 to 30 minutes82
• 100 mL of blood per hour evacuated through a thoracostomy
tube after the initial 1000 mL drainage in the first 30
minutes83
• Refractory hypotension in the presence of continued
evacuation of blood through a thoracostomy tube
• Recent or in-emergency-department cardiac arrest after a
penetrating wound to the chest, but away from the
mediastinum
• Need for reconstruction of the chest wall in the patient with
open pneumothorax
• Massive air leak through the thoracostomy tube (presumptive
evidence of injury to the trachea or the bronchus)
• Retained foreign body (knife near hilum of lobe or lung)
FIGURE 9-19  Patient with gunshot wound to left midaxillary line
(skin clip) had exsanguinating hemorrhage from perforations to the
left lung.
Incisions
When there is hemorrhage likely to be from the right pulmo-
nary hilum or lung, the patient is placed in the supine posi-
tion; and a right anterolateral thoracotomy incision is made
on the inferior edge of the right male nipple. As previously
noted, the right breast of a female is retracted superiorly to
allow for a skin incision at the same level as in the male, but
without damaging the breast. A suspected injury to the tra-
cheobronchial tree at the level of the carina or right mainstem
bronchus is also approached through a right thoracotomy, but
this will need to be performed via a posterolateral, 4th inter-
costal space incision.
When hemorrhage is suspected to be emanating from the
left pulmonary hilum or lung, the patient is placed with the
left chest elevated 30 degrees on a rolled sheet or beanbag. This
allows for easier cross-clamping of the descending thoracic
aorta if this should become necessary. The standard anterolat-
eral thoracotomy incision is then made on the inferior edge
Box 9-2 Techniques for the General Surgeon to
Control Hemorrhage from a Perforation
or Rupture of the Pulmonary Artery
or Lung
PROXIMAL VASCULAR CONTROL
Intrapericardial clamping of the right or left pulmonary artery
Cross-clamping of the hilum of the lung
Hilar snare
Hilar twist
CONTROL OF HEMORRHAGE FROM THE LUNG
Suture pneumonorrhaphy
Stapled-wedge resection
Pulmonotomy (“pulmonary tractotomy”)
Lobectomy
Pneumonectomy (hilum ligated or stapled)
of the male nipple. An injury to the left mainstem bronchus
is also approached through a left-sided thorocotomy, but this
will need to be performed via a posterolateral 5th intercostal
space incision.
Proximal Vascular Control (Box 9-2)
Intrapericardial Clamping of Pulmonary Artery
An injury to the pulmonary hilum is a highly lethal injury, and
it is rare for a patient with this type of injury to reach the
trauma center with signs of life. If the hilum adjacent to the
pericardium is injured, it will be necessary to obtain intraperi-
cardial control of the pulmonary artery. An anterolateral tho-
racotomy incision made to expose the hilum and lung will
need to be extended across the sternum in a transverse direc-
tion to allow for proper exposure of the mediastinal and intra-
pericardial structures. The intrapericardial right pulmonary
artery is exposed by retracting the superior vena cava to the
right and the ascending thoracic aorta to the left. The right
pulmonary artery passes transversely behind the heart at this
level and is clamped in the space as the other vessels are sepa-
rated. The intrapericardial left pulmonary artery is exposed by
retracting the ascending thoracic aorta to the right and supe-
riorly. The left pulmonary artery passes transversely under the
transverse aortic arch and proximal descending thoracic aorta
and is clamped in this space.
Cross-Clamping of the Hilum of the Lung
Exsanguinating hemorrhage from the hilum of the lung
outside of the pericardial sac or from the parenchyma is con-
trolled with cross-clamping of the pulmonary hilum.84 In
order to place a DeBakey aortic clamp across the hilum of the
lung in the anteroposterior direction, the inferior pulmonary
ligament must be divided. Van Natta el al have described an
innovative technique in which the surgeon grips and manually
controls the pulmonary hilum.85 The left hand is used when a
right thoracotomy is performed, and the right hand is used
when a left thoracotomy is performed. An assistant evacuates
blood from the pleural cavity, retracts the lower lobe laterally,
divides the inferior pulmonary ligament, and assumes manual
control of the hilum. The surgeon then places the aortic cross-
clamp across the hilum in whichever direction allows for best
exposure of the injuries.

Hilar Snare
Over 20 years ago Powell and colleagues summarized that
cross-clamping the pulmonary hilum was unpredictably suc-
cessful in controlling parenchymal or hilar hemorrhage.86 The
authors subsequently performed a series of laboratory studies
during which they described passing a 100-cm-long cloth tape
around the hilum of the lung and then passing these cloth
tapes through a 36 Fr 12-cm-long plastic tube (i.e., Rummel
tourniquet).
Hilar Twist
The group at Ben Taub General Hospital in Houston described
the “hilar twist” in 2003 as a maneuver to be considered “when
appropriate clamps are lacking or difficult to place due to
exposure or bleeding.”87,88 This maneuver is performed after
division of the inferior pulmonary ligament by rotating or
twisting the lung and the hilum 180 degrees to occlude vessels
and the mainstem bronchus.
Control of Hemorrhage from the Lung (Box 9-2)
Suture Pneumonorrhaphy
With wounds or lacerations on the periphery of a lobe, hem-
orrhage and air leaks can be controlled by placing a continu-
ous 2-0 or 0 absorbable suture through the edges of the defect.
If hemorrhage is excessive and the defect on the edge is long,
a DeBakey aortic clamp can be placed underneath the lacera-
tion, and the continuous suture row can be placed over the
clamp.
Stapled Wedge Resection
Larger defects involving the outer half of a pulmonary lobe
may be excised using one of the standard staplers (4.8-mm
staples) up to 90 mm in length. The pulmonary hilum or lobar
hilum is clamped in these cases if a double lumen endotra-
cheal tube has not been placed. Standard lung clamps are then
used to elevate the injured segment into good view and an
appropriate length staple row is placed through normal paren-
chyma. It is possible to perform a partial lobectomy with two
staple lines at right angles to one another. This creates an
oddly shaped, but hemostatic and functional, remainder of a
lobe. Deep absorbable sutures are placed around areas of the
staple row when bleeding occurs. The major disadvantage of
large staple resections is that a bleeding intraparenchymal
vessel may not be ligated or excised. Continued hemorrhage
from such a vessel may enter the tracheobronchial tree through
an adjacent bronchial injury and lead to intraoperative aspira-
tion and asphyxia.
Pulmonotomy (Pulmonary Tractotomy) (Fig. 9-20)
Pulmonotomy or pulmonary tractotomy was derived from the
technique of hepatotomy and selective ligation of vessels fol-
lowing severe liver trauma. With deep lobar missile tracks or
lacerations and significant hemorrhage, neither suture pneu-
monorrhaphy nor stapled wedge resection is appropriate.
Properly performed, pulmonotomy will control parenchymal
hemorrhage without the need for lobectomy.68,72,88-94
With exsanguinating hemorrhage from vessels in the deep
parenchyma after a gunshot or stab wound, a hilar clamp is
applied after division of the inferior pulmonary ligament. A
linear stapling device is then passed through the entrance, and
9  /  Cardiac, Great Vessel, and Pulmonary Injuries 95
Left lung
Stapler
FIGURE 9-20  Linear stapling device passed through gunshot
entrance and exit sites to divide parenchyma (pulmonotomy or pul-
monary tractotomy) and to expose bleeding vessels. (From Asensio JA,
Demetriades D, Berne JD, et al: Stapled pulmonary tractotomy: a rapid
way to control hemorrhage in penetrating pulmonary injuries. J Am Coll
Surg 185:486–487, 1997. With permission.)
exit wounds in the same lobe and the outer pulmonary paren-
chyma are divided. When hemorrhage is coming from one
gunshot or stab wound in a lobe, a finger or clamp is placed
into the hole to determine the direction of the track. The
linear stapler can be used again to open the parenchyma, or
two DeBakey aortic clamps can be placed in apposition and
the parenchyma between them divided with a scalpel or with
electrocautery. Injured vessels in the now-open track are
ligated or repaired with 3-0 or 4-0 polypropylene suture.
After hemorrhage has been controlled, edema of the paren-
chyma almost always precludes closing the pulmonotomy site.
Individual suture ligation is used to control remaining vessels
under the rows of staples. If DeBakey clamps were used to
divide the parenchyma, 3-0 or 4-0 absorbable or polypropyl-
ene suture is placed in a continuous basting stitch under each
clamp. After a clamp is removed, the same continuous suture
is returned to the starting point in an over-and-over fashion
and tied to the original suture.
Lobectomy
Anatomic lobectomy is indicated when there is significant
injury to the vessels or bronchus in the hilum of the lobe,
injury to greater than 75% of the parenchyma of the lobe (i.e.,
shotgun wound), devascularization of the lobe, or a lobar
hematoma causing life-threatening ventilation–perfusion
mismatch. Prior to performing lobectomy, the residual tissue
in the fissures around the injured lobe is divided with a linear
stapling device or divided between clamps and then sutured.
A DeBakey aortic clamp is then placed across the entire lobe
96 SECTION 3  /  DEFINITIVE MANAGEMENT
just outside the hilum to stop bleeding or respiratory expan-
sion during lobectomy. The pleura over the hilar structures is
divided, and the lobar artery and proximal branches are
divided between 2-0 silk ties. The lobar vein and its branches
are divided in a similar fashion. Minimal skeletonization of
the lobar bronchus is performed to preserve bronchial blood
flow before stapling and before dividing the bronchus. An
airtight staple line is verified by filling the pleural cavity with
normal saline and by having the anesthesiologist hand bag the
patient. A 3-sided pleural flap is elevated off the paravertebral
area and sewn over the bronchial stump with 3-0 absorbable
sutures.83 Prior to insertion of two 36 Fr thoracostomy tubes,
the remaining lobe or lobes are hyperinflated. This maneuver
will confirm that no damage has occurred to other bronchi
during the lobectomy and that torsion of the remaining lobe
or lobes is not present and is unlikely to occur in the postop-
erative period. If there is a risk of torsion, either suturing or
stapling the lobes together or suturing the lobe to the medi-
astinal pleura at another point is performed.
Pneumonectomy
A pneumonectomy is only indicated when there is a signifi-
cant penetrating wound or shearing injury to the vessels or
bronchus in the hilum of the lung or a major injury encom-
passing more than 75% of all lobes.95 As most patients
requiring a trauma pneumonectomy are in extremis, the
“simultaneously stapled pneumonectomy” has been suggested
as an alternate approach to formal hilar dissection and ligation/
stapling.96 First described in 1995, the technique is to place a
55-mm or 90-mm stapler across all hilar structures simultane-
ously for temporary vascular control or fired for permanent
control of the hilum. Reexploration for possible further sta-
pling of a long bronchial stump and coverage with a vascular-
ized tissue pedicle were recommended as well.96
Damage control techniques are appropriate in patients
undergoing emergency pneumonectomy. These include
packing of the pleural cavity when coagulopathy is present,
coverage of the open thoracotomy incision with a plastic silo
(i.e., temporary thoracic closure), and continued resuscitation
in the intensive care unit. Right heart failure is common in
patients who survive trauma pneumonectomy; and postop-
erative management is quite intensive, often including infu-
sion of nitric oxide and/or inotropic support.97
Complications
Air Leak
Air leak that persists after injury to the lung is caused by
necrosis of the parenchyma at the site of sutures or staples, by
failure of an injured lung to heal, or by a missed bronchial
injury. Once technical problems have been excluded including
leaks in the tube thoracostomy circuit outside of the chest,
some centers choose to lower suction pressure on the under-
water seal system or even take the patient’s thoracostomy tube
off suction.98 Failure of this approach after 5 to 7 days is fol-
lowed by wedge resection of the remaining lung, pleural abra-
sion, or chemical pleurodesis by thoracoscopy with a
double-lumen endotracheal tube in place.
Ventilator-Associated Pneumonia
Ventilator-assisted pneumonia (VAP) is a nosocomial compli-
cation seen in both trauma and nontrauma patients in the
intensive care unit. New onset purulent sputum, elevation of
temperature, leukocytosis (occasional leukopenia), infiltrate
on chest x-ray and an increasing oxygen requirement are all
suggestive but not diagnostic of VAP. Fiberoptic bronchoscopy
with lavage or protected specimen brush for culture is the
diagnostic test of choice. Starting empiric antibiotic therapy
based on patient risk factors and local patterns of infection
while patient-specific cultures are pending is an accepted
standard.
Pulmonary Pseudocyst
Primarily diagnosed in patients with previous blunt trauma
to the chest, a posttraumatic pulmonary pseudocyst is a
parenchymal cavity that may have an air-fluid level. A chest
x-ray or thoracic CT confirms the diagnosis. Observation and
serial imaging studies are appropriate in asymptomatic
patients, while antibiotics and even catheter drainage may be
needed for an infected pseudocyst (pulmonary abscess).99,100
Empyema
Early evacuation of a persistent hemothorax after insertion of
thoracostomy tubes has lowered the incidence of posttrau-
matic empyema. Even so, most patients who develop an
infected hemothorax or empyema are in the group of patients
who were originally treated with thoracostomy tubes rather
than a thoracotomy. Other causes described in the literature
include contamination from the original penetrating trauma,
contamination from insertion of a tube thoracostomy, con-
tamination from the abdomen in the presence of a diaphragm
injury, and parapneumonic empyema following an injury to
the lung or pneumonia after injury.101
The incidence of empyema varies in the literature and is
related to different mechanisms and definitions (i.e., positive
bacterial culture or not). In two current trauma textbooks, the
incidence has been described as “0% to 18%”101 and “2% to
7%.”98 Empyema should be suspected when there is a retained
hemothorax or effusion on chest x-ray and the patient is
febrile with a leukocytosis and new onset or persistent respira-
tory failure. As previously noted, a retained hemothorax that
is suspected of being infected or having become an empyema
should be evacuated with a thoracoscopic approach. Other
fluid collections on a chest x-ray should be aspirated with an
ultrasound-guided thoracentesis, with the fluid sent for
culture, pH, glucose level, and lactate dehydrogenase (LDH)
level. A true exudate (pH <7.2, glucose <60, pleural LDH/
serum LDH >0.6) is treated with the insertion of a thoracos-
tomy tube and culture-specific antibiotics. A chest x-ray that
documents a complex fluid collection (large or loculated effu-
sion or suggestion of a pleural rind) in a symptomatic patient
should prompt a CT scan of the chest. CT imaging will be
helpful in assessing the thickness of any pleural rind, the status
of the underlying lung, and the location and extent of locula-
tions within the pleural cavity.
A chronic empyema cavity is treated with thoracoscopic or
pleuroscopic drainage and decortication of lung entrapped by
the pleural rind.98,101,102 When CT of the chest documents or
thoracoscopy confirms that dense pleural adhesions and a
very thick rind are present, a primary thoracotomy or conver-
sion from thoracoscopy to thoracotomy is indicated. Manage-
ment of the residual pleural space or the need for chronic open
drainage of an empyema cavity are discussed in other
publications.98,101

Table 9-9 Survival After Injuries to the Lungs
Author Suture/Wedge
95
Thompson et al, 1988 97%
Wall et al, 199891 — 83%
Velmahos et al, 199992 “Lung-sparing” = 97%
Karmy-Jones et al, 200172 91%/70%
Gasparri et al, 200193 −/95.5%
Cothren et al, 200294 −/90%
Huh et al, 200388 76.1/80%
Box 9-3 Damage Control for Thoracic Trauma
HEART
Sauerbruch maneuver to control hemorrhage
Inflow occlusion to control hemorrhage
Restore rhythm before suture repair.
Leave pericardial sac open/leave incision open.
GREAT VESSELS
Foley balloon catheter tamponade
Claviculectomy for injury to subclavian vessels
Insertion of temporary intraluminal shunt
Ligation of major injured veins
LUNGS
Hilar twist to control hemorrhage
Pulmonotomy (pulmonary tractotomy) for through-and-through
or deep lobar injuries
Simultaneously stapled pneumonectomy
Pack pleural cavity/leave incision open.
Adapted from Phelan HA, Patterson SG, Hassan MO, et al: Thoracic
damage-control operation: principles, techniques, and definitive
repair. J Am Coll Surg 203:933–941, 2006.
Survival
Survival figures in large series of patients with injuries to the
lungs since 1980 are listed in Table 9-9.
Thoracic Damage Control
Originally described for patients with penetrating wounds of
the abdomen, damage control operative principles have now
been described for patients with injuries to the neck, chest,
extremities, vessels, and bones.103 Similar principles are now
applied to patients undergoing emergency operations on the
general surgery and obstetrics services as well as those under-
going emergency procedures in the interventional radiology
suite. The most fundamental principle of damage control
surgery is that the patient with profound hypothermia, with
a significant metabolic acidosis, or with a marked coagulopa-
thy should have a limited first operation or procedure to
control hemorrhage and contamination (i.e., abbreviated
operating). For injuries to the heart, great vessels, or lungs,
many of the techniques described in this chapter fit the defini-
tion of thoracic damage control. Phelan et al have reviewed
these principles as summarized in Box 9-3.104
9  /  Cardiac, Great Vessel, and Pulmonary Injuries 97
Pulmonotomy Lobectomy Pneumonectomy
— 45% 0%
— —
80% —
87% 57% 50%
86% 83% 50%
100% 30% 0%
90.9% 65% 30.3%
REFERENCES
1. Wald ML: On-off switch for car airbags will be allowed. A reversal of
U.S. policy. Rule applies to passenger side and is intended to protect
children in front seats. New York Times Nov 18, 1997, p 1.
2. Holcomb JB: Damage control resuscitation. J Trauma 62:S36–S37,
2007.
3. Feliciano DV, Bitondo CG, Cruse PA, et al: Liberal use of emergency
center thoracotomy. Am J Surg 152:654–659, 1986.
4. ACS-COT Subcommittee on outcomes: practice management guidelines
for emergency department thoracotomy. J Am Coll Surg 193:303–309,
2001.
5. Cogbill TH, Moore EE, Millikan JS, et al: Rationale for selective applica-
tion of emergency department thoracotomy in trauma. J Trauma 23:
453–460, 1983.
6. Rhee PM, Acosta J, Bridgeman A, et al: Survival after emergency depart-
ment thoracotomy: review of published data from the past 25 years.
J Am Coll Surg 190:288–298, 2000.
7. Ivatury RR, Shah PM, Ito K, et al: Emergency room thoracotomy for the
resuscitation of patients with fatal penetrating injuries of the heart. Ann
Thorac Surg 32:377–385, 1981.
8. Seamon MJ, Shiroff AM, Franco M, et al: Emergency department tho-
racotomy for penetrating injuries of the heart and great vessels: an
appraisal of 283 consecutive cases from two urban trauma centers.
J Trauma 67:1250–1258, 2009.
9. Asensio JA, Garcia-Nunez LM, Petrone P, et al: Cardiac injuries. In
Asensio JA, Trunkey DD, editors: Current therapy of trauma and surgical
critical care, Philadelphia, 2008, Mosby Elsevier, pp 304–315.
10. Asensio JA, Petrone P, Pereira B, et al: Penetrating cardiac injuries: a
historic perspective and fascinating trip through time. J Am Coll Surg
208:462–472, 2009.
11. Mattox KL, Feliciano DV, Burch J, et al: 5,760 cardiovascular injuries in
4,459 patients. Epidemiologic evolution 1958-1987. Ann Surg 209:698–
707, 1989.
12. Texeira PGR, Inaba K, Oncel D, et al: Blunt cardiac rupture: a 5-year
NTDB analysis. J Trauma 67:788–791, 2009.
13. Naughton MJ, Brissie RM, Bessey PQ, et al: Demography of penetrating
cardiac trauma. Ann Surg 209:676–683, 1989.
14. Morse BC, Carr JS, Dente CJ, et al: Penetrating cardiac injuries: a 36-year
perspective at an urban, Level I trauma center. J Trauma in press.
15. Fowler NO, Gabel M: The hemodynamic effects of cardiac tamponade.
Mainly the result of atrial not ventricular compression. Circulation
71:154–157, 1985.
16. Moore EE, Malangoni MA, Cogbill TH, et al: Organ injury scaling IV.
Thoracic vascular, lung, cardiac, and diaphragm. J Trauma 36:299–300,
1994.
17. Callaham ML: Pericardiocentesis in traumatic and nontraumatic cardiac
tamponade. Ann Emerg Med 13:924–945, 1984.
18. Arom K, Richardson JD, Webb G, et al: Subxiphoid pericardial window
in patients with suspected traumatic pericardial tamponade. Ann
Thorac Surg 23:545–549, 1977.
19. Thorson CM, Namias N, Van Haren RM, et al: Does hemopericardium
after chest trauma mandate sternotomy? J Trauma 72:1518–1525, 2012.
20. Feliciano DV: Does hemopericardium after chest trauma mandate ster-
notomy? J Trauma 73:291, 2012. (Letter).
21. Navsaria PH, Nichol AJ: Haemopericardium in stable patients after pen-
etrating injury: is subxiphoid pericardial window and drainage enough?
A prospective study. Injury 36:745–750, 2005.
98 SECTION 3  /  DEFINITIVE MANAGEMENT
22. Huang YK, Lu MS, Liu KS, et al: Traumatic pericardial effusion: impact
of diagnostic and surgical approaches. Resuscitation 81:1682–1686,
2010.
23. Rozycki GS, Feliciano DV, Schmidt JA, et al: The role of surgeon-
performed ultrasound in patients with possible cardiac wounds. Ann
Surg 223:737–746, 1996.
24. Rozycki GS, Ballard RB, Feliciano DV, et al: Surgeon-performed ultra-
sound for the assessment of truncal injuries: lessons learned from 1540
patients. Ann Surg 228:557–567, 1998.
25. Rozycki GS, Feliciano DV, Ochsner MG, et al: The role of ultrasound in
patients with possible penetrating cardiac wounds: a prospective, mul-
ticenter study. J Trauma 46:543–552, 1999.
26. Newman PG, Feliciano DV: Blunt cardiac injury. New Horiz 7:26–34,
1999.
27. Illig KA, Swierzewski MJ, Feliciano DV, et al: A rational screening and
treatment strategy based on the electrocardiogram alone for suspected
cardiac contusion. Am J Surg 162:537–544, 1991.
28. Feliciano DV, Rozycki GS: Advances in the diagnosis and treatment of
thoracic trauma. Surg Clin North Am 79:1417–1429, 1999.
29. Velmahos GC, Karaiskasis M, Salim A, et al: Normal electrocardiography
and serum troponin I levels preclude the presence of clinically signifi-
cant blunt cardiac injury. J Trauma 54:45–51, 2003.
30. Flancbaum L, Wright J, Siegel JH: Emergency surgery in patients with
post-traumatic myocardial contusion. J Trauma 26:795–802, 1986.
31. Shamoun JM, Barraza KR, Jurkovich GJ, et al: In extremis use of staples
for cardiorrhaphy in penetrating cardiac trauma: case report. J Trauma
29:1589–1591, 1989.
32. Macho JR, Markison RE, Schecter WP: Cardiac stapling in the manage-
ment of penetrating injuries of the heart: rapid control of hemorrhage
and decreased risk of personal contamination. J Trauma 34:711–716,
1993.
33. Bowman MR, King RM: Comparison of staples and sutures for cardior-
rhaphy in traumatic puncture wounds of the heart. J Emerg Med 14:
615–618, 1996.
34. Pearce CW, McCool E, Schmidt FE: Control of bleeding from cardiovas-
cular wounds: balloon catheter tamponade. Ann Surg 166:257–259,
1966.
35. Harken DE: Foreign bodies in and relation to the thoracic blood vessels
and heart: techniques for approaching and removing foreign bodies
from the chambers of the heart. Surg Gynecol Obstet 83:117–125, 1946.
36. Lim R, Gill IS, Temes RT, et al: The use of adenosine for repair of pen-
etrating cardiac injuries: a novel method. Ann Thorac Surg 71:1714–
1715, 2001.
37. Kokotsakis J, Hountis P, Antonopoulos N, et al: Intravenous adenosine
for surgical management of penetrating heart wounds. Tex Heart Inst J
34:80–81, 2007.
38. Grabowski MW, Buckman RF, Goldberg AJ, et al: Clamp control of the
right ventricular angle to facilitate exposure and repair of cardiac
wounds. Am J Surg 170:399–400, 1995.
39. Degiannis E, Bowley DM, Westaby S: Technical tutorial. Penetrating
cardiac injury. Ann R Coll Surg Engl 87:61–63, 2005.
40. Agrifoglio M, Barili F, Kassem S, et al: Sutureless patch-and-glue tech-
nique for the repair of coronary sinus injuries. J Thorac Cardiovasc Surg
134:522–523, 2007.
41. Wall MJ, Jr, Mattox KL, Chen C-D, et al: Acute management of complex
cardiac injuries. J Trauma 42:905–912, 1997.
42. Castano W, Morales CH, Senior JM, et al: Relationship of echocardio-
graphic and coronary angiographic findings in patients with acute myo-
cardial infarction secondary to penetrating cardiac trauma. J Trauma
Acute Care Surg 73:111–116, 2012.
43. Beall AC, Jr, Hamit HF, Cooley DA, et al: Surgical management of trau-
matic intracardiac lesions. J Trauma 5:133–141, 1965.
44. Mattox KL, Limacher MC, Feliciano DV, et al: Cardiac evaluation fol-
lowing heart injury. J Trauma 25:758–765, 1985.
45. Tang AL, Inaba K, Branco B, et al: Postdischarge complications after
penetrating cardiac injury: a survivable injury with a high postdischarge
complication rate. Arch Surg 146:1061–1066, 2011.
46. Wall MJ, Jr, Rice D, Soltero E: Wounds of the heart. In Rich NM, Mattox
KL, Hirshberg A, editors: Vascular trauma, ed 2, Philadelphia, 2004,
Elsevier Saunders, pp 285–297.
47. Asensio JA, Berne JD, Demetriades D, et al: One hundred five penetrat-
ing cardiac injuries: a 2-year prospective evaluation. J Trauma 144:1073–
1082, 1998.
48. Mattox KL, Wall MJ, Jr, Lemaire S: Thoracic great vessel injury. In Feli-
ciano DV, Mattox KL, Moore EE, editors: Trauma, ed 6, New York, 2008,
McGraw-Hill, pp 589–603.
49. Lemaire S, Conklin LD, Wall MJ, Jr: Penetrating thoracic vascular injury.
In Rich NM, Mattox KL, Hirshberg A, editors: Vascular trauma, ed 2,
Philadelphia, 2004, Elsevier Saunders, pp 251–267.
50. DeBakey ME, Simeone FA: Battle injuries of the arteries in World War
II. An analysis of 2,471 cases. Ann Surg 123:534–579, 1946.
51. Elkin DC, DeBakey ME: Vascular surgery in World War II, Washington,
DC, 1944, US Government Printing Office.
52. Schumacker HB, Jr: Resection of the clavicle with particular reference
to the use of bone chips in the periosteal bed. Surg Gynecol Obstet
84:245–248, 1947.
53. Steenburg RW, Ravitch MM: Cervico-thoracic approach for subclavian
vessel injury from compound fracture of the clavicle: considerations of
subclavian-axillary exposures. Ann Surg 157:839–846, 1963.
54. Brawley RK, Murray GF, Crisler C, et al: Management of wounds of the
innominate, subclavian, and axillary blood vessels. Surg Gynecol Obstet
131:1130–1140, 1970.
55. Reul GJ, Jr, Beall AC, Jr, Jordan GL, Jr, et al: The early operative manage-
ment of injuries to the great vessels. Surgery 74:862–873, 1973.
56. Johnston RH, Jr, Wall MJ, Mattox KL: Innominate artery trauma: a thirty
year experience. J Vasc Surg 17:134–140, 1993.
57. Graham JM, Feliciano DV, Mattox KL, et al: Management of subclavian
vascular injuries. J Trauma 20:537–544, 1980.
58. O’Gorman RB, Feliciano DV: Arteriography performed in the emer-
gency center. Am J Surg 132:323–325, 1986.
59. Axisa BM, Loftus IM, Fishwick G, et al: Endovascular repair of an
innominate artery false aneurysm following blunt trauma. J Endovasc
Ther 7:245–250, 2000.
60. DuToit DF, Lambrechts AV, Stark H, et al: Long-term results of stent
graft treatment of subclavian artery injuries: management of choice for
stable patients? J Vasc Surg 47:739–743, 2008.
61. Carrick MM, Morrison CA, Pham HQ, et al: Modern management of
traumatic subclavian artery injuries: a single institution’s experience in
the evolution of endovascular repair. Am J Surg 199:28–34, 2010.
62. DuToit DF, Odendaal W, Lambrechts A, et al: Surgical and endovascular
management of penetrating innominate artery injuries. Eur J Vasc
Endovasc Surg 36:56–62, 2008.
63. Dente CJ, Wyrzykowski AD, Feliciano DV: Fasciotomy. Curr Probl Surg
46:773–839, 2009.
64. Feliciano DV, Graham JM: Major thoracic vascular injury. In Champion
HR, Robb JV, Trunkey DD, editors: Rob & Smith’s operative surgery,
London, 1989, Butterworth & Co., pp 283–293.
65. Pate JW, Cole FH, Walker WA, et al: Penetrating injuries of the aortic
arch and its branches. Ann Thorac Surg 55:586–592, 1993.
66. Graham JM, Feliciano DV, Mattox KL, et al: Innominate vascular injury.
J Trauma 22:647–655, 1982.
67. Lin PH, Koffron AJ, Guske PJ, et al: Penetrating injuries of the subclavian
artery. Am J Surg 185:580–584, 2003.
68. Asensio JA, Garcia-Nunez LM, Petrone P, et al: Operative management
of pulmonary injuries: lung-sparing and formal resections. In Asensio
JA, Trunkey DD, editors: Current therapy of trauma and surgical critical
care, Philadelphia, 2008, Mosby Elsevier, pp 282–297.
69. Molnar TF, Hasse J, Jeyasingham K, et al: Changing dogmas: history of
development in modalities of traumatic pneumothorax, hemothorax
and post-traumatic empyema thoracis. Ann Thorac Surg 77:372–378,
2004.
70. Fallon WF: Surgical lesson learned on the battlefield. J Trauma 43:209–
213, 1997.
71. Tominaga GT, Waxman K, Scannell G, et al: Emergency thoracotomy
with lung resection following trauma. Am Surg 59:834–837, 1993.
72. Karmy-Jones R, Jurkovich GJ, Shatz DV, et al: Management of traumatic
lung injury: a Western Trauma Association multicenter review. J Trauma
51:1049–1053, 2001.
73. Sisley AC, Rozycki GS, Ballard RB, et al: Rapid detection of traumatic
effusion using surgeon-performed ultrasonography. J Trauma 44:291–
297, 1998.
74. Kirkpatrick AW, Sirois M, Laupland KB, et al: Hand-held thoracic
sonography for detecting traumatic pneumothoraces: the Extended
Focused Assessment with Sonography for Trauma (EFAST). J Trauma
57:288–295, 2004.
75. Knudson JL, Dort JM, Helman SD, et al: Surgeon-performed ultrasound
for pneumothorax in the trauma suite. J Trauma 56:527–530, 2004.
76. Kerr TM, Sood R, Buckman RF, Jr, et al: Prospective trial of the six hour
rule in stab wounds of the chest. Surg Gynecol Obstet 169:223–225, 1989.
77. Kiev J, Kerstein MD: Role of three hour roentgenogram of the chest in
penetrating and nonpenetrating injuries of the chest. Surg Gynecol
Obstet 175:249–253, 1992.

78. Karaaslan T, Meuli R, Androux R, et al: Traumatic chest lesions in
patients with severe head trauma: a comparative study with computed
tomography and conventional chest roentgenograms. J Trauma 39:
1081–1086, 1995.
79. Inaba K, Lustenberger T, Recinos G, et al: Does size matter? A prospec-
tive analysis of 28-32 versus 36-40 French chest tube size in Trauma.
J Trauma 72:422–427, 2012.
80. Kulvatunyou N, Vijayasekuran A, Hansen A, et al: Two-year experience
of using pigtail catheters to treat traumatic pneumothorax: a changing
trend. J Trauma 71:1104–1107, 2011.
81. Coselli JS, Mattox KL, Beall AC, Jr: Reevaluation of early evacuation of
clotted hemothorax. Am J Surg 148:786–790, 1984.
82. Karmy-Jones R, Jurkovich GJ, Nathens AB, et al: Timing of urgent tho-
racotomy for hemorrhage after trauma. A multicenter study. Arch Surg
136:513–518, 2001.
83. Weigelt JA: Pulmonary resection for trauma. In Champion HR, Robb
JV, Trunkey DD, editors: Rob & Smith’s operative surgery, London, 1989,
Butterworth & Co., pp 311–317.
84. Wiencek RG, Jr, Wilson RF: Central lung injuries: a need for early vas-
cular control. J Trauma 28:1418–1424, 1988.
85. Van Natta TL, Smith BR, Bricker SD, et al: Hilar control in penetrating
chest trauma: a simplified approach to an underutilized maneuver.
J Trauma 66:1564–1569, 2009.
86. Powell RJ, Redan JA, Swan KG: The hilar snare, an improved technique
for securing rapid vascular control of the pulmonary hilum. J Trauma
30:208–210, 1990.
87. Wilson A, Wall MJ, Maxson R, et al: The pulmonary hilum twist. Am J
Surg 186:49–52, 2003.
88. Huh J, Wall MJ, Jr, Estrera AL, et al: Surgical management of traumatic
pulmonary injury. Am J Surg 186:620–624, 2003.
89. Wall MJ, Jr, Hirshberg A, Mattox KL: Pulmonary tractotomy with selec-
tive vascular ligation for penetrating injuries to the lung. Am J Surg
168:665–669, 1994.
90. Asensio JA, Demetriades D, Berne JD, et al: Stapled pulmonary trac-
totomy: a rapid way to control hemorrhage in penetrating pulmonary
injuries. J Am Coll Surg 185:486–487, 1997.
91. Wall MJ, Jr, Villavicencio RT, Miller CC, III, et al: Pulmonary tractotomy
as an abbreviated thoracotomy technique. J Trauma 45:1015–1023, 1998.
9  /  Cardiac, Great Vessel, and Pulmonary Injuries 99
92. Velmahos GC, Baker C, Demetriades D, et al: Lung-sparing surgery after
penetrating trauma using tractotomy, partial lobectomy and pneumon-
orrhaphy. Arch Surg 134:186–189, 1999.
93. Gasparri M, Karmy-Jones R, Kralovich KA, et al: Pulmonary tractotomy
versus lung resection: viable options in penetrating lung injury. J Trauma
51:1092–1097, 2001.
94. Cothren C, Moore EE, Biffl WL, et al: Lung-sparing techniques are asso-
ciated with improved outcome compared with anatomic resection for
severe lung injuries. J Trauma 53:483–487, 2002.
95. Thompson DA, Rowlands BJ, Walker WE, et al: Urgent thoracotomy
for pulmonary or tracheobronchial injury. J Trauma 28:276–280,
1988.
96. Wagner JW, Obeid FN, Karmy-Jones RC, et al: Trauma pneumonectomy
revisited: the role of simultaneously stapled pneumonectomy. J Trauma
40:590–594, 1996.
97. Halonen-Watras J, O’Connor J, Scalea T: Traumatic pneumonectomy: a
viable option for patients in extremis. Am Surg 77:493–497, 2011.
98. Karmy-Jones RC, Jurkovich GJ: Complications of pulmonary and
pleural injury. In Asensio JA, Trunkey DD, editors: Current therapy of
trauma and surgical critical care, Philadelphia, 2008, Mosby Elsevier,
pp 298–303.
99. Moore FA, Moore EE, Haenel JB, et al: Post-traumatic pulmonary pseu-
docyst in the adult: pathophysiology, recognition, and selective manage-
ment. J Trauma 29:1380–1385, 1989.
100. Melloni G, Cremona G, Ciriaco P, et al: Diagnosis and treatment of
traumatic pulmonary pseudocysts. J Trauma 54:737–743, 2003.
101. Livingston DH, Hauser CJ: Chest wall and lung. In Feliciano DV, Mattox
KL, Moore EE, editors: Trauma, ed 6, New York, 2008, McGraw Hill,
pp 525–552.
102. Scherer L, Battistella F, Owings J, et al: Video-assisted thoracic surgery
in the treatment of posttraumatic empyema. Arch Surg 133:637–642,
1998.
103. Rotondo MJ, Schwab CW, McGonigal MD, et al: “Damage control”: an
approach for improved survival in exsanguinating penetrating abdomi-
nal injury. J Trauma 35:375–383, 1983.
104. Phelan HA, Patterson SG, Hassan MO, et al: Thoracic damage-control
operation: principles, techniques, and definitive repair. J Am Coll Surg
203:933–941, 2006.
10  Blunt Thoracic Aortic Injury
DEMETRIOS DEMETRIADES, PEEP TALVING, AND KENJI INABA
Introduction
The screening, diagnosis, method, and timing of definitive
management of blunt thoracic aortic injuries (BTAI) have
undergone revolutionary changes over the past decade.
Routine chest computed tomography (CT) scan has replaced
plain x-rays for screening purposes, and contrast-enhanced
CT angiography (CTA) has replaced formal angiography as a
method of definitive diagnosis. Semi-elective definitive repair
of BTAI instead of emergency repair has now become the new
standard, and endovascular stent grafts have largely replaced
open operative repair. All of these changes have resulted in a
significant reduction in early mortality and complications.
Historical Background
The first case of blunt thoracic aortic injury was reported by
the anatomist Andreas Vesalius in a man who fell from a horse
in 1557. The first reported repair of an acute repair of a BTAI
occurred in the late 1950s. In the 1970s there was the develop-
ment and widespread use of various shunting techniques and
graft materials.1 In the 1990s, we see the first reports support-
ing routine use of CT scan as a screening method in patients
with a suspicious mechanism of injury; and soon afterward
contrast-enhanced CTA is advocated as the preferred method
of definitive diagnosis of BTAI.2 In 1997, the first endovascular
repair of a patient with BTAI was reported; and in the 2000s,
endovascular aortic repair (EVAR) became the new preferred
therapeutic approach.3
Epidemiology
It is estimated that 8000 to 9000 blunt-trauma victims suffer
thoracic aortic injury every year in the United States.4 The
majority of these are due to motor-vehicle crashes (about
70%), followed by motorcycle crashes (13%), falls from
heights (7%), automobile–pedestrian accidents (7%), and
other mechanisms.5 The overall incidence of thoracic aortic
injury in patients reaching the hospital alive is less than 0.5%.
In a series of 5838 pedestrian injuries reaching hospital care,
the incidence of BTAI was 0.3%. Likewise, in a study based on
National Trauma Data Bank (NTDB), Arthurs et al identified
3144 blunt thoracic aortic injuries among 1.1 million trauma
admissions for an overall incidence of 0.3%.6 In another study
of 1613 admissions following high-level falls, the incidence of
BTAI was 0.1%. The presence of a pelvic fracture is a marker
100
of an associated thoracic aortic injury. In analysis of 1450
pelvic fractures, aortic injury was diagnosed in 1.4%.7 However,
it seems that patients with this injury pattern who reach the
hospital alive are only the tip of the iceberg, and the real inci-
dence of BTAI is much higher. The vast majority of patients
with this injury dies at the scene and never reach hospital care.
The incidence of aortic injuries in fatal traffic injuries is very
high. In a recent analysis of 304 deaths due to blunt trauma
in the county of Los Angeles, 102 patients (33%) had a rupture
of the thoracic aorta. About 80% of the deaths due to a free
rupture of the aorta occurred at the scene, and only 20%
occurred in the hospital (Fig. 10-1).8 In another autopsy anal-
ysis of 25 fatalities in a recent train crash in Los Angeles,
thoracic aortic rupture was found in 8 cases (33%). All mor-
talities occurred at the scene.9
The incidence of aortic trauma increases with age, and it is
rare to find this injury in the pediatric population. In a NTDB
analysis, the incidence of thoracic aortic injury in children
younger than 16 years old was 7 times lower than in adults
(0.03% vs. 0.21%). In an analysis of 5838 automobile–
pedestrian injuries, there were no aortic injuries in the age
group 14 years and younger. The incidence increased to 0.2%
in the group 15 to 65 years, to 0.5% in the group 56 to 65
years, and to 1.5% in the group older than 65 years.10
About 40% of patients with aortic rupture have severe
associated injuries (body area Abbreviated Injury Scale [AIS]
score ≥ 4), the most common being the head and abdomen.
The mean injury severity score (ISS) of 40 is a strong indicator
of the grave condition of patients with pattern of vascular
trauma.5,6
Site and Type of Aortic Injury
The most common anatomic location of aortic injury is the
medial aspect of the lumen, distal to the left subclavian artery
(Fig. 10-2). In a prospective analysis of 185 cases of thoracic
aortic injury, the rupture involved the isthmus in 75%, fol-
lowed by the descending thoracic aorta in 22% and the ascend-
ing aorta in 4%.5 Computer simulation and cadaver studies
have shown that the combination of increased intraaortic
pressure (mean 1149 mm Hg) and rotational forces exerts a
highly focused stress at the isthmus. In addition, the tensile
strength at the isthmus was found to be only 63% of that of
the proximal aorta.11 The most common type of injury is a
false aneurysm (58%), followed by dissection (25%) and
intimal tear (20%) (Fig. 10-3).5
 10  /  Blunt Thoracic Aortic Injury 100.e1

ABSTRACT
Most patients with blunt thoracic aortic injuries (BTAI) die
at the scene and never receive medical care. For those cases
reaching hospital care, early diagnosis and appropriate
intervention remain the main tenets for survival and good
functional results. Plain chest radiography is an unreliable
screening method for BTAI, and contrast-enhanced CT
scans should be considered for evaluation of all patients
with high-speed deceleration injuries. Multislice CT scan
technology provides a reliable and precise diagnosis, and
traditional contrast arteriography is rarely needed. Early
and intensive blood pressure control with restricted fluid
resuscitation and administration of beta-blocker therapy
are critical to reduce the risk of free rupture of contained
aortic injuries. Delayed semi-elective repair of aortic injury
is preferable in instances of contained rupture and is associ-
ated with better results than early emergent repair. Endo-
vascular stent-graft repair has now become the most
commonly used method of management in patients with
BTAI. Endovascular repair is associated with improved sur-
vival and reduced incidence of paraplegia compared to
open operative repair. However, the endovascular tech-
nique is associated with a risk of device-related complica-
tions, and there are no long-term results with this method.
Conservative management with blood pressure control and
monitoring may have a role in selected patients with minor
BTAI. Overall, management of BTAI by multidisciplinary
teams and in centers of excellence has resulted in major
improvement in outcomes.

Key Words:  blunt trauma,

thoracic aortic injury,
screening,
diagnosis,
open repair,
endovascular repair,
device-related complications,
mortality,
paraplegia
 10  /  Blunt Thoracic Aortic Injury 101

FIGURE 10-2 Classic site of the blunt thoracic aortic injury. Medial

FIGURE 10-1  Transected thoracic aorta noted at autopsy. aspect of the aorta, distal to the left subclavian artery. (Illustration by
Alexis Demetriades.)

A B
FIGURE 10-3  A, Aortography: traumatic false aneurysm of the descending aorta is the most common type of injury. B, Sagittal view of a CTA
depicting a blunt thoracic aortic injury with an extensive dissection.

Natural History of Blunt Thoracic
Aortic Injuries
The majority of patients with BTAI die at the scene (before
reaching hospital care). In analysis of 242 fatal BTAI, Burkhart
et al reported that 57% of the deaths occurred at the scene or
on arrival to the hospital, 37% died within first 4 hours of
admission, and 6% died at a time point greater than 4 hours
after admission.12 In another autopsy study of 102 patients
with BTAI, about 80% of the deaths occurred at the scene
and only 20% in the hospital.8 In a recent NTDB-based study,
68% of patients suffering BTAI never underwent an attempt
102 SECTION 3  /  DEFINITIVE MANAGEMENT
A B
FIGURE 10-4  A, Chest x-ray shows a very widened mediastinum due to blunt thoracic aortic injury. B, Chest X-ray (top) depicts a normal
mediastinum but CT angio (bottom) shows an aortic injury.
at treatment due to early death or severity of associated
injuries.6
Screening and Diagnosis
Supine chest x-ray has been used as the primary screening tool
for diagnosis of BTAI. Numerous radiographic findings have
been described as markers of aortic trauma, including the
presence of a widened upper mediastinum (greater than 8 cm
on an anteroposterior supine chest film at the level of the
aortic knob) (Fig. 10-4), obliteration of the aortic contour,
and loss of the paravertebral pleural stripe. Additionally,
depression of the left mainstem bronchus; rightward devia-
tion of the nasogastric tube; left apical pleural hematoma (i.e.,
apical cap); left hemothorax; and fracture of the sternum,
scapula, upper ribs, or clavicle have been shown to be associ-
ated with this pattern of vascular trauma.4 The presence of a
widened mediastinum is the most common finding, but this
finding still has a low sensitivity and specificity. Many condi-
tions, such as fracture of the sternum or thoracic spine or
simply the supine position in an obese patient may cause a
widened appearance of the mediastinum on chest x-ray. The
most specific signs are loss of the aortic knob, an abnormality
of the aortic arch and deviation of the nasogastric tube.
However, the sensitivity of these findings is still quite low.
Traditionally, a normal chest x-ray had been considered
reliable in excluding BTAI. However, numerous studies have
now shown that basic chest x-ray is a poor screening tool for
aortic trauma and that a significant number of injuries may
not show any mediastinal abnormalities.2,13 Given this under-
standing of the limitations of chest x-ray, many centers now
use contrast-enhanced CT scan of the chest as the primary
screening tool for BTAI, irrespective of x-ray findings. The
sensitivity and negative predictive value of the CT scan in the
diagnosis of BTAI approaches 100%.
Recently, Starnes and colleagues proposed an insightful
classification of BTAI based on high-quality, contrast-
enhanced CT imaging. These authors stratified aortic injury
into four categories related to the presence or absence of an
abnormality in the external contour of the wall of the descend-
ing thoracic aorta. The injuries without external contour
alterations include small intimal tears (less than 10 mm; Cat-
egory I) and more extensive intimal flaps (greater than 10 mm;
Category II). Injuries with changes in external-wall contour
include pseudoaneurysms (Category III) and rupture of the
aorta (Category IV) (Fig. 10-5). These investigators also sug-
gested readily applicable treatment guidelines related to this
useful radiographic classification.14
Catheter-based arch aortography remained the gold stan-
dard for the definitive diagnosis of BTAI until the late 1990s.
However, it is invasive, takes time, and carries with it a small
risk of stroke. In the last few years the contrast-enhanced CT
scan has replaced formal aortography in the definitive diag-
nosis of BTAI. The new generation multislice CT scanners
with 3-D reconstruction have been shown to have almost
100% sensitivity and specificity and 90%-positive and
100%-negative predictive values. In these studies, the overall
diagnostic accuracy of contrast-enhanced CT imaging has
been shown to be greater than 99% (Fig. 10-6). Catheter-based
arch aortography still has a limited diagnostic role in the rare
cases where the CT scan findings are suspicious but not diag-
nostic. Aortography with or without intravascular ultrasound
 10  /  Blunt Thoracic Aortic Injury 103

ABSENT EXTERNAL CONTOUR ABNORMALITY PRESENT EXTERNAL CONTOUR ABNORMALITY

Type of aortic injury Definition Example Type of aortic injury Definition Example
Intimal tear No aortic external Pseudoaneurysm Aortic external contour
contour abnormality: abnormality: contained
tear and/or associated
thrombus is <10 mm

Large intimal flap No aortic external Rupture Aortic external contour

contour abnormality: abnormality: not
tear and/or associated contained, free rupture
thrombus is >10 mm

FIGURE 10-5 Classification of blunt thoracic aortic injury with treatment guidelines. (From Starnes BW, Lundgren RS, Gunn M, et al: A new clas-
sification scheme for treating blunt aortic injury. J Vasc Surg 55:47–54, 2012.)

Table 10-1 Changing Perspectives: Diagnostic

Modalities for Blunt Thoracic Aortic
Injury: AAST1 (1997) Versus AAST2
(2007)
AAST1 AAST2 p-value
Number 253 193
Aortogram 207 (87%) 16 (8.3%) <0.001
CT scan 88 (34.8%) 180 (93.3%) <0.001
TEE 30 (11.9%) 2 (1.0%) <0.001

From Demetriades D, et al: Diagnosis and treatment of blunt thoracic

aortic injuries: changing perspectives. J Trauma 64:1415–1419,
2008.
AAST, The American Association for the Surgery of Trauma; CT, com-
puted tomography; TEE, transesophageal echography.

diagnosis of thoracic aortic injuries decreased from 87% and

FIGURE 10-6 CTA with 3-D reconstruction provides a reliable and
detailed information about the site, size, and type of aortic injury.
(IVUS) may also be performed as the initial diagnostic or
therapeutic step in the endovascular treatment of BTAI (i.e.,
stent-graft repair).
Transesophageal echocardiography (TEE) is another diag-
nostic modality in the evaluation of suspected BTAI. The
initial enthusiasm surrounding this modality has been replaced
by skepticism and failure to gain popularity because of con-
flicting reports about accuracy and concerns regarding its
ready availability.15 The dramatic shifting from formal aortog-
raphy and TEE to contrast-enhanced CT scanning in the
diagnosis of BTAI is demonstrated by a multicenter study
sponsored by the American Association for the Surgery of
Trauma (AAST). The use of angiography and TEE for the
12%, respectively, in 1997 to only 8% and 1% in 2007 (Table
10-1).5 Other diagnostic modalities such as magnetic reso-
nance imaging (MRI) or IVUS may be useful in rare patients
where the CTA findings are not definitive.
In summary, the new generation of scanners has made
contrast-enhanced CT scanning the standard diagnostic
modality for screening and diagnosis of BTAI. Traditional
catheter-based aortography may have a diagnostic role in
patients undergoing arteriography for other injuries such as
pelvic fracture or complex liver injury or as an initial step to
endovascular repair of BTAI. TEE might be useful in critically
ill patients in the intensive care unit who cannot be transferred
safely to the radiology suite for CT scan.
Initial Management of Thoracic
Aortic Injuries
Prompt diagnosis and early appropriate treatment remain the
primary tenets of survival for patients with BTAI. Stabilization
and prevention of free rupture of a contained aortic injury
until definitive repair can be performed is the most urgent
104 SECTION 3  /  DEFINITIVE MANAGEMENT
priority. The risk of free rupture is highest in the first few
hours after the injury, with more than 90% of ruptures occur-
ring within the first 24 hours.16 In an AAST multicenter study
by Fabian et al, 24 (8.8%) of the 274 patients in the study
population progressed to free rupture.4 However, rigorous
blood pressure control reduces the risk of rupture to about
1.5%.17 Blood pressure control is best achieved with a combi-
nation of fluid restriction and pharmacologic intervention.
The systolic blood pressure should be kept as low as tolerated,
in most patients at about 90 mm Hg to 110 mm Hg. In
elderly patients, the optimal systolic pressure may be slightly
higher. Cautious restriction of intravenous fluids and admin-
istration of beta-blocker therapy in the form of an esmolol
drip are the most commonly used modalities for blood pres-
sure control.
Timing of Definitive Management
Untreated, the risk of rupture of a BTAI is highest in the first
24 hours after injury. In the AAST multicenter study by Fabian
et al, 24 (8.8%) of patients progressed to free rupture. Ninety-
two percent of patients with ruptures died within 24 hours of
injury, 1 at 30 hours and 1 at 6 days. In the group of 13 free
ruptures in which the time of rupture was known, 46%
occurred within 4 hours and another 38% took place within
8 hours after injury.18 For these reasons, the definitive manage-
ment of TAI had been considered as an emergency, and this
policy remained the standard for many years. However,
subsequent studies demonstrated that the early initiation of
pharmacologic blood pressure control with restrictive fluid
resuscitation decreases wall stress in the region of the injury
and reduces the risk of rupture to approximately 1.5%.17,18
Patients with contained aortic injury who survive beyond 4
hours after injury with this medical management rarely prog-
ress to rupture and death.17 The successful management of
these injuries therefore hinges on early diagnosis and careful
blood pressure control.
In the late 1990s and early 2000s, some studies suggested
that select patients with BTAI and major associated injuries
could be managed safely with delayed aortic repair. This
approach was demonstrated to be safe and allowed for stabi-
lization of other major associated injuries provided that the
patient’s blood pressure was adequately controlled.17-19 The
concept of delayed repair was subsequently adopted more lib-
erally and was shown to be safe in patients with no severe
associated injuries or other major comorbidities.
The safety of delayed BTAI repair and its effect on out-
comes was a matter of controversy until recently. Most clinical
studies of this scenario included only patients with major
associated injuries and reported contradictory results. Some
studies showed improved outcome with delayed repair while
others failed to show benefit. Wahl et al, in a retrospective
review of 48 cases, reported that delayed (greater than 24
hours following injury) aortic repair was safe but was associ-
ated with longer hospital stay and was costlier than early
repair.20 A similar study of 78 patients by Hemmila et al
reported a higher complication rate and a longer hospital stay
in the group of patients who underwent delayed (greater
than16 hours following injury) repair.17
However, other studies suggested that delayed repair was
associated with improved outcome.19,21 A recent AAST multi-
center, prospective study analyzed outcomes in 178 patients
with BTAI according to timing of repair. In this study, early
repair was classified as being within 24 hours of injury, and
delayed repair was classified as that performed after 24 hours.5
In this study, the two groups were similar with regard to injury
severity major associated injuries, type of aortic injury, and
type of aortic repair (operative versus endovascular). The
mean time from injury to repair was 10.2 hours in the early
group and 126.2 hours in the delayed group. In the study, the
overall mortality in the delayed-repair group was lower than
that of the early-repair group (5.8% versus 16.5%, p = 0.034).
A multivariate analysis adjusting for injury severity, severe
extrathoracic injuries, Glasgow Coma Score (GCS), hypoten-
sion on admission, advanced age, and method of aortic injury
repair showed an increased risk of death in the early-repair
group (adjusted OR [95% CI] 7.78 [1.69 to 35.70], adjusted
p-value = 0.008). The survival benefits in the delayed-repair
group were confirmed in the subanalysis of the groups with
or without major associated injuries. The incidence of para-
plegia was similar in the two groups (early repair 1.8%;
delayed repair 1.4%). In a more recent trauma registry study
of 145 BTAI repairs, delayed repair was identified as the
only independent factor shown to be associated with lower
mortality.22
These recent studies provide the strongest evidence to date
that with adequate medical management delayed repair is not
only safe but may be preferable to emergent repair in select
patients. This approach allows for optimizing patient risk
factors and physiologic condition and ensures that other more
life-threatening injuries can be prioritized. The optimal time
from injury or admission to repair is unknown and should be
individualized, taking into account factors such as the pres-
ence of other severe injuries or comorbid conditions, the
physiologic status of the patient, and the type and severity of
the aortic injury. Delayed repair should not be attempted in
cases with active leaking from the aortic injury (Fig. 10-7).
Urgent repair, within a few hours of diagnosis, remains advis-
able in cases with large contained injuries.
Extravasation
FIGURE 10-7 CTA demonstrating active extravasation from a trau-
matic thoracic aortic aneurysm.

Table 10-2 Changing Perspectives: Methods of
Definitive Treatment of Thoracic
Aortic Injuries: AAST1 (1997)
Versus AAST2 (2007)
AAST1 AAST2 p-value
N 207 193
Open repair 207 (100%) 68 (35.2%) <0.001
 Clamp-and-sew 73/207 11/68 0.003
(35.3%) (16.2%)
  Bypass 134/207 57/68 0.003
(64.7%) (83.8%)
Endovascular repair 0/207 (0%) 125/193 <0.001
(64.8%)
From Demetriades D, et al: Diagnosis and treatment of blunt thoracic
aortic injuries: changing perspectives. J Trauma 64:1415–1419,
2008.
AAST, The American Association for the Surgery of Trauma.
Definitive Management of Thoracic
Aortic Injuries
Open operative repair of BTAI was for many decades the only
standard definitive management. However, in the last decade
there has been a dramatic increase in the use of endovascular
stent grafts to treat this injury pattern. This shift is clearly
demonstrated by two large prospective studies by the AAST in
1997 and in 2007.4,5 In the 1997 study, all 207 cases of BTAI
were managed with open operative repair; while, in the 2007
study, 65% of the 193 cases of BTAI were managed with endo-
vascular stent-graft repair and only 35% with open operative
repair (Table 10-2). Currently, the only absolute indications
for open repair are a small aorta or an injury involving the
aortic arch where placement of an endograft might be techni-
cally difficult or impossible. A third and evolving therapeutic
option for select cases with minor aortic injuries is observa-
tion combined with medical therapy.
Open Surgical Repair
DeBakey and Cooley performed the first successful open oper-
ative repair of blunt thoracic aortic injury in 1953.23 The
clamp-and-sew technique, as it was known, became the stan-
dard for many decades. Advantages of this technique included
a relatively expedient repair and alleviation of the need for
systemic anticoagulation. The clamp-and-sew technique was
initially practiced without distal aortic perfusion and resulted
in a significant rate of paraplegia when aortic cross-clamp
times exceeded 30 minutes. In more recent years, open repair
performed with the use of roller/centrifugal pumps to provide
active distal aortic perfusion in an effort to reduce risk of
paraplegia has become the standard.
There are several techniques for active distal aortic perfu-
sion during open repair and aortic cross-clamping. The most
common is the left heart partial bypass with the inflow into
the pump achieved through the cannula inserted in the left
atrium through the left atrial appendage or left pulmonary
vein. The outflow cannula is inserted into the distal aorta
beyond the distal aortic clamp using the purse-string con-
trolled aortotomy (Fig. 10-8) or in the femoral artery. Alter-
natively, right atrial to distal aortic cannulation is used in
10  /  Blunt Thoracic Aortic Injury 105
conjunction with the oxygenator that requires a full heparin
bolus of 300 to 400 units/kg to achieve and maintain activated
clotting time (ACT) above 400 seconds. This configuration is
used very infrequently in trauma settings due to the risk of
hemorrhage from associated injuries. Debate over the need for
and the type of distal aortic perfusion is still evolving.24
During an open operative repair of BTAI, double-lumen
intubation and independent lung ventilation is instituted. The
patient is placed in the right lateral decubitus position and
access to the aortic isthmus is obtained through a left postero-
lateral thoracotomy in the fourth or fifth intercostal space. The
proximal aorta and left subclavian artery are identified, iso-
lated and controlled with vessel loops. The thoracic aorta
distal to the injury is identified and likewise isolated with a
vessel loop. The aortic clamps are applied proximal and distal
to periaortic hematoma and the subclavian artery. Decision
making with regard to the location of clamp placement has
been greatly aided by the use of 2-D and 3-D reconstruction
of CTAs. When feasible, the clamp placed on the arch is
transferred distal to the origin of the left subclavian artery to
reduce cardiac afterload and spinal cord ischemia during the
clamp time.
The periaortic dissection plane is identified and the aortic
lesion is exposed. A transverse aortotomy is performed to
allow inspection of the aortic tear and subsequently decide
whether primary repair or interposition graft placement is
required. In adult patients, the interposition-graft reconstruc-
tion of the thoracic aortic injury is most commonly utilized
(Fig. 10-8). The intercostal arteries in proximity of the aortic
lesion are preferentially not ligated or oversewn, but are incor-
porated into the tailored aortic repair. A cell-saver device may
be successfully used for autotransfusion of blood from the
chest in the case of major hemorrhage. The aortic injury is
repaired utilizing 2-0 or 3-0 polypropylene suture material
and a collagen-coated or preclotted Dacron tube graft that
reduces bleeding from the graft. The size of the interposition
graft ranges from 22 mm to 40 mm and is chosen to match
the size of the aorta. Primary repair is utilized only in rare
cases of pediatric blunt aortic injuries to avoid aortic coarcta-
tion as the child grows (Fig. 10-8).
In the AAST1-sponsored prospective multiinstitutional
study in 1997, the clamp-and-sew technique without distal
aortic perfusion was performed in 35% (n = 73) of all patients
undergoing operative repair. In these instances, the paraplegia
rate was 16.4%. By comparison, in the 134 patients undergo-
ing repair using distal aortic perfusion, the paraplegia rate was
lower at 4.5%. The most important independent risk factor
for paraplegia was cross-clamp time of more than 30 minutes
(odds ratio 15).4
A decade later, a second AAST-sponsored multiinstitu-
tional prospective AAST2 study was published; it included 193
patients subjected to definitive repair of BTAI. The rate of
clamp-and-sew technique without bypass had decreased from
35% in 1997 to 16% in 2007. Likewise, during the decade
between AAST1 and AAST2, the overall incidence of procedure-
related paraplegia in patients undergoing open surgical repair
decreased significantly from 8.7% to 1.6% (p = 0.001). Cur-
rently, approximately 85% of thoracic aortic injuries treated
with open operative repair are managed with some form of
distal aortic perfusion technique.5
Numerous studies have demonstrated that active distal
perfusion is superior to passive perfusion in reducing the
106 SECTION 3  /  DEFINITIVE MANAGEMENT
Adult
a Pediatric
C
A position graft in adult patients. C, Clamp-and-sew
incidence of procedure-related paraplegia.4 A meta-analysis of
mortality and risk of paraplegia following repair of traumatic
aortic rupture in 1492 patients showed an overall postopera-
tive paraplegia rate of 9.9%. Among patients treated with
simple aortic clamping, the case fatality and incidence of
paraplegia were 16% and 19.2%, respectively. By utilizing
passive shunts, the mortality decreased to 12.3%, and paraple-
gia decreased to 11.1%. Furthermore, the rate of paraplegia
was reduced to 2.3% with active perfusion.25
In the relatively rare instances where operative repair is
performed, these data have led to a new standard of care
requiring the use of distal perfusion adjuncts. While open
operative repair is less common in today’s practice secondary
to the emergence of endovascular stent grafts, there are
instances in which EVAR is prohibitive, such as in aortic arch
injuries, in young patients with a small aorta, in hemodynamic
instability, in active extravasation from the aorta seen on CTA
(see Fig. 10-7), and in patients with occlusive disease at vas-
cular access sites (i.e., iliac and femoral vessels).
Endovascular Aortic Repair
Endovascular aortic repair (EVAR) (Fig. 10-9) for thoracic
aortic injuries was first utilized by Kato and colleagues in
FIGURE 10-8  A, Distal aortic perfusion during
open surgical repair utilizing partial left heart
bypass to the distal aorta (a) or common femoral
artery (b). B, Clamp-and-sew technique with inter-
with primary repair in selected pediatric patients.
(Illustrations by Sarah A. Chen.)
1997.3 Initially, endovascular repair was recommended only
for high-risk patients sustaining BTAI with severe associated
injuries or with comorbid conditions.26 The next decade saw
a steady increase in the use of endovascular stents in the man-
agement of BTAI (Fig. 10-10). In the AAST1 study in 1997, no
patient was treated with the EVAR technique.4 A systematic
review of the literature up to 2006 found a total of only 284
patients with traumatic aortic injury treated with endovascu-
lar repair.27 However, the more recent AAST2 study in 2007
reported that almost 65% of the 193 patients with BTAI
were managed definitively with EVAR. Furthermore, 60% of
patients with no major extrathoracic injuries, and 57% of
patients less than 55 years old and no major associated trauma
were treated with endovascular techniques.
Endovascular repair of BTAI is associated with significantly
better early outcomes than open repair. In the AAST-study,
multivariate analysis adjusting for age greater than 55, GCS
less than 8, hypotension on admission, and critical extratho-
racic injuries showed a lower adjusted mortality and fewer
blood transfusions in the endovascular group compared to the
open repair group. In the subgroup of patients with no critical
extrathoracic injuries, endovascular repair was associated with
a lower case fatality rate and fewer blood transfusions than
open repair. A survival benefit was likewise identified in the
 10  /  Blunt Thoracic Aortic Injury 107

FIGURE 10-9  Illustration of deployed endovascular stent graft for

blunt thoracic aortic injury. (Illustration: Alexis Demetriades.) A

subgroup of patients with associated critical extrathoracic

injuries.5 A recent metaanalysis of 699 blunt aortic injuries
demonstrated lower mortality in patients who were managed
with endovascular techniques (7.6%) compared with patients
who were treated with open operation (15.2%; p = 0.008).
The incidence of procedure-related paraplegia was 5.6% in the
open repair group, while no paraplegia was reported in the
endovascular group. The incidence of stroke was likewise
lower in EVAR group compared to the open repair group (0.8
versus 5.3%, respectively; p = 0.003).28
Despite improved early outcomes associated with endovas-
B
cular repair of BTAI, there remains some concern because of
a small incidence of device-related complications. In the FIGURE 10-10 CT scan shows a successfully deployed endovascular
AAST2 study, 20% of patients subjected to EVAR developed stent grafts on axial and sagittal images.
device-related complications including endoleaks, access-site
vessel complications, occlusions of the left subclavian or left
carotid arteries, device collapse, and stroke (Table 10-3). The
Table 10-3 Device-Related Complications in
most common complication was an endoleak which was
Patients Treated With Endovascular
observed in 14% of patients. The proper sizing of the stent is
Repair in AAST2 Study
essential in avoiding complications such as endoleaks or stent
collapse (Fig. 10-11).29 Optimal deployment of the stent Complications N 125 (%)
requires oversizing the device by 10% to 20%.27,30 However, Endoleak 18 (14)
this is not always possible, especially in young patients, because Access vessel injury 4 (3)
the commercially available devices come in a limited range Subclavian artery occlusion 4 (3)
of sizes. Stroke 2 (1.6)
Some authors have voiced concerns that patients in a hypo- Paraplegia 1 (0.8)
volemic state may manifest a disproportionately small aortic Carotid artery occlusion 1 (0.8)
diameter on admission CTA. Sizing an aortic stent graft based Partial collapse of the device 1 (0.8)
on imaging performed during this transient state of hemor- Insertion site infection 1 (0.8)
rhagic shock could result in placement of a graft that is too
small once the patient is resuscitated to normal circulatory From Demetriades D, et al: Operative treatment or endovascular stent
graft in blunt thoracic aortic injuries: results of American Associa-
volume. In a translational research study examining this phe- tions for The Surgery of Trauma multicenter study. J Trauma 64:561–
nomenon, Jonker et al confirmed a reduction in aortic diam- 571, 2008.
eter associated with the hemorrhagic shock in both an animal AAST, The American Association for the Surgery of Trauma.
108 SECTION 3  /  DEFINITIVE MANAGEMENT

A B
FIGURE 10-11 CT scan depicting stent-graft related complications. Poor apposition between the graft and the aortic wall may cause (A)
endoleak (arrows) and (B) partially collapsed stent graft.

model and in trauma patients. The use of repeat CTA or IVUS

at the time of the endovascular procedure have been pro-
moted as ways to reduce the risk of undersizing a stent graft
in this circumstance.31-33 Another factor that increases the risk
of endoleak relates the morphometry (i.e., shape and curve)
of the aorta, especially at the angle between the left subclavian
artery and the descending aorta. This angle can be as steep as
90 degrees, which results in poor apposition between the stent
graft and the aortic wall, especially in the inner aspect of the
aortic curve (Fig. 10-12). Excessive oversizing of the stent in
attempts to reduce the risk of endoleak is associated with
complication as well. Too large a diameter of stent graft
increases the risk of infolding and the risk of collapse of the
device. Although uncommon, graft infolding has potentially
catastrophic consequences, including varying degrees of tho-
racic aortic occlusion (i.e., functional aortic coarctation).29
New thoracic aortic endograft designs, including those made
specifically for use in BTAI, promise to improve one’s ability
to optimally size and place these devices with lower rates of
device-related complications.
Another concern with endovascular treatment of BTAI is
the lack–of-outcomes data, especially in younger individuals.
Because of this, the durability of these devices as the aorta
becomes more tortuous and dilated is not known. Limited
FIGURE 10-12  Poor apposition between the stent graft and the
amounts of medium-term outcome data are available and aortic wall may occur in the inner corner of the graft (arrow).
demonstrate a small but definable rate of device-related com-
plication. In a study of 20 patients with EVAR for BTAI, Fer-
nandez et al34 reported two patients with left subclavian artery
occlusion requiring revascularization, one case of stent-graft subclavian artery, expanded at a greater rate than the aorta
collapse (6 months after injury) and one of stent-graft fracture distal to the graft. The clinical significance of this radiographic
requiring intervention 4 years after injury. In this same study, observation is unknown at this time.
the authors observed one case of stent-graft thrombosis 1 year Despite these concerns, endovascular management of BTAI
following placement (Fig. 10-13) presumably from infolding has become the new standard because of the lower morbidity
and occlusion. In another series of 17 patients treated with and mortality associated with its use (Table 10-4). For optimal
EVAR and a minimum of 1 year follow-up, Forbes et al35 results, it is essential that EVAR be performed in centers
reported that the proximal thoracic aorta, just distal to the left of excellence staffed with multidisciplinary teams that are
 10  /  Blunt Thoracic Aortic Injury 109

B C
FIGURE 10-13  Thrombosed stent graft on CT images.

Table 10-4 Open Versus Endovascular Aortic should be monitored and reported through a quality improve-
Repair of Thoracic Aortic Injuries ment process.
in AAST2 Study
All Open Advances in Endograft Design
Patients Repair EVAR p-value
Since introduction of the aortic stent graft as a treatment
N 193 58 125 option for age-related vascular disease such as abdominal
Mean ISS 39.5 38.9 39.4 0.83 aortic aneurysms in the mid-1990s, endograft technology has
Severe associated 39.2% 31.3% 43.4% 0.10 improved incrementally. However, until recently nearly all of
injuries the improvements in endograft design were related to their
Mortality 13.0% 23.5% 7.2% 0.001 use in aortic aneurysm disease. In fact, until very recently, the
Paraplegia 1.6% 2.9% 0.8% 0.28 indication for use of all commercially available aortic endo-
Systemic 45.1% 50.0% 42.4% 0.31 grafts was the management of aortic aneurysm disease. This
complications
reality and the off-label use of covered stent grafts to treat
From Demetriades D, et al: Operative treatment or endovascular stent aortic trauma partly explains the device-related complications
graft in blunt thoracic aortic injuries: results of American Associa- observed in some of the retrospective studies examining this
tions for The Surgery of Trauma Multicenter Study. J Trauma 64: treatment modality. With consistent improvement in endo-
561–571, 2008.
AAST, The American Association for the Surgery of Trauma; EVAR: vascular technology and now endografts being designed and
endovascular aortic repair; ISS, injury severity score. approved specifically for BTAI, one can surmise that device-
related complications will decrease in the years to come.
experienced in the management of the polytrauma patient. It The most clinically relevant differences between the aorta
has been shown that higher-volume centers have fewer sys- injured by trauma and the aneurysmal aorta affected by age-
temic and local complications and have shorter lengths of stay related disease are diameter, tortuosity, and calcification. The
than low-volume centers.5 The results of endovascular repair often young, previously healthy thoracic aorta disrupted by a
of this injury pattern, especially device-related complications, deceleration mechanism is smaller and less tortuous and has
110 SECTION 3  /  DEFINITIVE MANAGEMENT

a better-defined distal taper. Smaller artery size in the general

trauma population includes the iliofemoral segment which
serves as access for the large sheaths required to perform
EVAR. This phenomenon can result in limited access for EVAR
in trauma and a higher rate of access-site complications (e.g.,
iliofemoral artery injury). In this context, one of the most
notable advances in endograft design in the past 5 to 10 years
is the development of lower-profile devices that are able to be
placed through smaller sheaths. While 5 years ago nearly all
aortic stent grafts required 22 Fr or larger sheaths, most endo-
grafts for trauma can now be placed through 18 Fr or smaller
access.
Similarly, smaller diameter, trauma-specific endografts
have been developed to provide the surgeon with a broader
range of options for EVAR. Use of an oversized graft can lead
to imperfect seal, endoleak, infolding, and even collapse of the
graft. Currently endografts that can be utilized in patients with
aortic diameters as small as 16 mm to 18 mm are being devel-
oped with more appropriate indications for use. In addition
to considerations related to diameter, the aorta of a younger
trauma patient may not be fully elongated and thus have a
more-acute angle at the transition zone from transverse to
descending. This acute angle may prevent complete apposi-
tion of the endograft to the aortic wall in its proximal seal
zone, especially along the lesser curvature or the inner corner.
This phenomenon may result in what is referred to as a “bird’s
beak deformity” based on its radiographic appearance and a
propensity for Type I endoleak. If this proximal seal zone
imperfection is not corrected at the time of the procedure or
if it does not resolve with time, it may result in graft infolding,
migration, or even collapse. Obviously imperfect proximal or
distal seal zones and the persistence of a Type I endoleak also
mean that the aortic injury is not adequately treated and that
the disrupted segment remains pressurized and prone to
rupture. Some new generation endographs have this aortic
curvature incorporated into their design and can better
conform to the natural contour of the younger aorta effected
by trauma.
There are presently three main endografts utilized for BTAI
in the United States. Including the Cook Zenith® TX2 with
Pro-Form design, the Medtronic Talent endograft and the
Gore TAG® endoprostheses. These devices have available graft
diameters that range from 28 mm to 42 mm, from 18 mm to
42 mm, and from 21 mm to 45 mm, respectively. Currently,
the only endograft to have a trauma indication for use or
instruction for use (IFU) from the U.S. Food and Drug
Administration (FDA) is the Gore TAG Endoprosthesis.36 It is
a dynamic time for the development and regulatory approval
of aortic endograft devices for trauma. As such, it is difficult
to encapsulate here the accurate specifics of technology that
will become available in the coming years. The description
offered here of these devices, their diameters, and the state of
their FDA approval is a general guide reflective of the state of
technology at the time of this writing and editing.
Another significant procedural challenge faced during the
use of aortic endografts for trauma is the relationship of
major aortic branch vessels to the site of disruption. Specifi-
cally, if the site of BTAI is within 1 cm to 2 cm of a major
branch vessel such as the left subclavian or celiac artery, the
branch vessel may need to be covered in order for EVAR to
have an adequate proximal seal zone. This anatomic challenge
or reality most commonly involves proximity of the site of
FIGURE 10-14  Occlusion of the left subclavian artery (arrow) by a
deployed stent graft.
aortic injury to the origin of the left subclavian artery
(Fig. 10-14).
If establishing an adequate proximal seal zone requires cov-
erage of the left subclavian artery origin, one must consider
whether or not this vessel needs to be reconstructed before or
during the endovascular procedure. Covering the origin of the
left subclavian in the distal transverse arch typically extends
the proximal landing or seal zone by 2 cm to 3 cm. However,
covering the origin of the left subclavian also eliminates
normal perfusion to the left vertebral and axillary arteries, and
in some reports it has been associated with a higher risk of
paraplegia. Antegrade perfusion to the left subclavian and ver-
tebral arteries can be maintained with a left common carotid–
to-subclavian bypass (Fig. 10-15). Some centers routinely
perform this operation before EVAR for traumatic aortic
injury allowing for significant peace of mind and extension of
the proximal landing zone across the left subclavian origin in
every case. Preservation of flow into the left subclavian and
vertebral arteries through so-called “chimney” stent grafts37
delivered retrograde from the left axillary or brachial artery is
another option (Fig. 10-16). In the future, the development
and use of prepackaged, branched endografts will likely allow
for maintenance of flow through branch arteries near the site
of aortic injury without placement additional stent grafts.
Nonoperative Management
Experience with the nonoperative management of BTAI is
increasing and is used nearly exclusively in select patients of
advanced age or those with minor aortic injuries. As defined
by the Starnes criteria (Categories I and II), minimal aortic
injury (MAI) consists of a small intimal flap with no periaor-
tic hematoma and occurs in about 10% percent of BTAI.38
These injures may be managed with blood pressure control
and observation, without surgical or endovascular interven-
tion. Patients with MAI managed without operation should
have repeat CT imaging at fairly regular intervals during the
first year after injury until the injury regresses or heals. The

FIGURE 10-15  Reimplantation of the aortic branch vessels with
endovascular stent-graft placement (arrow) for an injury extending to
the aortic arch.
FIGURE 10-16  Arch branch grafts can address injuries to the aortic
arch and avoid occlusion of the major arch vessels.
literature related to the nonoperative management of MAI
consists of mainly small case series, and the preliminary results
are encouraging. In the studies to date and in the authors’
experience, patients with MAI can be safely managed with
blood pressure control and surveillance imaging with a very
low risk of injury progression.
In a study by Malhotra et al, 6 patients with MAI were
managed without an operation. In two patients the intimal
flap resolved, and in one it remained stable and asymptomatic.
10  /  Blunt Thoracic Aortic Injury 111
The remaining patients formed small asymptomatic pseudoa-
neurysms.39 The authors concluded that many intimal injuries
heal spontaneously and hence may be managed without open
or endovascular repair. In another study, Akins et al success-
fully managed 5 patients with MAI using blood pressure
control and surveillance imaging.40 In another small series of
5 patients with intimal tear of the descending thoracic aorta,
Kepros et al41 reported resolution of all injuries within 3 to 19
days. In a larger series of 27 cases managed with only blood
pressure control and surveillance imaging, Caffarelli24 reported
stable lesions in 19 patients and complete resolution in 5 at
approximately 3 months of follow-up. In that series, of MAI
three patients had progression of injury all of whom had this
identified during the surveillance imaging. One patient with
progression underwent open operative repair while the other
two underwent effective EVAR. It has been suggested that
small false aneurysms (Starnes Category III) have the similar
low risk of progression and rupture as their true aneurysmal
counterparts. However, most patients with an abnormality of
the aortic wall contour (Starnes Categories III and IV) should
undergo endovascular or open repair as there are very few
natural history studies of these injuries.
Summary
The screening, definitive diagnosis, and management of blunt
thoracic aortic injury have all undergone momentous evolu-
tion in the past decade. Routine use of contrast-enhanced CT
imaging of the chest for patients with suspicious mechanism
of injury has replaced basic chest x-ray as a screening tool.
Contrast CT imaging has provided a useful grading system for
blunt aortic injury and has replaced catheter-based aortogra-
phy as the mode for definitive diagnosis. Delayed repair of
blunt aortic injury is now the preferred approach in most
cases, and categories of minimal aortic injury may be managed
effectively without an operation. Finally, endovascular stent
graft repair has replaced open aortic repair as the most
common mode of operative treatment. Mid- and long-term
studies of this modality are required. However, as endovascu-
lar device technology and skills evolve, this mode of treatment
is likely to continue to provide low rates of morbidity and
mortality associated with repair. This complex pattern of vas-
cular trauma is best managed in experienced centers with
multidisciplinary teams that are familiar with the spectrum of
care required for the polytrauma patient.
REFERENCES
1. Mattox KL, Wall MJ, Jr: Historical review of blunt injury to the thoracic
aorta. Chest Surg Clin N Am 10(1):167–182, x, 2000.
2. Demetriades D, Gomez H, Velmahos GC, et al: Routine helical computed
tomographic evaluation of the mediastinum in high-risk blunt trauma
patients. Arch Surg 133(10):1084–1088, 1998.
3. Kato N, Dake MD, Miller DC, et al: Traumatic thoracic aortic aneurysm:
treatment with endovascular stent-grafts. Radiology 205(3):657–662,
1997.
4. Fabian TC, Richardson JD, Croce MA, et al: Prospective study of blunt
aortic injury: multicenter trial of the American Association for the
Surgery of Trauma. J Trauma 42(3):374–380, discussion 380–383, 1997.
5. Demetriades D, Velmahos GC, Scalea TM, et al: Operative repair or endo-
vascular stent graft in blunt traumatic thoracic aortic injuries: results of
an American Association for the Surgery of Trauma Multicenter Study.
J Trauma 64(3):561–570, discussion 570–571, 2008.
6. Arthurs ZM, Starnes BW, Sohn VY, et al: Functional and survival out-
comes in traumatic blunt thoracic aortic injuries: an analysis of the
National Trauma Databank. J Vasc Surg 49(4):988–994, 2009.
112 SECTION 3  /  DEFINITIVE MANAGEMENT
7. Demetriades D, Karaiskakis M, Toutouzas K, et al: Pelvic fractures: epi-
demiology and predictors of associated abdominal injuries and outcomes.
J Am Coll Surg 195(1):1–10, 2002.
8. Teixeira PG, Inaba K, Barmparas G, et al: Blunt thoracic aortic injuries:
an autopsy study. J Trauma 70(1):197–202, 2011.
9. Shackelford S, Nguyen L, Noguchi T, et al: Fatalities of the 2008 Los
Angeles train crash: autopsy findings. Am J Disaster Med 6(2):127–131,
2011.
10. Demetriades D, Murray J, Martin M, et al: Pedestrians injured by auto-
mobiles: relationship of age to injury type and severity. J Am Coll Surg
199(3):382–387, 2004.
11. Siegel JH, Belwadi A, Smith JA, et al: Analysis of the mechanism of lateral
impact aortic isthmus disruption in real-life motor vehicle crashes using
a computer-based finite element numeric model: with simulation of pre-
vention strategies. J Trauma 68(6):1375–1395, 2010.
12. Burkhart HM, Gomez GA, Jacobson LE, et al: Fatal blunt aortic injuries:
a review of 242 autopsy cases. J Trauma 50(1):113–115, 2001.
13. Ekeh AP, Peterson W, Woods RJ, et al: Is chest x-ray an adequate screening
tool for the diagnosis of blunt thoracic aortic injury? J Trauma 65(5):1088–
1092, 2008.
14. Starnes BW, Lundgren RS, Gunn M, et al: A new classification scheme for
treating blunt aortic injury. J Vasc Surg 55(1):47–54, 2012.
15. Minard G, Schurr MJ, Croce MA, et al: A prospective analysis of trans-
esophageal echocardiography in the diagnosis of traumatic disruption of
the aorta. J Trauma 40(2):225–230, 1996.
16. Parmley LF, Mattingly TW, Manion WC, et al: Nonpenetrating traumatic
injury of the aorta. Circulation 17(6):1086–1101, 1958.
17. Hemmila MR, Arbabi S, Rowe SA, et al: Delayed repair for blunt thoracic
aortic injury: is it really equivalent to early repair? J Trauma 56(1):13–23,
2004.
18. Fabian TC, Davis KA, Gavant ML, et al: Prospective study of blunt aortic
injury: helical CT is diagnostic and antihypertensive therapy reduces
rupture. Ann Surg 227(5):666–676, discussion 676–677, 1998.
19. Pate JW, Gavant ML, Weiman DS, et al: Traumatic rupture of the aortic
isthmus: program of selective management. World J Surg 23(1):59–63,
1999.
20. Wahl WL, Michaels AJ, Wang SC, et al: Blunt thoracic aortic injury:
delayed or early repair? J Trauma 47(2):254–259, discussion 259–260,
1999.
21. Maggisano R, Nathens A, Alexandrova NA, et al: Traumatic rupture of
the thoracic aorta: should one always operate immediately? Ann Vasc Surg
9(1):44–52, 1995.
22. Estrera AL, Gochnour DC, Azizzadeh A, et al: Progress in the treatment
of blunt thoracic aortic injury: 12-year single-institution experience. Ann
Thorac Surg 90(1):64–71, 2010.
23. De Bakey ME: Successful resection of aneurysm of distal aortic arch and
replacement by graft. J Am Med Assoc 155(16):1398–1403, 1954.
24. Caffarelli AD, Mallidi HR, Maggio PM, et al: Early outcomes of deliberate
nonoperative management for blunt thoracic aortic injury in trauma.
J Thorac Cardiovasc Surg 140(3):598–605, 2010.
25. von Oppell UO, Dunne TT, De Groot MK, et al: Traumatic aortic rupture:
twenty-year metaanalysis of mortality and risk of paraplegia. Ann Thorac
Surg 58(2):585–593, 1994.
26. Semba CP, Kato N, Kee ST, et al: Acute rupture of the descending thoracic
aorta: repair with use of endovascular stent-grafts. J Vasc Interv Radiol
8(3):337–342, 1997.
27. Lettinga-van de Poll T, Schurink GW, De Haan MW, et al: Endovascular
treatment of traumatic rupture of the thoracic aorta. Br J Surg 94(5):525–
533, 2007.
28. Tang GL, Tehrani HY, Usman A, et al: Reduced mortality, paraplegia, and
stroke with stent graft repair of blunt aortic transections: a modern meta-
analysis. J Vasc Surg 47(3):671–675, 2008.
29. Idu MM, Reekers JA, Balm R, et al: Collapse of a stent-graft following
treatment of a traumatic thoracic aortic rupture. J Endovasc Ther 12(4):
503–507, 2005.
30. Tehrani HY, Peterson BG, Katariya K, et al: Endovascular repair of tho-
racic aortic tears. Ann Thorac Surg 82(3):873–877, discussion 877–878,
2006.
31. Jonker FH, Giacovelli JK, Muhs BE, et al: Trends and outcomes of endo-
vascular and open treatment for traumatic thoracic aortic injury. J Vasc
Surg 51(3):565–571, 2010.
32. Jonker FH, Indes JE, Moll FL, et al: Management of iatrogenic injuries of
the supra-aortic arteries. J Cardiothorac Vasc Anesth 24(2):322–329,
2010.
33. Jonker FH, Mojibian H, Schlosser FJ, et al: The impact of hypovolaemic
shock on the aortic diameter in a porcine model. Eur J Vasc Endovasc
Surg 40(5):564–571, 2010.
34. Fernandez V, Mestres G, Maeso J, et al: Endovascular treatment of trau-
matic thoracic aortic injuries: short- and medium-term follow-up. Ann
Vasc Surg 24(2):160–166, 2010.
35. Forbes TL, Harris JR, Lawlor DK, et al: Aortic dilatation after endovascu-
lar repair of blunt traumatic thoracic aortic injuries. J Vasc Surg 52(1):45–
48, 2010.
36. Medical Devices. 2012 www.fda.gov. Device Approvals. Accessed:
5/3/2012.
37. Criado FJ, McKendrick C, Criado FR: Technical solutions for common
problems in TEVAR: managing access and aortic branches. J Endovasc
Ther 16(Suppl 1):I63–I79, 2009.
38. Gavant ML: Helical CT grading of traumatic aortic injuries. Impact on
clinical guidelines for medical and surgical management. Radiol Clin
North Am 37(3):553–574, vi, 1999.
39. Malhotra AK, Fabian TC, Croce MA, et al: Minimal aortic injury: a lesion
associated with advancing diagnostic techniques. J Trauma 51(6):1042–
1048, 2001.
40. Akins CW, Buckley MJ, Daggett W, et al: Acute traumatic disruption of
the thoracic aorta: a ten-year experience. Ann Thorac Surg 31(4):305–
309, 1981.
41. Kepros J, Angood P, Jaffe CC, et al: Aortic intimal injuries from blunt
trauma: resolution profile in nonoperative management. J Trauma 52(3):
475–478, 2002.
Abdominal Aortic Trauma,
Iliac and Visceral Vessel
Injuries
MARCUS CLEANTHIS AND MICHAEL JENKINS
Introduction
Injuries to the major vessels in the abdomen are associated
with a high mortality. Following penetrating abdominal
trauma, vascular injuries are the most common causes of
death. Intraabdominal hemorrhage can be catastrophic due to
the difficulty of rapidly accessing the retroperitoneal vessels.
It is for this reason that early recognition of a possible vascular
injury is essential and transfer to a center capable of early
surgical intervention is vital. The early diagnosis of these inju-
ries has been facilitated with the increasing use of computed
tomography (CT) angiography and with its availability close
to the resuscitation room.
The majority of vascular trauma involves the extremities.1
By comparison, injuries to the abdominal vessels are less
common, and hence it is difficult for a trauma center and its
surgeons to accumulate large caseloads of specific arterial
injuries. The incidence of injuries differs between military and
civilian trauma. Although penetrating trauma is the more
common mechanism for both civilian and military settings,
blunt trauma resulting in abdominal vascular injuries is more
common in the civilian setting.2 During the Vietnam War and
World War II, the incidence of penetrating abdominal vascu-
lar injuries was less than 3%.3 In populations with a high
incidence of knife crime, the incidence approaches 10%; and
this figure doubles to more than 20% in populations with gun
crime.4 For aortic penetrating injuries, the incidence still
remains low and is less than 3% for penetrating trauma.5 In
the context of blunt trauma, the incidence of abdominal vas-
cular injury remains low at 3% and even lower (0.04%) for
aortic injuries.1
Mechanism of Injury
The vast majority of abdominal vascular injuries are a result
of penetrating trauma.6 In the context of noniatrogenic inju-
ries, penetrating injuries usually occur either from stab
wounds or firearms. Injuries resulting from explosions (e.g.,
bomb blast) are complex, resulting in mixed patterns of pen-
etrating and blunt trauma.
Stab wounds (e.g., knife wounds) result in localized inju-
ries whereby the path of injury follows the track of the weapon.
The type of injury that results from firearms is variable
depending on the nature of the firearm. Gunshot wounds may
be high-velocity or low-velocity. Low-velocity gunshot wounds
are defined as wounds caused by projectiles such as a bullets
or missiles with speeds of less than 600 m/s.)7 Low-velocity
gunshot wounds such as those that occur with handguns cause
11 
localized injury to the structures that lie in the paths of the
projectiles. They are associated with a lower transfer of energy
compared with high-velocity gunshot wounds. Military
wounds are more often a result of high-velocity (greater than
600 m/s) projectiles. A high-velocity projectile carries with it
a significant amount of kinetic energy that is transferred to
the surrounding tissue and results in extensive injury around
the path of the projectile as well as the immediate damage to
any tissue in the path of the projectile. The amount of energy
transferred to the patient will be decided by a combination of
factors including the energy carried by the missile, the cross-
sectional area of the missile that comes into contact with the
tissue, and the degree of retardation of the missile within the
patient, that is, whether the missile passes through the tissue
(delivering less energy) or comes to rest within the tissue
(delivering all of its kinetic energy).
The injury that results from shotgun wounds is dependent
on the range at which the shotgun is fired. If the range is less
than 5 m, the chance of survival is approximately 10%. At this
range, although shotgun is made up of multiple pellets, the
lead shot projects as a single mass on impact and subsequently
spreads out. When the shotgun is fired from a greater distance
(e.g., 5 m to 15 m) the shot behaves as multiple low-energy
missiles, resulting in less injury. At close range, vascular inju-
ries tend to be multiple, complex, and frequently contami-
nated either with bowel contents or external contaminants
such as the victims clothing.8
Vascular injuries as a result of blunt trauma are far less
common compared with penetrating trauma. The mechanism
by which blunt trauma results in vascular injury is either by
severe deceleration, by crush injuries, or by direct laceration
from a fractured bone fragment. Severe deceleration can occur
in the context of high-speed road traffic accidents or falls from
significant heights. Crush injuries also occur in road traffic
accidents and may result in an anteroposterior crush injury as
seen in a seatbelt-restrained passenger. This can also be associ-
ated with shearing injuries of the aortic branches. Fractures
of the spine or pelvis can result in direct laceration to the aorta
and iliac vessels, respectively. Renal vessels may be damaged
with acceleration—deceleration type injuries causing shearing
forces to be applied to the renal pedicle.
While the adventitia is the most durable part of the arterial
wall, the intima remains the least elastic and therefore most
likely to be torn during blunt injury. Hence the artery is fre-
quently injured from “inside to outside,” and the adventitia
may remain intact. This creates a thrombogenic environment
within the artery resulting in thrombosis and occlusion. Alter-
natively the intima may be sheared resulting in a dissection. If
113
 11  /  Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 113.e1

ABSTRACT
Abdominal and pelvic trauma that results in vascular inju-
ries is associated with high mortality rates. Survival is
dependent on early diagnosis and rapid intervention. A
detailed knowledge of the operative approach to the aorta,
iliac vessels, and visceral branches is required if rapid control
of bleeding is to be achieved. Endovascular techniques
have evolved and continue to evolve with embolotherapy
providing an alternative or, in some cases, an adjunct to
operative treatment. The approach is that of a multidisci-
plinary team incorporating vascular surgeons, interven-
tional radiologists, hematology, and emergency medicine.
Patients are best managed in experienced trauma centers
where the resuscitation room, computed tomography (CT)
suite, operating theater, and interventional radiology room
all lie within close proximity.
Much of what is now practiced in treating civilian
trauma has been learned from military experience. However,
civilian trauma differs from military trauma in both the
pattern of injury and the environment in which the patient
is managed. The principles of damage control surgery still
apply in the civilian setting, and complex arterial repairs
should be avoided (when possible) in the cold, acidotic,
and coagulopathic patient.
This chapter describes the mechanism of injury, diagno-
sis, and operative approaches to the aorta, iliac vessels, and
visceral vessels. A section on endovascular treatment is
included because it plays a vital role in the diagnosis and
treatment of these patients.

Key Words:  aortic trauma,

iliac artery trauma,
abdominal vascular trauma,
visceral artery trauma
114 SECTION 3  /  DEFINITIVE MANAGEMENT
Zone II Zone I Zone II
Zone III
FIGURE 11-1  The three anatomical zones of the retroperitoneum
used to describe the locations of vascular injuries presenting as retro-
peritoneal hematomas. Zone I extends from the aortic hiatus to the
sacrum and includes the midline vessels and origins of the visceral
branches. Zone II exists on either side of Zone I and includes the
kidneys, renal vessels and paracolic gutters. Zone III lies inferior to the
level of the sacral promontory and includes the iliac vessels and pelvic
retroperitoneum. Zone IV is not depicted in the diagram.
the adventitia remains intact the artery may still be weakened
contributing to delayed aneurysmal degeneration. Total trans-
mural injury can lead to perforation, hemorrhage, and false
aneurysms.
Anatomy
Vascular injuries in the abdomen are classified according to
geographical location (Fig. 11-1). These are usually defined
within three zones, albeit a fourth zone is occasionally
included.
Zone I begins at the point of entry of the aorta through
the diaphragm (i.e., the aortic hiatus) and extends down to
the sacrum. The aorta enters the abdomen at the level of the
twelfth thoracic vertebra passing behind the median arcuate
ligament of the diaphragm. The aorta descends to the level of
the fourth lumbar vertebra where it bifurcates into the left and
right common iliac arteries. Zone I includes the central retro-
peritoneal area and the base of the mesentery. The area is
further divided into the supramesocolic and inframesocolic
areas. The supramesocolic and inframesocolic areas are
defined by the levels of the renal arteries. The suprarenal aorta,
celiac axis, superior mesenteric artery (SMA), renal arteries,
inferior vena cava (IVC), and superior mesenteric vein all lie
within this supramesocolic area. The inframesocolic area con-
tains the infra renal aorta, the inferior mesenteric artery, and
the IVC.
Zone II exists either side of zone I and contains the para-
colic gutters, kidneys, and renal vessels. It is also referred to as
the upper lateral retroperitoneum.
Zone III containing the iliac vessels is also known as the
pelvic retroperitoneum.
The hepatic artery, portal vein, retrohepatic IVC, and
hepatic veins all lie within an area occasionally referred to as
zone IV.
Clinical Presentation
The patient should be inspected for signs of penetrating
injury. Stab wounds in the abdomen should be obvious but
be aware that stab wounds in the chest, back, and gluteal
regions can result in injury to abdominal and pelvic vessels.
With both penetrating and blunt trauma, examine for
bruising in the flanks. This can be a sign of a retroperitoneal
bleeding. With gunshot wounds, examine the patient for entry
and exit wounds. An attempt to predict the trajectory may
provide some idea of the vessels and organs injured. Do not
assume that the injury is localized to the missile path. The
presentation of arterial injuries may be early or late depending
on the artery involved, as well as the type and mechanism
of injury.
Early presentation is usually in the form of hemorrhage
and hypovolemic shock. Urgent laparotomy will reveal either
blood in the peritoneal cavity or a retroperitoneal hematoma.
The zone should be defined according to Figure 11-1. Some
patients may respond to resuscitation but presentation with a
distended abdomen should raise the suspicion of a vascular
injury. Patients who are stabilized and taken for trauma CT of
the abdomen revealing vascular injury may also be included
as early presenters. Thrombosis, dissections, and occlusions
may present with lower limb ischemia (absent or diminished
femoral pulses; cold, pale limbs). This should be considered
in the context of blunt injury resulting in pelvic fractures or
abdominal crush. Be aware that the presentation may not be
immediate with intimal tears, and repeated examinations are
mandatory. Injuries to the renal pedicles may present with
hematuria. Anuria as a result of bilateral renal artery throm-
bosis is rare.
Both penetrating and blunt trauma can result in vascular
injuries that present late. With the increasing use of CT angi-
ography, arterial injuries are being detected early reducing the
incidence of late presentation. Pseudoaneurysms frequently
present late. They may each present as a pulsatile mass com-
pressing adjacent structures. Compression of the duodenum
may present as bowel obstruction. The false aneurysm may
erode into the bowel resulting in massive gastrointestinal
hemorrhage. Similarly internal iliac pseudoaneurysms have
presented with rectal bleeding.9,10 Pseudoaneurysm of the
renal artery can present with hematuria. Arterial fistulas have
been seen with hepatic artery injuries and penetrating liver
injuries. These fistulas may present with hemobilia, right
upper quadrant pain, and upper gastrointestinal hemorrhage.
Injuries involving both arteries and veins can cause arteriove-
nous fistulas. The clinical manifestation may be obvious or
subtle. Aortocaval fistulas are associated with lower limb
 11  /  Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 115
edema and an abdominal bruit. Other arteriovenous fistulas
may present later with high-output cardiac failure and lower
limb chronic venous skin changes.
Investigations
The choice of investigation will depend on the patient’s hemo-
dynamic stability and the available local facilities. CT has
become the gold standard investigation. Availability close to
the resuscitation room is an important factor in the planning
of a major trauma center. Catheter angiography still maintains
an important role in trauma and has the advantage of being
coupled with therapeutic options such as stenting and embo-
lotherapy. Early availability of experienced interventional
radiologists and the location of the radiology suite often limit
use to the hemodynamically stable patient. The use of ultra-
sound in trauma has increased in the form of focused assess-
ment with sonography for trauma (FAST) scans. Bedside
ultrasonography is able to detect intraabdominal free fluid,
facilitating the decision for early exploratory laparotomy. The
exploratory trauma laparotomy remains an important diag-
nostic tool and is coupled with the techniques of damage
control surgery. Duplex scanning is less useful in the acute
trauma presentation. It has a role in assessing neck trauma
and can be used for surveillance to detect late pseudoaneu-
rysms and arteriovenous fistulas. In the context of abdominal
vascular injuries, its use is limited.
Surgical Techniques
The operative approach will be dependent on the location of
the hematoma and the degree of urgency. The latter is dictated
by the degree of hemodynamic shock.
When a decision is made to proceed to surgery, the patient
should be prepared with sterile drape application allowing
exposure of the abdomen, chest, and groins. This allows for
incisions to be extended into the chest; and, if necessary, a
thorocotomy can be utilized to gain control of the descending
aorta. To facilitate distal control, exposure of the common
femoral arteries may be required. The initial incision is a long
midline laparotomy from the xiphisternum to the pubis. If
further access is required, the incision may be extended in the
midline to include a median sternotomy or through the 6th
or 7th intercostal spaces for a lateral thorocotomy.
On initiating the laparotomy the surgeon may be presented
with an abdominal cavity containing free blood. At this stage
it may be difficult to establish the source of bleeding and the
principles of damage control surgery should be applied. In
order identify the source of bleeding, the surgeon should
proceed with packing of the abdominal cavity, using large
packs to either stop or slow the bleeding. These packs are then
removed from each compartment until the source of bleeding
is identified. The four-quadrant packing technique requires
packs to be placed in the right upper quadrant over the right
lobe of the liver, the left upper quadrant, the infracolic com-
partment (elevate the greater omentum and pack either side
of the small bowel mesentery), and the pelvis. Pelvic packing
is performed by lifting the small bowel out of the pelvis before
applying the packs into the pelvis.
Exposure of the aorta and its branches is best achieved
using the technique of a medial visceral rotation. This can be
performed from either the left or right side; the decision will
be dependent on which vessels need to be exposed. The medial
visceral rotation can be a time-consuming technique, even in
experienced hands; and temporary control may be required,
especially if active hemorrhage is occurring from the supra-
mesocolic aorta. Direct manual compression of the aorta
against the spine may control the bleeding but frequently
restricts exposure of the aorta and therefore subsequent repair.
It can be a useful technique to control the inflow, but the
ultimate aim should be to apply a clamp.
Division or creation of a window within the lesser omentum
enables exposure of the supraceliac aorta. This technique is
aided by retracting the stomach and the esophagus to the left.
The liver is retracted in a cephalad direction. Division of the
diaphragmatic crura further aids exposure, and then a supra
celiac aortic clamp can be applied. This is the quickest way to
apply a supraceliac clamp and to gain control of the bleeding
abdominal aorta. Although inflow will be controlled, back-
bleeding from the visceral vessels and lumbar arteries may be
significant. The presence of visceral branches can make distal
control challenging.
In order to perform a left-sided medial visceral rotation,
the peritoneal attachments of the sigmoid and the descending
colon are divided. The incision is started in the lateral avascu-
lar peritoneal reflection of the sigmoid colon and is continued
proximally along the left paracolic gutter. The plane is devel-
oped by mobilizing the sigmoid colon and the descending
colon to the midline. The retroperitoneal attachments of the
left kidney, pancreatic tail, and spleen can be divided, mobiliz-
ing these organs to the midline and hence facilitating complete
exposure of the abdominal aorta from its origin at the dia-
phragm to its bifurcation at the level of the fourth lumbar
vertebra (Figs. 11-2 and 11-3). This technique carries a signifi-
cant risk of damage to the spleen, left kidney and left renal
vessels. Developing a dissection plane anterior to the left
kidney can reduce the risk of intraoperative renal injury.
If rapid proximal control of the abdominal aorta is required
before the medial visceral rotation, a clamp can be applied to
the distal descending thoracic aorta. This is especially useful
with an expanding zone I hematoma. The aorta is exposed by
division of the left crus of the diaphragmatic aortic hiatus.
Incision is made at the 2 o’clock position exposing the descend-
ing thoracic aorta and hiatal aorta. This is the quickest way to
achieve proximal control during a medial visceral rotation.
The presence of celiac nerves and lymphatic tissue around the
aorta, together with dense diaphragmatic muscle fibers, makes
careful dissection of the most proximal abdominal aorta dif-
ficult, time consuming, and hence unsuitable for the severely
hypotensive patient.
The advantage of this technique is that, after mobilizing the
spleen and the tail of the pancreas, the anterior midline vis-
ceral branches of the aorta are well exposed and can be con-
trolled, repaired, or ligated.
A right-sided medial visceral rotation is performed by
dividing the peritoneal reflection lateral to the ascending
colon (Fig. 11-4). A dissection plane is developed anterior to
the kidney, facilitating mobilization of the colon and terminal
ileum to the midline. This allows exposure of the duodenum,
which can then be kocherized. The duodenum and the pan-
creatic head are mobilized to the left, and the retroperitoneal
tissue left of the IVC is divided to expose the suprarenal aorta,
the celiac axis, and the SMA. If exposure of the diaphragmatic
hiatal aorta is required, this technique should be avoided.
116 SECTION 3  /  DEFINITIVE MANAGEMENT
Liver
Stomach
Pancreas
Spleen
Celiac trunk
Transverse Superior mesenteric artery
colon
Left renal artery
Aorta
Descending
colon
Left kidney
Small
intestine IVC
Left ureter
Sigmoid
colon
If injury is isolated to the infrarenal aorta, exposure to this
part of the aorta can be achieved via an anterior approach that
resembles that for an infrarenal abdominal aortic aneurysm.
Peritoneal incision is made left of the duodenojejunal flexure,
the peritoneum dissected off the aorta and an infrarenal aortic
clamp applied. More proximal application of an infrarenal
aortic clamp can be facilitated by ligation and division of the
left renal vein, preferably preserving its adrenal and gonadal
tributaries.
Surgical exposure of the celiac artery is either via a medial
visceral rotation or via a direct dissection through the lesser
sack. Fullen’s anatomical classification can be used for the
purpose of describing injuries to the SMA. Exposure of the
proximal SMA (Fullen’s zone I) is via a left medial visceral
rotation. If severe bleeding dictates very rapid exposure, this
part of the SMA can be exposed by dividing the neck of the
pancreas. The easiest and quickest way of doing this is by using
a stapling device; but, if this is not available, intestinal clamps
should be applied before the division of the pancreatic neck
to control any bleeding. The proximal infrapancreatic SMA
can be exposed through root of the small bowel mesentery,
and this may be facilitated further by mobilization of the
duodenum and retraction of the pancreas. The more distal
SMA may be exposed directly in the bowel mesentery.
The inferior mesenteric artery origin is easily exposed via
an infrarenal approach to the aorta. The renal arteries can be
exposed through respective medial visceral rotation tech-
niques. In the presence of a large retroperitoneal hematoma,
the application of a supraceliac aortic clamp should be used
FIGURE 11-2  Left-sided medial visceral rotation.
The peritoneum is incised lateral to the descending
colon allowing the colon, left kidney, and spleen to
be mobilized to the right. This allows exposure of
the left renal artery, the SMA, and the celiac artery.
IVC, Inferior vena cava.
for proximal control. If the renal artery is bleeding from a
more distal point (e.g., renal hilum), the renal artery can be
exposed at its origin without the need for a visceral rotation.
The small bowel is eviscerated to the right, and the aorta is
approached anteriorly. The duodenojejunal flexure is mobi-
lized as previously described. The left renal vein can be either
divided as previously described or retracted proximally. The
latter can be facilitated by division of the left gonadal and
adrenal veins. This will allow exposure of the origin of the
renal arteries.
The left renal artery can be seen following dissection of the
surrounding peritoneal tissue. The right renal artery may
require lateral retraction of the IVC to identify its origin.
Additionally medial rotation of the duodenum and then of
the pancreas may be required to visualize the right renal vein,
which will need to be looped and retracted before the remain-
ing right renal artery can be exposed. The presence of a large
retroperitoneal hematoma around the right kidney and jux-
tarenal IVC can make this a challenging dissection. Identifying
the IVC distally and then dissecting in a proximal direction
along the course of the IVC through the hematoma is an
alternative approach.
Although the focus of this chapter is on arterial injuries
due to their close proximity, the veins may be injured with the
artery in the patient with multiple injuries. Achieving hemo-
stasis during combined venous and arterial bleeding can be
challenging. The application of clamps to a large vein can
further tear the vein and therefore should be avoided or used
with extreme caution. Using mounted sponges or swabs to
 11  /  Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 117

Stomach

Pancreas

IVC

Spleen

Left kidney
A Aorta

Kidney

FIGURE 11-3  A, Plane of dissection for left sided

visceral rotation indicated by the arrow and dotted
line. B, The lateral retroperitoneal attachments are
divided to facilitate medial mobilization of the spleen,
descending colon and kidney. IVC, Inferior vena cava. B

apply pressure above and below the injury can achieve hemor-
rhage control and is less likely to damage the vein. With the
aid of an experienced assistant, the surgeon can repair or ligate
the vein. An alternative technique is using Foley catheters
within large veins to control the inflow and back-bleeding.
Aortic Injuries
The majority of injuries to the aorta are consequences of
penetrating traumas. Blunt injuries are rare and may be asso-
ciated with seatbelt injuries and thoracolumbar fractures of
the spine. The majority of patients who experience a rupture
do not survive transport to hospital.
The complex forces that are associated with blunt trauma
can damage the aortic intima resulting in aortic dissection,
thrombosis, and consequently end organ ischemia or limb
ischemia. This may not be apparent at the initial presentation,
and a high index of clinical suspicion is vital. Less commonly,
patients may have delayed presentation with a pseudoaneu-
rysm or arteriovenous fistula.
An aortic branch may be avulsed and present as a large
retroperitoneal hematoma during the trauma laparotomy.
Gunshot wounds appear to be associated with a higher inci-
dence of aortic injuries than knife wounds.11 The clinical pre-
sentation will be dependent on a number of factors. If the
injury results in bleeding into the peritoneal cavity, the patient
118 SECTION 3  /  DEFINITIVE MANAGEMENT
Small
Cecum
intestine
Ascending
colon
Duodenojejunal
flexure
Right
kidney
Ureter
IVC
Aorta
presents in severe shock with peritonitis and a distended
abdomen. Frequently these patients do not survive transfer to
the hospital. If the injury is to the lateral wall and bleeding is
confined to the retroperitoneum, hemorrhage may tampon-
ade temporarily within the retroperitoneum.
Investigations
Hemodynamically unstable patients who do not respond to
initial fluid resuscitation should be taken immediately to the
operating room for a trauma laparotomy. Patients who are
stable can be investigated with a trauma CT scan. This will
identify significant bleeding or retroperitoneal hematomas.
With the increasing availability of CT angiography, the use of
catheter angiography as a diagnostic tool has diminished.
Catheter angiography does, however, offer the possibility of
combining both diagnostic and therapeutic options with the
use of endovascular stents, occlusion balloons, and emboliza-
tion techniques.
Treatment
The choice of treatment is dependent on patient factors and
institutional factors. Patient factors include hemodynamic
status, injuries to other intraabdominal organs, and degree of
intraabdominal contamination. Institutional factors include
Descending
colon
FIGURE 11-4  Right-sided medial vis-
ceral rotation. This shows the Kocher
and Cattell-Braasch maneuvers. The ret-
roperitoneal attachment of the cecum,
Sigmoid ascending colon, duodenum, and small
colon bowel mesentery are divided. This al-
lows exposure of the inferior vena cava
(IVC), the right renal vessels, and the
right iliac vessels.
the availability of local facilities (e.g., interventional radiology,
CT imaging, and medical expertise).
Injuries to the infrarenal aorta have been successfully
treated with endovascular techniques. These include endovas-
cular stent-grafts for dissection flaps and aortocaval fistulas,
as well as embolization (e.g., coiling) of aortic visceral
branches.
The trauma laparotomy may reveal a retroperitoneal hema-
toma. Central hematomas require exploration, and the prin-
ciples of gaining both proximal and distal arterial control
should be applied. Exposure of the aorta and its branches has
been previously described. Small aortic lacerations may be
closed with a 3-0 or 4-0 Prolene suture using the technique of
lateral aortorrhaphy. If there is a defect in the aorta and lateral
aortorrhaphy is likely to narrow the aorta, consideration
should be given to repairing the defect using a prosthetic patch
or tube graft (Fig. 11-5). Consideration must always be given
to the principles of damage control surgery. The surgeon
should avoid prolonged complex arterial repairs in the patient
who is acidotic, hypothermic, and coagulopathic.
The decision to use prosthetic grafts will be affected by the
degree of intraabdominal contamination from other injuries.
Many surgeons will opt for an extra anatomical bypass in the
presence of abdominal contamination. Some surgeons do not
 11  /  Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 119
FIGURE 11-5  Exposure of the suprarenal aorta through a left-sided
medial visceral rotation and replacement with a Dacron prosthetic
graft. This was to repair a pseudoaneurysm of the aorta at the level
of the SMA after a penetrating aortic injury. SMA, Superior mesenteric
artery.
consider mild contamination as a contraindication to the use
of prosthetic grafts in the trauma patient. Instead the con-
tamination is dealt with, the peritoneum is washed out, and a
graft is used if needed. Like many controversies in vascular
trauma there is a lack of evidence in the literature to either
support or negate the use of prosthetic grafts in this setting.
Follow-up
Young patients treated with endovascular stents will need
to be in a long-term surveillance program, as the durability
of these grafts in young patients remains unknown. If there
has been abdominal contamination and a prosthetic graft
used, the patient should be followed up for signs of graft
infection.
Injuries to the Visceral Arteries
Celiac Artery and Branches
Isolated injuries to the celiac artery are rare. The majority of
patients have other vascular injuries. It is for this reason that
these injuries are associated with a high mortality. The major-
ity of injuries to the celiac artery are a consequence of pene-
trating trauma.
Bleeding from the celiac trunk or its branches close to their
origin can be difficult to control. This is because of the small
size of the vessel, especially in a shocked patient where vaso-
constriction makes exposure all the more difficult. The sur-
rounding connective tissue and the location of the celiac trunk
contribute to a difficult dissection. Urgent control may be
needed with a supraceliac aortic clamp. This is best achieved
as previously described via a window through the lesser
omentum. Exposure of the celiac axis is best achieved via a left
medial visceral rotation but this is time consuming and
dependent on the hemodynamic status of the patient.
Injuries to the left gastric or splenic artery should not be
repaired as these are small vessels and are better managed with
ligation. The surgeon should be aware that the left hepatic
artery may arise entirely from the left gastric artery in up to
10% of patients.12 If there is an injury to the celiac trunk, this
can also be managed by ligation provided the SMA is patent
FIGURE 11-6  Superior mesenteric artery (SMA) disruption after a
rapid deceleration injury. The image indicates a central hematoma and
hemorrhage into the small bowel mesentery.
and the ligation is proximal to the branches of the celiac trunk.
Evidence from elective endovascular aneurysm repairs sug-
gests that the risk of ischemic foregut complications is low
in most.13
If the common hepatic artery is injured, there are a number
of options. The artery can be identified in the lesser omentum
and its exposure facilitated by retracting the duodenum infe-
riorly. At the epiploic foramen, it lies anterior to the portal
vein and medial to the common bile duct; and hence the
Pringle maneuver may facilitate control of bleeding when the
injury is at the porta hepatis. Ligation of the common hepatic
artery proximal to the origin of the gastroduodenal artery is
possible, again dependent on the patency of the inferior pan-
creaticoduodenal branch of the SMA. The common hepatic
artery may have a sufficient diameter so that it is possible to
perform arteriorrhaphy. Alternatively limited resection and
an end-to-end anastomosis may be attempted. If end-to-end
anastomoses is not possible, reconstruction with autologous
vein graft or even prosthetic graft may be considered; however,
in the young resuscitated patient with patent SMA, circula-
tion and a well-developed gastroduodenal artery, primary
ligation or embolization is unlikely to cause any long-term
sequelae.12
If the patient is stable and local facilities and expertise
permit, endovascular options may be considered. Catheter
angiography can be used to identify bleeding, and this proce-
dure can be combined with coil embolization.
Superior Mesenteric Artery
The most common mechanism of injury to the SMA is pen-
etrating trauma. This is frequently associated with other inju-
ries. With the exception of the renal artery, the SMA is the
most commonly injured aortic visceral branch following blunt
trauma.2 Rapid deceleration can result in either avulsion of
the SMA at its origin (Fig. 11-6). Alternatively, deceleration
injuries may present as an intimal tear, dissection and throm-
bosis. This comes as no surprise when consideration is given
to the mobility of the small bowel and its mesentery. These
injuries can present either early or late as intestinal ischemia.
Injuries may occur at any level. When describing the man-
agement of superior mesenteric artery injuries, it is useful to
120 SECTION 3  /  DEFINITIVE MANAGEMENT
Table 11-1 Fullen’s Classification of SMA
Injuries
Fullen’s Zones SMA Region
I From the SMA origin to the inferior
pancreaticoduodenal artery
II From the inferior pancreaticoduodenal
artery to the middle colic artery
III Distal to the middle colic artery
IV Segmental branches
SMA, Superior mesenteric artery.
consider Fullen’s classification whereby four zones are
described (Table 11-1).
Exposure of the superior mesenteric artery has been previ-
ously described. The decision to perform a rapid left medial
visceral rotation will depend on the state of the patient and
the experience of the surgeon. The presence of a large expand-
ing central hematoma during a trauma laparotomy may
require a supraceliac clamp in the severely hypotensive patient.
Time permitting, the medial visceral rotation will provide the
best exposure of the superior mesenteric artery at its origin.
Ligation of the superior mesenteric artery at any point between
its origin and the middle colic branch is likely to result in
massive ischemia of the small bowel, the cecum, and the
ascending colon. Consequently, injuries to this part of the
SMA (Fullen’s zones I and II) should be repaired. Penetrating
injuries resulting in a partial transection may be amenable to
primary repair with 6-0 Prolene suture. If a direct repair is not
possible, an interposition graft using saphenous vein or a
prosthetic graft should be used.
If the overall condition of the patient dictates that a damage
control procedure is required, prolonged reconstruction can
be avoided by the placement of a temporary intraluminal
shunt. This will allow for a delayed reconstruction after a
period of appropriate resuscitation and correction of hypo-
thermia, acidosis, and coagulopathy. If there is significant
small bowel necrosis, consideration maybe given to ligation of
the proximal superior mesenteric artery. Collateral flow may
preserve the proximal jejunum. However, this decision should
not be taken lightly as it is not without its complications,
including short bowel syndrome.
When considering definitive repair of the SMA using an
interposition graft, the distal anastomosis is to the distal
stump of the SMA and the proximal anastomosis is to the
anterior surface of the disease-free infrarenal aorta. If there
are associated pancreatic injuries or small-bowel contamina-
tion, the graft should be covered with either omentum or
surrounding soft tissue to protect the graft from pancreatic
enzymes and to reduce the risk of enteral-arterial fistulas. Aim
to pass the graft to the posterior surface of the small bowel
mesentery and to ensure the graft does not kink when the
bowl is returned to the abdomen.
Injuries to the SMA distal to the middle colic artery (Ful-
len’s zone III) may be treated with ligation but are likely to
result in segmental bowel ischemia. Hence the decision to
ligate will be dependent on how proximal the injury is.
More-proximal injuries should be revascularized to avoid sig-
nificant midgut ischemia. Injuries to the segmental SMA
branches (Fullen’s zone IV) are treated by ligation and bowel
resection.
A low threshold for a second-look laparotomy at 24 hours
should be maintained. If temporary intraluminal shunts are
used, the surgeon must always consider the possibility of
shunt occlusion or dislodgement when a patient fails to
improve or clinically deteriorates. When segmental SMA
branches are ligated, a second-look laparotomy should be con-
sidered mandatory. If damage control techniques are applied
at the primary surgery, small-bowel resections can be anasto-
mosed at the time of the second-look laparotomy provided
the physiology permits.
Inferior Mesenteric Artery
Injuries to the inferior mesenteric artery are rare and certainly
far less common than those to the SMA or celiac trunk. They
are almost always a consequence of penetrating trauma.
Exposure of the inferior mesenteric artery is easy compared
with the exposure of the SMA or the celiac trunk. Injuries are
managed by ligation; and in the absence of associated injuries
to the SMA or internal iliac arteries, ischemic complications
are rare. There are no reports of ischemic colon in trauma
cases although this is possible if there is coexisting occlusive
arterial disease. Any deterioration in the patient postopera-
tively should warrant a second-look laparotomy and bowel
viability confirmed.
Renal Artery Injuries
There is a slightly higher incidence of injury to the left renal
artery compared with the right renal artery. Half of the cases
of blunt injury to the renal artery result in thrombosis and/or
dissection. Complete avulsion occurs in approximately one in
ten cases.14 Injuries to the distal renal artery may present with
a hematoma or hemorrhage in zone II (lateral compartment
or perirenal area) most injuries to the proximal renal arteries
present with a more central or supramesocolic hemorrhage.
When considering treatment of the injured renal artery, it
is important to remember the potential for a solitary function-
ing kidney and also one third of the population have an acces-
sory renal artery. The latter anatomical variation is more
commonly to the inferior pole of the kidney.
The initial diagnosis renal artery injury may be made
during the trauma laparotomy, and it is more commonly the
case when the patient presents with hypertension following
penetrating trauma. With blunt trauma, provided hemody-
namic status allows for imaging, renal artery injury is more
commonly identified following a trauma CT scan.
There appears to be some controversy regarding explora-
tion of perirenal hematomas. Most would advocate explora-
tion following penetrating trauma; however, stable perirenal
hematomas away from the hilum in a patient who is hemody-
namically stable can be managed by close surveillance.
Management of injuries resulting from blunt trauma will
be dependent on the duration of renal ischemia. Diagnostic
delays and late presentation in this group of patients may
result in significant loss of function in the affected kidney. A
kidney ischemic for more than 6 hours is unlikely to improve
with revascularization; however, if they present within 4 to 6
hours, revascularization is generally recommended. Despite
these recommendations, the majority of stable patients are
managed nonoperatively.
Zone II hematomas should always be explored if the hema-
toma is expanding, if the patient remains hypotensive, or
if the kidney has been shown to be nonfunctioning. If the
 11  /  Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 121
hematoma is significantly lateral, control may be achieved by
exposing the proximal renal artery at the aortic origin.
With the left renal artery, proximal exposure can be
achieved as previously described by retracting the transverse
mesocolon superiorly, eviscerating the small bowel to the
right, mobilizing the duodenojejunal flexure, and retracting
the left renal vein in a cephalic direction.
The origin of the right renal artery may also be controlled
in this way; however, due to the dense retroperitoneal tissue,
rapid exposure of the proximal renal artery may not always be
possible. Kocherization of the duodenum with lateral retrac-
tion of the IVC may be needed to expose the right renal artery.
If more rapid control is required in a hypotensive patient with
an expanding hematoma or hemorrhage, supraceliac clamp-
ing is likely to be the quickest option. Injury to the proximal
renal artery should always be considered in patients with
expanding central hematoma, and the quickest and safest
technique for control of bleeding is to apply a supraceliac
clamp.
When a patient presents with multiple injuries and damage
control surgery is indicated, ligation of the renal artery and
nephrectomy are reasonable options provided the kidney is
not solitary. The experienced trauma surgeon should be able
divide the overlying renal fascia, elevate the kidney, and apply
a vascular clamp proximal to the hilum to control bleeding
from a distal renal artery injury. This may be possible without
applying a supraceliac clamp.
If the patient has a single functioning kidney, nephrectomy
is contraindicated and repair should be performed. With small
lacerations from penetrating trauma, a suture repair maybe
possible. With larger lacerations, the segment may require
resection. Reconstruction with an end-to-end anastomosis or
interposition grafting using long saphenous vein prosthetic
graft can be performed. Another option is to translocate the
splenic artery onto the left renal artery or interpose a graft
between the right renal artery and the hepatic artery.
Other options for renal revascularization include a bypass
graft directly from the aorta and auto transplantation of the
kidney into the pelvis.
If the diagnosis is delayed, nonoperative management for
a stable injury is an option and should be considered in the
patients with multiple injuries.
Overall, the results of revascularization have tended to be
poor, which has led to a conservative approach in many
centers. The absolute indications for revascularization are soli-
tary functioning kidney injuries or bilateral renal artery inju-
ries. Delayed hypertension remains a problem in up to half of
the patients who undergo revascularization. Patients who are
managed conservatively can also develop this delayed hyper-
tension, and this has been seen in at least one third of patients
managed conservatively.15
Endovascular Treatment
Stable patients presenting after blunt trauma and identified as
having intimal flaps, fistulas, pseudoaneurysm, and occlusion
should be considered for endovascular treatment.
If local facilities and expertise allow, stenting should be
considered although the long-term outcome remains un-
known. These patients will need long-term surveillance. Em-
bolization may be considered as an alternative to nephrectomy.
However, delayed nephrectomy may be required because the
patient may suffer from resistant hypertension.16
Mortality
The majority of blunt trauma results in occlusive injuries and
consequently isolated renal artery injuries have a low mortal-
ity rate. As expected, mortality is higher when associated with
other injuries.
Injuries to the Iliac Artery
Anatomy
The bifurcation of the abdominal aorta into the left and right
common iliac arteries occurs at the level of the fourth lumbar
vertebra. The common iliac arteries continue inferolaterally
and bifurcate into the internal and external iliac arteries over
the sacroiliac joints. It is at this point that the ureter crosses
from lateral to medial. The common iliac veins merge to form
the IVC posterior to the right common iliac artery at the level
of the fifth lumbar vertebra, t. While the external iliac artery
courses beneath the inguinal ligament to become the common
femoral artery, the internal iliac artery passes medially and
divides into anterior and posterior divisions. Posteromedial to
the left common iliac artery courses the left common iliac vein
while the right common iliac vein passes inferoposterior to the
right common iliac artery bifurcation. The close proximity of
the iliac arteries and veins is the reason for the high incidence
of combined injuries.
Mechanism of Injury
The most common mechanism of injury is penetrating
trauma, usually involving injury to the common iliac arter-
ies, with blunt trauma being a rare cause of arterial injury.
With blunt trauma, the injury is more commonly associated
with pelvic fractures, causing either direct laceration or
intimal tears (associated with thrombosis) and more com-
monly affects the internal iliac artery and its branches. One
quarter of patients have combined arterial and venous
injuries.
Clinical Presentation
Injury to the iliac vessels should always be suspected in a
severely hypotensive patient with a low-abdominal penetrat-
ing injury. The index of suspicion should be raised in the
presence of abdominal distension; and, if the femoral pulse is
weak or absent, it is almost diagnostic of a common iliac or
external iliac arterial injury. The presence of signs suggesting
pelvic visceral injuries such as hematuria should also raise the
index of suspicion.
The majority of cases will be diagnosed during the trauma
laparotomy or, if the patient is sufficiently stable, by trauma
CT. Injuries associated with blunt trauma frequently accom-
pany pelvic fractures. Infrequently, they may have delayed
presentation with an ischemic leg secondary to an intimal tear
and subsequent thrombosis.
Investigations
Not all patients should undergo radiological investigations.
This is dictated by the patient’s clinical stability. Hemody-
namically unstable patients with penetrating injury should be
taken immediately for a trauma laparotomy. The pelvic x-ray
taken as part of the initial Advanced Trauma Life Support
(ATLS) resuscitation series may show fragments suggesting
foreign bodies (e.g., gunshot wounds, blast injuries), and
122 SECTION 3  /  DEFINITIVE MANAGEMENT
consideration should be given to the possibility of iliac vascu-
lar injuries.
With blunt injuries examine the pelvic x-ray for sacroiliac
joint disruption, widening of the symphysis pubis, and for
bilateral fractures of both superior and inferior pubic rami.
These radiological findings are associated with an increased
risk of iliac vascular injuries.
The two most-utilized investigations are CT angiography
and catheter angiography. CT angiography is performed rou-
tinely in most if not all trauma centers. The CT images should
be examined for pelvic hematomas, extravasation of contrast,
false aneurysms, intimal flaps, and thrombosis (suggested by
the absence of contrast within the arterial lumen).
Catheter angiography still has a vital role in the manage-
ment of pelvic hematomas. It has both a diagnostic role and
a therapeutic role. Its use is dependent on the availability of
local expertise and is dictated by local facilities. If the inter-
ventional radiology suite is close to the operating room or the
trauma center and has the ability to perform interventional
techniques within the operating room (e.g., a hybrid theater),
catheter angiography provides an ideal means of identifying
the source of arterial bleeding and treating it by using embo-
lization techniques; however, careful consideration must
always be given when transferring a patient who is at risk of
becoming hemodynamically decompensated to a radiology
department that is remote from the operating room and that
lacks optimal resuscitation facilities.
As well as identifying and treating the source of bleeding,
angiography is also useful in diagnosing intimal flaps of the
common and external iliac arteries. Some of these can be
treated with stents. In addition, massive bleeding can be con-
trolled by the proximal placement of intraluminal occlusion
balloons, following which the patient can be transferred to the
operating room for surgery.
Angiography should be considered early in patients with
pelvic fractures subsequent to blunt trauma especially if there
is evidence of bleeding. Box 11-1 lists the radiographic find-
ings on pelvic films that are associated with increased risk of
vascular injury and should prompt early angiography.
Surgical Management
In the context of penetrating trauma, laparotomy may identify
free intraperitoneal bleeding or a large zone III (pelvic) hema-
toma, or both. Traditionally, all zone III hematomas caused by
penetrating injury merited surgical exploration. If the patient
is hemodynamically unstable, this is still the recommended
action. However, in the patient who is stable—and if facilities
permit—consideration may be given to intraoperative angi-
ography and an endovascular treatment option. Bleeding from
branches of the internal iliac artery can be managed by
embolization.
The zone III hematoma resulting from blunt injury should
not be routinely explored. The exception to this is in the
Box 11-1 Pelvic Radiographic Findings Associated
With Increased Risk of Vascular Injury
Pubic diastasis greater than 2.5 cm
Sacroiliac joint disruption
Butterfly fractures (bilateral superior and inferior rami fractures)
presence of an absent or reduced femoral pulse suggesting
either common iliac or external iliac arterial injury. It is
important to remember that blunt injuries may be associated
with arterial intimal tears and thrombosis, and hence the
absence of a zone III retroperitoneal hematoma does not
exclude a major vascular injury.
Active bleeding is managed according to the principles
damage control surgery. This involves the application of direct
compression and then proximal and distal exposure of the
artery to control inflow and back-bleeding.
In the presence of a large pelvic hematoma it may be dif-
ficult to determine the site of bleeding in the iliac artery; and,
if rapid proximal control is required, aortic cross-clamping
can be achieved as previously described. The clamp may be
applied just above the level of the aortic bifurcation. Similarly
if the injury is close to the proximal common iliac artery, con-
trol is best achieved by cross-clamping the distal aorta. If the
injury is more distal (e.g., external iliac artery), the common
iliac artery can be exposed by dividing the overlying perito-
neum. Proximal control can be gained by using a nylon vascu-
lar tape to encircle the artery, carefully avoiding damage to the
neighboring common iliac vein. Exposure of the common iliac
and external iliac vessels may require mobilization of the
cecum or sigmoid colon and care should be taken to avoid
overlying ureters. With external iliac injuries, proximal control
will also require exposure and control of the internal iliac
artery. This is achieved by proximal and distal vascular retrac-
tion and by dissecting medially. Distal control may be difficult
with a large hematoma. If direct exposure is not possible (e.g.,
a narrow pelvis), consider either adding a transverse lower
abdominal incision or exposing the artery at the groin. Longi-
tudinal incision and division of the inguinal ligament may be
required. Exposure of the artery in the groin can be combined
with the passage of occlusion balloon catheters to gain proxi-
mal control. However, if there is a complete transection of the
artery or a large defect, the catheter may pass out of the artery
rather than into the artery proximal to the site of injury.
The choice of repair will be dependent on the size and
location of the injury and the degree of contamination. Small
arterial injuries (e.g., stab wounds) can undergo primary
repair with a 5-0 or 4-0 Prolene suture. If a patch is required,
either a venous or prosthetic patch may be used (e.g., polytet-
rafluoroethylene [PTFE]; bovine pericardium). In the pres-
ence of contamination, a venous patch is preferred. Complete
transection may be repaired by mobilization of the arterial
ends and an end-to-end anastomosis.
Most patients with blunt injury or gunshot wounds require
end-to-end anastomosis or interposition grafting. Gunshot
injuries may be associated with significant intimal damage.
The ends of the artery should be carefully examined. Débride-
ment is usually required and an appropriate section of normal
artery selected for the anastomosis of the interposition graft.
Embolectomy catheters should always be passed distally to
remove any residual clot.
It is best to avoid complex arterial reconstructions requir-
ing extraanatomical bypasses and mobilization of the internal
iliac arteries. These are time consuming and are best avoided
in the context of major trauma. If the patient is critical and
requires damage control, arterial continuity may be temporar-
ily established with the use of intraluminal shunts.
If a vascular shunt isn’t available, an alternative is to
construct one using a wide bore sterile gastric tube, an
 11  /  Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 123
intravenous tube, or a urethral catheter. These should be
secured with distal and proximal ligatures. Later, once the
patient’s condition has stabilized, a definite arterial recon-
struction can be performed. Shunts frequently thrombose,
and therefore the limb should be monitored for ischemia.
Ideally the patient should be prophylactically anticoagulated.
However, the critical patient is frequently coagulopathic, and
hence systemic anticoagulation is contraindicated.
Beyond the most critical of situations, the common and
external iliac arteries should never be ligated without some
means of ensuring distal perfusion (shunt or extraanatomic
reconstruction), due to the high incidence of limb loss and the
risk that the ischemia will result in general deterioration of
the patient. Subsequent reperfusion attempts that cause severe
reperfusion injury and organ failure are associated with high
mortality.
If the patient is stable, interposition grafting can be per-
formed. Extraanatomical bypass should be considered if there
is significant enteric contamination, purulent peritonitis, or
infection in the injured zone. It is worth noting, however, that
one case series of 16 patients reported by Burch et al describes
the use of PTFE grafts in the presence of colonic and urologi-
cal contamination without subsequent graft infection.17
Injuries to the internal iliac artery and its branches can be
difficult to manage. Due to cross-filling from branches of the
contralateral internal iliac artery, ligation of the injured inter-
nal iliac artery (or its branches) may not provide hemorrhage
control. Additionally the surgical exposure is difficult. If the
hematoma is not expanding, do not explore. Angiography and
embolization are the best options. Always consider pelvic
packing with subsequent angiography and embolization as a
potential option.
Bleeding may persist even after vascular repair or ligation
of internal iliac branches. This is not infrequent after gunshot
wounds. The safest options are to pack the pelvis and arrange
angiography with subsequent embolization.
Complications of Vascular Trauma
The most common early complication following arterial
reconstruction is thrombosis. The use of meticulous surgical
technique, embolectomy balloon extraction of clots, intraop-
erative local heparinization, and angiography can all reduce
the incidence of this complication. Postoperative monitoring
of the limb is essential. Lower limb compartment syndrome
remains a common postoperative problem, and the surgeon
should have a low threshold for performing fasciotomies.
Some centers advocate prophylactic fasciotomies, but this
remains a topic of debate. An awareness of abdominal com-
partment syndrome should be maintained. Monitoring
intraabdominal pressure, urine output, and ventilatory pres-
sure can alert the team of this possibility and the need for
abdominal decompression. The use of prosthetic grafts raises
the possibility of graft infections. Late complications can also
occur, with delayed presentations of pseudoaneurysms, arte-
riovenous fistulas, and aortoenteric fistulas
Endovascular Treatment of
Intraabdominal Trauma
The most common interventional techniques used in trauma
are balloon occlusion, embolotherapy, and stent grafting.18
Control of Bleeding by Embolization
Endovascular embolization techniques are especially useful
for hemorrhage control. The decision to embark on an inter-
ventional treatment plan will depend on the availability of
local expertise and interventional facilities. These factors must
also be balanced against the hemodynamic stability of the
patient. An unstable patient should not be treated in an inter-
ventional radiology suite that is located away from resuscitat-
ing facilities or the operating theater. Should the patient
become unstable, it is vital that quick and easy transfer to an
operating theater is possible. The interventional radiologist
should be confident of his or her technical ability to perform
selective embolization.
A number of principles need to be considered before
embarking on embolization. A detailed understanding of the
anatomy is essential, including variations in arterial anatomy.
It is important to recognize whether a feeding vessel or an
entire vascular bed requires embolization. The presence of
anastomoses and collaterals between arterial territories must
be appreciated as this will require embolization of both inflow
and outflow arteries. Finally the effect on the end organ or
vascular territory must also be considered.
Embolization agents used in trauma can be divided into
those that result in permanent vessel occlusion or those where
occlusion is temporary. Agents can be further divided into
mechanical occlusion devices (e.g., coils), particulate agents
(e.g., gel foam), and liquid agents (e.g., sclerosants, adhe-
sives).19 The decision to use a type of agent is dictated by the
duration of occlusion required, the number of bleeding points,
the size of the artery, and whether an individual feeding vessel
or an entire vascular bed is the target.
Gelfoam results in temporary occlusion, which can last up
to a few weeks—a useful property in trauma that allows time
for the vessel to heal. Gel foam is available as either a powder
or a sheet. The powder form is made up of small particles and
hence facilitates occlusion down to the capillary level. The
sheet form is more useful for larger vessels and is cut into small
pledgets of 1-mm to 2-mm diameter that are soaked in con-
trast media before syringing and injecting. Gelfoam is suitable
for multiple bleeding points and is frequently the choice in
pelvic trauma. Coil embolization results in permanent occlu-
sion through both a mechanical obstruction and a thrombo-
genic effect. The coils are made from stainless steel or platinum
and are available in a range of sizes, usually coated with
thrombogenic fibers. To be effective, they must be tightly
packed in a stable position within the artery. When using coils
it is vital to consider the supply to the bleeding vessel. If the
vessel is an end artery (e.g., renal), only inflow requires embo-
lization; but where this is not the case, both inflow and outflow
vessels must be embolized to prevent back-bleeding and to
gain hemorrhage control.
Before embolization, a preliminary angiogram is always
performed. If contrast extravasation is confirmed, the degree
of extravasation must be matched to the hemodynamic status
of the patient. If the amount of extravasation does not cor-
relate with the shock, other sources of bleeding should be
sought before embarking on embolization. The end-organ
ischemic effects of embolization should always be anticipated.
For instance, embolization of a renal artery should never be
performed without confirming the presence of two function-
ing kidneys. Use of “end-hole only” catheters passed by the
124 SECTION 3  /  DEFINITIVE MANAGEMENT
A B
FIGURE 11-7  A, Branch of left internal iliac artery showing extravasation of contrast. This patient presented following a stab injury to the
buttock. B, The arrow shows the extravasation of contrast. Post embolization of iliac artery bleeder. This is the same patient depicted in Figure
7B following coil embolization.
shortest and straightest possible path and maintained in a
stable position facilitates accurate delivery of the emboliza-
tion agent to the target vessel and prevents inadvertent occlu-
sion of nontargeted arteries. If using particulate agents, a test
injection with contrast is usually sufficient to confirm that the
catheter tip is not displaced during the injection. If using
coils, passage of a guide wire will allow the operator to see
whether the delivery catheter tip is not in a stable position.
During delivery of the agent, continuous fluoroscopy is essen-
tial, and completion angiography should be performed to
confirm the effect on flow. After coil embolization, provided
the flow is not too brisk, patience and a delay of a couple of
minutes may be all that are required to facilitate vessel throm-
bosis. If the flow does appear brisk, further coils will need to
be packed into the region. Embolization may not always be
successful in controlling bleeding. Equally a patient may
become hemodynamically compromised during the proce-
dure necessitating open surgery. If a decision is made to
convert to open surgery, a temporary occlusion balloon can
be placed in the artery proximal to the injury (e.g., in the
common iliac artery or aorta). Care needs to be applied when
transferring the patient but this technique is the endovascular
equivalent of arterial clamping—restoring blood pressure and
providing time for the surgeon to proceed with damage
control techniques.
Endovascular Treatment of Solid Organs
and Pelvic Trauma
Pelvic bleeding as a consequence of blunt trauma is most com-
monly associated with pelvic fractures. The first-line treat-
ment is to stabilize the fracture through application of a pelvic
binder, and this frequently results in cessation of venous
bleeding. Continued instability suggests arterial bleeding, and
gelfoam angioembolization of the internal iliac arteries is
usually indicated. Internal iliac artery embolization carries a
risk of pelvic ischemia; if angiography reveals extravasation
from isolated branches, selective embolization is preferable as
the ischemic burden is lower (Fig. 11-7). Stabilization of the
bony pelvis may require urgent external fixation either before
or during concomitant laparotomy. Control of pelvic bleeding
during the trauma laparotomy can be challenging, and intra-
operative hemostasis can be facilitated via the technique of
preperitoneal packing in order to facilitate tamponade. Pre-
peritoneal packing can be combined with follow-on emboliza-
tion to ensure cessation of hemorrhage. Mortality from major
pelvic bleeding still remains high, exceeding 30%.20
Although this chapter has focused on the management of
arterial injuries, the techniques of angioembolization are also
applied to the nonoperative management of solid abdominal
organ injury, which therefore warrants brief discussion. The
spleen remains one of the most commonly injured organs
following blunt abdominal trauma.21 Angiography is indi-
cated for active bleeding (extravasation), pseudoaneurysms,
hemoperitoneum on CT (Fig. 11-8), and high-grade splenic
injuries. Embolization is required if angiography confirms
active bleeding. There is controversy regarding the use of
proximal embolization over more distal selective emboliza-
tion. It has been postulated that distal embolization (Fig. 11-8)
may offer benefits with regard to preserving splenic function—
coupled with a higher risk of rebleeding—though the authors
of a recent metaanalysis22 were not able to confirm these dif-
ferences in outcome. Blunt trauma to the liver results more
frequently in parenchymal venous than arterial injury. Liver
trauma can usually be managed conservatively in the first
instance given patient stability and the absence of a contrast
blush or active extravasation on CT.21 With renal trauma it is
vital to ensure two functioning kidneys before proceeding
with any embolization. Renal extravasation, arterial lacera-
tions, pseudoaneurysms, and arteriocalyceal fistulae can
be treated with embolization. Selective embolization can
 11  /  Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries 125
A B
FIGURE 11-8  A, CT imaging of splenic injury following blunt abdominal trauma. B, The perisplenic hematoma is arrowed. Selective coil
embolization of the splenic artery.
facilitate renal salvage and can reduce the volume of renal
infarction. Other injuries such as dissection flaps can be
managed with endovascular stents.23
Complications of Embolization
Misplacement of coils or gelfoam can result in nontargeted
embolization; the consequences will depend on the territory
supplied by the misembolized artery. It is feasible to retrieve
errant coils, but this is not an option with gelfoam. Emboliza-
tion of the common or external iliac artery may require urgent
bypass in order to restore limb perfusion. Even properly tar-
geted selective embolization may result in unanticipated and
massive tissue infarction in solid organs such as the liver.
Clinically the presentation is of early abdominal pain and
delayed fever, nausea, and vomiting caused by the release of
vasoactive agents. The patient will require analgesia and sup-
portive treatment; but, assuming there is no abscess, the symp-
toms are usually self-limiting with resolution after about 3
days. Renal embolization can result in hypertension; and, if
uncontrollable by antihypertensive medication, it may warrant
delayed nephrectomy.
REFERENCES
1. Coimbra R, Hoyt DB: Vascular trauma: epidemiology and natural history.
In Cronenwett JL, Johnston KW, editors: Rutherford’s vascular surgery,
ed 7, Philadelphia, 2010, Saunders Elsevier, pp 2312–2317.
2. Mattox KL, Feliciano DV, Burch J, et al: Five thousand seven hundred
sixty cardiovascular injuries in 4459 patients: epidemiologic evolution
1958 to 1987. Ann Surg 209:698–705, 1989.
3. DeBakey ME, Simeone FA: Battle injuries of the arteries in World War
II:an analysis of 2471 cases. Ann Surg 123:534–579, 1946.
4. Asenio JA, Forno W, Roldan G, et al: Abdominal vascular injuries: injuries
to the aorta. Surg Clin North Am 81:1395–1416, 2001.
5. Demetriades D, Theodorou D, Murray J, et al: Mortality and prognostic
factors in penetrating injuries of the aorta. J Trauma 40:761–763, 1996.
6. Asensio TA, Chahwan S, Hanpeter D: Operative management and out-
comes of 302 abdominal vascular injuries. Am J Surg 180:528–534, 2000.
7. Lichte P, Oberbeck R, Binnebösel M, et al: A civilian perspective on bal-
listic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med
18:35, 2010.
8. Gunshot, fragment and blast injuries. In Botha A, Brooks A, Loosemore
T, editors: Definitive surgical trauma skills, London, 2002, The Royal
College of Surgeons of England, pp 101–111.
9. Mokoena T, Robbs JV: Surgical management of mycotic aneurysms. S Afr
J Surg 29:103–107, 1991.
10. Robbs J: Abdominal vascular injuries. In Barros D’Sa AA, Chant AD,
editors: Emergency vascular and endovascular surgical practice, ed 2,
London, 2005, Hodder Arnold, pp 429–442.
11. Davis TP, Feliciano DV, Rozycki GS, et al: Results with abdominal vascular
trauma in the modern era. Am Surg 67:565–571, 2001.
12. Burdick TR, Hoffer EK, Kooy T, et al: Which arteries are expendable? The
practice and pitfalls of embolization throughout the body. Semin Interv
Rad 25:191–203, 2008.
13. Mehta M, Darling RC, Taggert JB, et al: Outcomes of planned celiac artery
coverage during TEVAR. J Vasc Surg 52:1153–1158, 2010.
14. Clark DE, Georgitis JW, Ray FS: Renal arterial injuries caused by blunt
trauma. Surgery 90:87–96, 1981.
15. Haas CA, Spirnak JP: Traumatic renal artery occlusion: a review of the
literature. Tech Urol 4:1–11, 1998.
16. Shoobridge JJ, Corcoran NM, Martin KA, et al: Contemporary manage-
ment of renal trauma. Review in Urology 13:65–72, 2011.
17. Burch JM, Richardson RJ, Martin RR, et al: Penetrating iliac vascular
injuries: recent experience with 233 consecutive patients. J Trauma 30:
1450–1459, 1990.
18. Gould JE, Vedantham S: The role of interventional radiology in trauma.
Semin Interv Rad 23:270–278, 2006.
19. Embolization. In Kessel D, Robertson I, editors: Interventional radiology:
a survival guide, ed 2, Philedelphia, 2005, Elsevier, pp 193–212.
20. Thorson CM, Ryan ML, Otero CA, et al: Operating room or angiography
suite for hemodynamically unstable pelvic fractures? Trauma Acute Care
Surg 72:364–370, 2012.
21. Yao DC, Jeffrey RB, Mirvis SE: Using contrast-enhanced helical CT to
visualise arterial extravasation after blunt abdominal trauma: incidence
and organ distribution. AJR 178:17–20, 2002.
22. Schnüriger B, Konstantinidis A, Lustenberger T, et al: Outcomes of proxi-
mal versus distal splenic artery embolization after trauma: a systematic
review and meta-analysis. J Trauma 70:252–260, 2011.
23. Chabrot P, Cassagnes L, Alfidia A, et al: Revascularisation of traumatic
renal artery dissection by endoluminal stenting: three cases. Acta Radiol
51:21–26, 2010.
 Inferior Vena Cava, Portal,
and Mesenteric Venous
12  Systems
STEPHANIE A. SAVAGE AND TIMOTHY C. FABIAN
Introduction
Injury to a major vein of the abdomen is highly lethal, thus
accounting for limited operative experience. The current lit-
erature consistently describes mortality rates of 50% to 70%
for injuries to the superior mesenteric vein (SMV), the portal
vein (PV), and the inferior vena cava (IVC).1-3 With IVC inju-
ries alone, 30% to 50% of patients will not survive to hospital
arrival.4 These arresting mortality figures have been attributed
to factors including difficulty in operatively accessing the
structures, both for exposure of the vessel and for proximal
and distal control, as well as torrential hemorrhage from a
high-flow, low-pressure system.2,5 Low incidence renders few
trauma surgeons greatly experienced in their management
and limits the opportunity for study. Despite modern advances
in patient transport, hemorrhage control, operative manage-
ment, and intensive care unit (ICU) care, mortality rates for
this series of injuries have remained fixed.
Historical Background
The infrequency of these injuries is reinforced in the historical
literature. Reviews of combat injuries from World War I
through the Korean War mention a variety of vascular injuries
but contain little reference to either venous or arterial abdom-
inal vascular injuries.2 One of the few references, from DeBakey
and Simeone, mentions 2% of 2471 vascular injuries from
WWII were intraabdominal.6 Three decades later, an oblique
reference from the Walter Reed vascular registry documented
lower extremity edema as a sequela of injuries to the vena cava
managed by ligation.7 The Baylor group has published some
of the most comprehensive reviews of visceral vascular inju-
ries among civilian populations. In a 1982 review of 312
patients with vascular injury, venous injuries most commonly
occurred to the internal jugular vein (5.7% of vascular inju-
ries), with the SMV injured 2% of the time and the inferior
mesenteric vein (IMV) injured in 0.4% of patients.2,8 An addi-
tional review of 4459 patients over a 30-year period found
33.7% were to the abdominal vasculature and 3.8% were to
the mesenteric vessels.9
The mortality associated with this triad of abdominal
venous injuries has changed little in the last 30 years, despite
advances in other areas of trauma care. Though comprehen-
sive reviews are uncommon, case reports of heroic efforts to
save patients using highly specialized management options are
abundant. Approaches describing the role of interventional
vascular techniques in hemorrhage control and repair are
becoming increasingly common. The military experience with
vascular shunts provides a unique opportunity to expose
126
injuries and to resuscitate patients in relatively bloodless fields.
While aggressive options such as venovenous bypass and liver
explantation are largely anecdotal, they may provide future
opportunities to repair the most profound injuries to the cava,
porta vein, and SMVs.
Infrequent injury to the major abdominal veins is largely
due to the protection provided by surrounding organs and the
retroperitoneum. Penetrating trauma accounts for 95% of
injury to these structures.2,10 Stab wounds yield a slightly
better survival than injuries produced by gunshot wounds or
blunt injuries.11 The American Association for the Surgery of
Trauma includes injuries to the major abdominal veins in the
Organ Injury Scale for Abdominal Vascular Trauma (Table
12-1).12 Not surprisingly, the most common cause of death is
exsanguination, whether in the field or intraoperatively.
Patients with major venous injuries who survive to the
hospital may present in profound shock or may be relatively
stable. A recent report of patients sustaining these injuries
documented an average hospital admission systolic blood
pressure of 90 mm Hg and a heart rate of 95 beats per
minute.13 In addition to lower blood pressure, nonsurvivors
following abdominal venous trauma also had a higher injury
severity score (ISS), had more associated injuries, were older,
and had greater blood loss at laparotomy.11 Considering quan-
tity of hemorrhage, a blood loss of greater than 7.2 L has been
associated with mortality,10 while patients with major vein
injuries require an average of 19 units of packed cells with 7 L
of crystalloid.14 Some authors have also found Glasgow Coma
Scale (GCS) to be a statistically significant predictor of mor-
tality. This association may variably represent degree of shock
or associated injuries.10
Associated injuries are almost uniformly found in patients
with trauma to the major abdominal veins, due to their inti-
mate association with key visceral and vascular structures.
Asensio et al documented two to four associated organ inju-
ries for every visceral vessel damaged.2 Among intraabdomi-
nal organs, the liver and stomach tend to be most frequently
injured with trauma to the IVC, PV, and SMV.3 Injuries to the
liver may be especially challenging, as attempts to mobilize the
organ can place torque on the associated vascular structures
with worsening of the vascular rent. Injury to a major venous
structure is also frequently accompanied by damage to the
associated artery, including the hepatic arteries, the aorta, and
the superior mesenteric artery.3 In a review of the subject by
Coimbra, 94% of portal and superior mesenteric venous inju-
ries had associated intraabdominal injuries, with 61% of these
including other major vascular injuries (most commonly
IVC and superior mesenteric artery [SMA]).1 With 35% of
superior mesenteric arterial injuries having associated SMV
 12  /  Inferior Vena Cava, Portal, and Mesenteric Venous Systems 126.e1

ABSTRACT
Trauma injury to the inferior vena cava (IVC), portal, and
mesenteric venous systems is uncommon. Such injuries
have high mortality, primarily due to exsanguination.
Therapy for this triad of injuries is primarily operative and
focuses on rapid identification of the injury and excellent
vascular technique. Primary repair is preferred. When the
patient’s physiologic status will not tolerate prolonged
repair or when the injury is too extensive, ligation is an
acceptable alternative. Increasing familiarity with balloon
occlusion to control hemorrhage and with placement of
stents increases the surgeon’s options. Additionally, a vas-
cular shunt may provide an acceptable bridge for later
repair when damage control is pursued.

Key Words:  inferior vena cava (IVC),

portal vein,
mesenteric veins,
venous trauma,
noncompressible hemorrhage
 12  /  Inferior Vena Cava, Portal, and Mesenteric Venous Systems 127
Table 12-1 American Association for the
Surgery of Trauma—Organ Injury
Scale for Abdominal Vascular
Injury*
Grade Description
Grade 1 Non-named superior mesenteric artery or superior
mesenteric vein branches
Non-named inferior mesenteric artery or inferior
mesenteric vein branches
Phrenic artery or vein
Lumbar artery or vein
Gonadal artery or vein
Ovarian artery or vein
Other non-named small arterial or venous structures
requiring ligation
Grade 2 Right, left, or common hepatic artery
Splenic artery or vein
Right or left gastric arteries
Gastroduodenal artery
Inferior mesenteric artery or inferior mesenteric vein,
trunk
Primary named branches of mesenteric artery or vein
Other named abdominal vessels requiring ligation or
repair
Grade 3 Superior mesenteric vein, trunk
Renal artery or vein
Iliac artery or vein
Hypogastric artery or vein
Vena cava, infrarenal
Grade 4 Superior mesenteric artery, trunk
Celiac axis proper
Vena cava, suprarenal and infrahepatic
Aorta, infrarenal
Grade 5 Portal vein
Extraparenchymal hepatic vein
Vena cava, retrohepatic or suprahepatic
Aorta, suprarenal, subdiaphragmatic
From Moore EE, Cogbill TH, Jurkovich GJ, et al: Organ injury scaling
III: Chest wall, abdominal vascular, ureter, bladder and urethra.
J Trauma 33:337, 1992.
*This classification system is applicable to extraparenchymal vascular
injuries. If the vessel injury is within 2 cm of the organ parenchyma,
refer to the specific organ injury scale. Increase one grade for mul-
tiple grade 3 or 4 injuries involving >50% vessel circumference.
Downgrade one grade if <25% vessel circumference laceration for
grades 4 or 5.
injuries, close apposition of major structures places all at
risk.15 Additional work from the same group demonstrated the
impact of multiple vascular injuries on survival. From a cohort
of 302 patients with injuries to the abdominal vasculature,
those with a single injured vessel had a mortality rate of 45%.
When two vessels were injured, the mortality rose to 60% and
the mortality climbed to 73% if three vessels were injured.
Injury to more than three intraabdominal vessels was uni-
formly fatal.16
Complication rates are significant with such injuries. The
genesis of postoperative complications is multifactorial and
attributable to associated injuries, patient age, comorbidities,
and degrees of shock and hemorrhage. General complications
include respiratory failure, dehiscence, sepsis, and infection.
Abdominal complications included thrombosis of the repaired
vessel, abdominal compartment syndrome, unplanned return
to the operating room (OR) for bleeding, a vasoactive medica-
tion requirement, and gastrointestinal complications. In sur-
vivors, late ischemia to either the gut or liver attributed to
ligation of the vessel or prolonged occlusion during repair, are
additional serious complications.2,17
Preoperative Preparation
The most important components of preoperative preparation
are entering the operating room with both thorough anatomic
knowledge and with plans for vascular exposure, vascular
control, and basic techniques for repair. Little other preopera-
tive planning is possible in the hemodynamically unstable
patient; the unstable patient must be taken directly to the
operating room. However, not all patients with these injuries
are in extremis. For some patients, preoperative imaging is
limited to a positive focused assessment with sonography for
trauma (FAST) exam. For others, the role of computed tomog-
raphy (CT) will be defined by the nature of the injury. In
penetrating abdominal trauma, CT will have a limited role
that is relegated to its use in the stable patient who lacks peri-
toneal signs, and in whom the injury is thought to be extra-
peritoneal. CT is of benefit in the event of blunt injury to a
major abdominal vein (primarily the IVC).
Identifying a caval injury on CT scan is challenging. Active
extravasation of contrast from the IVC is not typically seen in
the hemodynamically stable patient. The most common indi-
cation of an underlying major vein injury is a retroperitoneal
hematoma. Approximately 75% to 91% of retroperitoneal
hematomas develop in zone I, 18% of patients will demon-
strate a zone II hematoma, and 9% will have a zone III hema-
toma.2,13 The presence of retroperitoneal blood should raise
suspicion for a major abdominal vessel injury; zone of occur-
rence does not necessarily reflect the involved vessel, though
hematomas localized around the ascending colon and duode-
num are fairly specific for IVC injuries. The retroperitoneum
is capable of containing a large blood volume, up to half of
the total blood volume, and serves to tamponade the bleeding
from the relatively low-pressure venous system.
Additional CT findings may also indicate potential venous
injury. A flat IVC on CT is a good indicator of hypovolemia
and potential IVC pathology. A flat IVC is defined as one with
a maximal transverse-to-anteroposterior ratio of less than
4 : 1. The presence of a flat IVC in conjunction with other
injuries predicted the need for therapeutic intervention in
84% of the cases in one study.18 The flattened IVC as an indica-
tor of pending hemodynamic collapse may be a useful finding
in the trauma bay, because this finding can be detected with
ultrasound. Subtle CT findings, peculiar to IVC injury, may
include an irregular contour to the cava or a filling defect
within the caval lumen.19 In rare cases, a herniation of perica-
val fat into the vessel lumen may also indicate a laceration of
the IVC.20 Exploration of these hematomas may be injudicious
as it allows inadvertent release of torrential hemorrhage, to the
detriment of the patient.21 While mechanism of injury and
patient status may necessitate operative exploration, fore-
warning of the severity of the venous injury allows the surgeon
to plan the best approach and allows anesthesia and the
remainder of the operative team to prepare for significant
blood loss.
Despite all attempts, patients may deteriorate too rapidly
for either radiologic study or even rapid admission to the
operating room. In these cases, a resuscitative thoracotomy
has been advocated in either the emergency department (ED)
128 SECTION 3  /  DEFINITIVE MANAGEMENT
or the operating room (OR) as a bridge until more definitive
therapy is accomplished. Currently, this approach is believed
to be more harmful than beneficial, because significant nega-
tive metabolic and physiologic sequelae attend the opening
of the thoracic cavity. Indications for ED thoracotomy are
extremely limited, due to the very poor survival rate. Patients
in whom resuscitative thoracotomy may be considered are
those with witnessed arrest in penetrating injury and arrest
following arrival in the hospital for blunt-trauma patients. A
review of resuscitative thoracotomies used in the setting of
abdominal vascular injuries, mostly arterial, over 30 years con-
tinues to demonstrate limited, but occasional, survival. A
current literature review demonstrates a 10.5% (4 of 38) sur-
vival rate in patients undergoing resuscitative thoracotomy in
the setting of abdominal vascular injuries.11,22,23 Those pre-
senting with penetrating abdominal trauma, unstable hemo-
dynamics, and a distended abdomen may benefit from this
type of resuscitation. The maneuver significantly limits or
stops ongoing blood loss and allows exploration and identifi-
cation of the injury in a field free of ongoing hemorrhage.
While thoracic access allows a much easier approach to the
aorta for cross-clamping than that presented by the suprace-
liac aorta, it must be balanced by the additional insult. The
incision creates a significant heat sink, and distal ischemia
imposes a finite time constraint. Balancing benefits and risks
is the surgeon’s continuous challenge.
Operative Management
The Inferior Vena Cava
Of the three major abdominal veins discussed in this chapter,
the IVC is the most frequently damaged and requires some of
the most complex decision making. The overall incidence of
IVC injury ranges from 0.5% to 5% of penetrating injuries
and 0.6% to 1% of blunt trauma.7 Approximately 30% to 50%
of patients will die before reaching the hospital, either from
exsanguination or associated injuries.4,7 Of the patients who
survive to the hospital, 20% to 57% will not survive to dis-
charge, either dying intraoperatively from exsanguination or
during the precarious immediate postoperative period.4
Penetrating injury to the IVC is slightly more common
(0.5% to 5%) than is a blunt mechanism of injury (0.6% to
1%).7 When blunt IVC injury does occur, it is the result of
torque on the vessel from extensive tributaries and retroperi-
toneal fixation. The retrohepatic cava in particular is protected
by the hepatic ligaments, the retroperitoneum, and the hepatic
parenchyma. Significant force must be sustained to tear or to
avulse this structure, resulting in catastrophic injury.24
Of all of major abdominal venous injuries, trauma to the
IVC, whether blunt or penetrating, is the most amenable to
nonoperative management. Because the IVC is a low-pressure
(3 cm to 5 cm H2O) retroperitoneal structure, bleeding is ini-
tially contained within the confines of the retroperitoneum,
allowing for tamponade of the injury. Studies with swine have
found nonoperative management of IVC lacerations to be an
effective strategy at times.25 Patients presenting hemodynami-
cally stable with contained vena cava hematomas are candi-
dates for nonoperative management.18 When the peritoneum
is torn, however, the tamponade can be released. In order to
minimize the likelihood of releasing the tamponade effect,
vigorous intravenous fluid resuscitation should be avoided.
Large-volume resuscitation will substantially enlarge the vena
cava, including the injured region, and will increase the venous
pressure with resulting hemorrhage. Similarly, those patients
with penetrating major vascular injuries are the group most
likely to benefit from fluid restriction and hypotensive resus-
citation, by avoiding the effect of hydrostatically forcing the
clot off the injured area. Patients with the potential for major
abdominal venous injuries should not have intravenous fluids
administered through lower extremity access sites. Obvious
signs of deterioration, including hemodynamic instability,
peritonitis, and changes in lactate level or base deficit, indicate
failure of the current course of management and the need for
surgical exploration.18
The anatomy of the IVC impacts surgical decision making
and patient outcome. The distal IVC arises from the conflu-
ence of the common iliac veins. Traveling cephalad through
the right retroperitoneum, the vena cava receives venous
outflow from several tributaries including lumbar vein, the
right gonadal vein, both renal veins, the right adrenal vein and
the inferior phrenic veins. The vena cava then traverses cepha-
lad, posterior to the liver parenchyma. In many cases, the liver
completely engulfs the vena cava, making retrohepatic expo-
sure more challenging. At or immediately below the diaphrag-
matic hiatus, the hepatic veins join the IVC, including multiple
small branches entering the lateral retrohepatic cava from the
liver. After traversing the diaphragm, the proximal IVC enters
the pericardium and drains into the right atrium.
For operative considerations, the IVC is divided into four
anatomic segments: the infrarenal IVC, the suprarenal IVC,
the retrohepatic IVC, and the suprahepatic IVC (Fig. 12-1).
Injuries to the infrarenal IVC have the best survival due to the
relative ease of access and tolerance to ligation, when neces-
sary. The suprarenal IVC remains relatively accessible but is
more intimately associated with structures such as the kidneys,
the pancreatic head, and the portal structures. Suprarenal liga-
tion is poorly tolerated.10 The retrohepatic IVC is approxi-
mately 7 cm long and is directly behind, or within, the liver
parenchyma. Injury to this subsegment almost invariably
includes damage to the liver parenchyma, allowing free bleed-
ing from the vein into the peritoneum via the injury tract
through the liver. Exposure is very difficult and survival is
poor.26 Finally, the suprahepatic IVC includes the course of the
vessel from the dome of the liver to the right atrium, including
the hepatic veins and the transition across the diaphragm.
Mortality from injuries in this region approaches 100% due
to difficulty gaining proximal and distal control in this
extremely high-flow region. Due to the large diameter of this
vessel and the difficulty of surgical access, in those rare cir-
cumstances when the injury is identified preoperatively, per-
cutaneous interventional techniques will likely provide better
salvage than open approaches.
Exposure and Mobilization
Access to the IVC is dependent on the portion that is injured.
Upon identification of a large retroperitoneal hematoma sus-
picious for caval injury regardless of which segment, the cava
is approached from the right. Specifically, the White Line of
Toldt is divided along its length; and the ascending colon,
hepatic flexure, and transverse colon are mobilized and
reflected cephalad and to the patient’s left side or midline. An
extensive Kocher maneuver is then performed, mobilizing
the duodenum and pancreatic head leftward as well, using
 12  /  Inferior Vena Cava, Portal, and Mesenteric Venous Systems 129
Suprahepatic
Retrohepatic
Suprarenal
Infrarenal
FIGURE 12-1  Inferior vena cava (IVC) anatomy with subsegments of
infrarenal, suprarenal, retrohepatic, and suprahepatic.
visualization of the left renal vein as the cue that mobilization
is adequate (Fig. 12-2). Often, these maneuvers will expose a
hematoma overlying the area of injury. In these cases, the
hematoma should not be explored until a cogent operative
plan is made. Although proximal and distal control of the IVC
is advisable in most cases, this is not always possible. Even in
instances where proximal and distal control can be achieved,
significant bleeding may still occur from lumbar veins and
other tributaries. Regardless of whether or not one has been
able to accomplish proximal and distal control of the vena
cava, if active hemorrhage is encountered, direct pressure on
the area of injury should be applied. Then control may be
achieved by starting proximal and distal to this region and
“marching” toward the defect. In this manner, the site of
injury may be localized without intermittent episodes of
profuse bleeding. A common mistake is not dissecting down
to the actual substance of the IVC and attempting to sew the
peritoneal tissues in an effort to achieve hemostasis. Division
of the overlying filmy tissues leads to identification of the
substance of the IVC and a superior repair.
Control of the retrohepatic and suprahepatic portions of
the IVC is particularly difficult to achieve given their friable
nature and their anatomic location.27 Retraction of the liver
upward will allow access to the most proximal portion of the
infrahepatic IVC.28 Complete mobilization of the liver by divi-
sion of the suspensory ligaments, including the right triangu-
lar, the coronary, and the falciform ligaments, will provide
some mobility to access the retrohepatic portion of the cava.
Attempts to mobilize the liver in this region, however, usually
result in increased bleeding from the retrohepatic wound, as
torque on the liver and IVC may increase the size of the lacera-
tion. Though lobar resection may seem appropriate, especially
in cases of damaged liver parenchyma, this maneuver is gener-
ally discouraged. Removal of the overlying liver also removes
the possibility of tamponade by the organ and adds disrupted
liver parenchyma to sources of ongoing hemorrhage. Approach
to the suprahepatic IVC will almost invariably require division
of the diaphragm for adequate exposure. Additionally, a ster-
notomy may be indicated for proximal control of injuries to
the suprahepatic IVC, as the infradiaphragmatic section of the
IVC is not amenable to easy clamping and repair.29 Extreme
care must be taken when working in this region to avoid dis-
lodging thrombus from the injury or to disrupt the thin-
walled hepatic veins from the cava. Percutaneous approaches
that involve use of compliant endovascular balloons for inflow
and outflow occlusion may be sought to address injuries to
this portion of the IVC.
Control of Hemorrhage
If massive hemorrhage is encountered on entering the
abdomen, immediate cross-clamping of the aorta is usually
required. The standard vascular principle of proximal and
distal control always applies, regardless of size and location of
the vessel injury. Initial manual compression of the IVC allows
visualization of the field of injury, in order to begin dissection.
The traditional teaching is to apply sponge sticks above and
below the wound for proximal and distal control.4,10 This tech-
nique can be problematic if not accomplished with great care,
as forceful application may widen the injury, may create an
iatrogenic injury, or may avulse a branch. Direct pressure on
the area of injury is generally better starting with one’s fingers,
which provides a gentler tactile application of pressure.
Although effective at controlling initial hemorrhage, this
maneuver obscures the operative field and does not allow for
use of that hand in exposing or repairing the injury. As such,
the subsequent steps involve using other atraumatic, blunt
instruments to maintain the control achieved with manual
pressure. These instruments are often sponge sticks, which can
then be replaced by lower-profile Kittner dissectors. In these
instances, either the sponge stick or the Kittner dissector can
be gently placed directly on or above and below the source of
venous bleeding for control. The objective in this setting is to
work back from the use of one’s fingers or hand to a visible
and workable operative space to allow clearer dissection, visu-
alization, and repair of the injury. The initial use of one’s hand,
the sponge stick, or the Kittner dissector avoids having to place
a larger metallic vascular clamp before the vena cava or the
edges of the injury have been clearly defined.
The importance of good lighting, well-set and wide retrac-
tion, and multiple suction devices cannot be overemphasized
in accomplishing these steps. In the case of linear injuries to
the major abdominal veins, the vein edges may be grasped
130 SECTION 3  /  DEFINITIVE MANAGEMENT
Liver
Gallbladder
IVC
Right kidney
with Judd-Allis clamps and closed either with a Satinsky
clamp or sutures (Fig. 12-3). A simple stitch placed at the
proximal and distal extent of the laceration, with accompany-
ing gentle upward traction, will also elevate and collapse the
laceration. This allows control of hemorrhage and exposure
for primary suture closure.30 Another consideration in repair
of the IVC and other large vein injuries is use of a larger non-
cutting needle (e.g., 4-0 polypropylene on an small half [SH]
needle) that can be visualized and directed in the presence of
considerable amounts of blood. Although well intended, too
small a needle often becomes submerged in blood and is not
able to be directed with intention; therefore it is prone to
extending the original injury. Another common misstep is not
dissecting down to the actual substance of the IVC wall and
attempting to blindly place a clamp or to sew the peritoneal
tissues in an attempt to achieve hemostasis. Division of the
overlying filmy tissues leads to identification of the substance
of the wall of the IVC and allows for control and suture repair
of the injury.
Hemorrhage control presents unique challenges in the case
of blunt retrohepatic and suprahepatic IVC injuries. The IVC
injury is usually combined with significant hepatic parenchy-
mal disruption. Hemorrhage results from both the disrupted
liver parenchyma and from the retroperitoneum. Visualiza-
tion and identification of the precise area of injury is particu-
larly difficult. In this circumstance, direct pressure consists of
compressing the liver parenchyma to reapproximate tissues
and directing pressure posteriorly until anesthesia is able to
catch up with blood loss. A Pringle maneuver should be uti-
lized if the liver parenchyma is contributing to the hemor-
rhage. Complete mobilization of the liver, including division
of the triangular and coronary ligaments and retroperitoneal
attachments, should be carefully weighed in the circumstance
of retrohepatic caval injuries. When hematoma is identified
behind the hepatic suspensory ligaments, division of the
Posterior duodenum
Small
intestine
Ascending
colon
FIGURE 12-2  Medial visceral rotation ex-
posing the inferior vena cava (IVC) in situ.
ligaments should be avoided. With the liver completely mobile,
existing tamponade is released and it will not be possible to
reestablish tamponade with a freely floating liver.31 Control by
direct pressure may be difficult and incomplete, and adjunc-
tive endovascular techniques may be beneficial. The use of a
compliant percutaneous endovascular occlusion balloon may
provide a superior option for control of hemorrhage. Inflation
of the balloons can provide a bloodless field, allowing time to
obtain traditional proximal and distal control with vessel
loops or even to allow immediate primary repair. If circum-
stances permit, occlusive balloons should be introduced and
positioned via percutaneous access before exposing the injury
to keep the site free for repair. The proximal and distal bal-
loons may be introduced via bilateral femoral vein sticks or
via a combined femoral and internal jugular approach.32 In
some cases, insertion through the site of injury may be more
expeditious. Endovascular grafts are also options for hemor-
rhage control in the patient with multiple injuries. In these
cases, an endovascular graft may be inserted to cover the
injury site and to allow control of the bleeding while other
injuries are addressed.
Total hepatic vascular exclusion may be employed to
control hemorrhage with profound bleeding from the perihe-
patic IVC or the liver parenchyma. This requires control of the
suprahepatic and infrahepatic IVC.21 Because there is little
room between the diaphragm and the liver to place a clamp
or vessel loop for suprahepatic control, this maneuver requires
either sternotomy or right thoracoabdominal incision with
division of the diaphragm. A Pringle maneuver completes the
isolation. In theory, bleeding should be controlled with total
hepatic exclusion. In actuality, these maneuvers only decrease
hemorrhage by approximately 40% to 60%.33 While these
maneuvers slow bleeding, repair needs to be expeditious.
Warm ischemia must be limited to 45 to 60 minutes.17,21 Inter-
mittent release of the Pringle clamp should be performed.
 12  /  Inferior Vena Cava, Portal, and Mesenteric Venous Systems 131
Allis clamp
IVC
A done with fine monofilament suture. Bites should be adequate
Liver
IVC
Left renal vein
B ligation is more successful when an abundant collateral circu-
FIGURE 12-3  A, Judd-Allis clamps approximating an inferior vena
cava (IVC) laceration. B, Intraluminal repair of a back wall, IVC
laceration.
Unfortunately, this results in resumption of bleeding. Broer-
ing et al have proposed changing the nature of the ischemia
to a cold-ischemia protocol. By infusing the liver with cold
preservation solution, ischemia time may be prolonged, allow-
ing better opportunity for repair.17 However, in these exceed-
ingly unstable, hypothermic patients such complex procedures
are rarely successful.
If hepatic isolation is inadequate to allow visualization and
repair, total abdominal vascular exclusion is required. In addi-
tion to occlusion of the IVC and the performance of a Pringle
maneuver, a supraceliac aortic clamp is placed to prevent all
inflow to abdominal and distal structures. The loss of venous
return in an already-hypotensive patient often leads to full
arrest.33,34 While mortality is very high, an occasional patient
in this extreme state will survive.
Considerations for Venous Repair
Following hemorrhage control and injury identification,
attention is directed to the details of vascular repair. As with
any elective procedure, standard principles of vascular surgery
are applied. These principles include adequate proximal and
distal control, not just to control bleeding but to provide
enough vessel length to work. Ligation and division of branch
vessels often provide mobilization and enhanced injury expo-
sure. Primary repair is the preferred method of management.
The vascular injury should be irrigated with heparinized
saline to remove clots and allow adequate inspection of the
vessel. If the edges of the injured site are jagged and their
viability compromised, débridement is required to ensure the
integrity of the suture line, but débridement should be judi-
cious in order to minimize narrowing and subsequent throm-
bosis. Closing longitudinal tears transversely will minimize
narrowing; that is not possible with long tears. Repairs are
to avoid the suture tearing through the tissue, but attention is
paid to avoidance of excessive tissue incorporation in order to
minimize narrowing. One should consider using a larger
needle with the fine monofilament suture to allow visualiza-
tion and direction in significant amounts of blood.
Application of the technique of primary repair for the
venous injury will depend on the location of the injury, the
extent of vein disrupted, and the associated injuries. When
primary repair is not possible, end-to-end anastomosis, patch
angioplasty, graft interposition, and ligation should be consid-
erations. The most important factor in the decision for repair
versus ligation is the patient’s physiologic status. Because all
options beyond primary repair take significant time to com-
plete, critically unstable patients who are cold, coagulopathic,
and acidotic are not candidates. In those instances, the choice
is usually limited to damage control measures with ligation.
Ligation
Ligation of the infrarenal IVC, iliac veins and left renal vein
are tolerated fairly well. Conversely, ligation of the portal vein
and the SMV are poorly tolerated; and ligation of the right
renal vein often results in loss of the kidney.16 As expected,
lation exists.
Caval ligation is well described in the literature. It is associ-
ated with a high mortality, primarily due to the instability of
those patients requiring a damage control approach. Experi-
ence in multiple wars of the 20th century resulted in ligation
standing as an accepted practice to address injuries to the
cava.7 Ligation remains a relatively common practice in
dealing with caval injuries in the modern era. Navsaria et al
practiced ligation in 63% of patients cared for in one series.30
Huerta et al ligated one third of 36 caval injuries for a survival
rate of 41.7%.10 Sullivan et al reviewed 100 IVC injuries col-
lected over a 13-year time period. Of patients with infrarenal
132 SECTION 3  /  DEFINITIVE MANAGEMENT

IVC injuries, 43% underwent ligation. As a group, patients

undergoing ligation had a 41% early mortality rate and a 59%
overall mortality rate. While patients in the repair group fared
better with an early and overall mortality rate of 21%, the
patients in the ligation group were significantly more ill.
Suprarenal caval ligation is even more poorly tolerated with a
high mortality rate, unless the patient happens to have existing
generous collaterals with the azygos and lumbar venous
systems.10,35 Ligation of the vena cava at or above the retrohe-
patic segment is uniformly fatal.
Hesitation to ligate the major abdominal veins stems not
only from mortality concerns but from the potential sequelae
of ligation. A major consideration following ligation of the
infrarenal IVC is swelling of the lower extremities, potentially
severe enough to cause acute compartment syndrome. Some
groups advocate for prophylactic fasciotomy in patients
undergoing ligation of the vena cava. In a recent publication
on the topic by Sullivan et al, prophylactic fasciotomy was
performed in three quarters of patients who underwent liga- Graft
tion of the IVC, as opposed to 4% of patients who underwent
IVC repair. Follow-up of nine patients with IVC ligation in Cannula
this series from Grady Memorial Hospital demonstrated that
none had more than trace residual lower extremity edema in
follow-up.7 Another series of 30 IVC ligations noted some
lower extremity edema but found no need to proceed to fas- IVC
ciotomy in any patient.30 Earlier studies by Lucas and Ledger-
wood of infrarenal IVC ligation further support the supposition
that, if the patient survives the initial insult, few long-term FIGURE 12-4  Spiral vein graft used for inferior vena cava (IVC) repair.
sequelae result from the ligation of this vessel.36 Therefore,
fasciotomy is not recommended as a routine prophylactic
measure following IVC ligation. Rather, as part of the patient’s true where segments of the vessel have been lost to traumatic
postoperative care, close monitoring of the compartments of mechanism or where débridement is required. If loss of length
the lower extremities should be routine. A low index of suspi- prevents an end-to-end anastomosis, interposition grafting is
cion should result in rapid fasciotomy should there be evi- a consideration.
dence of rising compartment pressures. The large caliber of the cava is such that standard saphe-
nous vein interposition will not provide adequate luminal size,
Reconstructive Techniques though saphenous vein may be used to construct a spiral vein
When hemodynamic and physiologic stability are ensured, graft (see Fig. 12-4). The internal jugular or external iliac veins
more complex repairs of the vena cava can be considered. are large-caliber donor options that may be used for caval
Though some narrowing may be expected and accepted fol- interposition. A significant amount of time is required for
lowing venorrhaphy, attempts to primarily close injuries that vessel acquisition and reconstruction with these techniques,
are greater than 50% circumference of the cava may result in and this must be considered when deciding whether the
excessive restriction of luminal size, subsequent thrombus for- patient is stable for such repair.
mation, and even complete thrombosis. The method of repair
largely depends on extent of venous injury. The combination The Portal Vein
of an anterior and posterior caval laceration is common. In Injury to the portal vein is uncommon, documented in one
the infrarenal portion of the cava, adequate mobilization may series at 0.1% of all traumatic injuries over 20 years.11 Morbid-
allow visualization of the posterior aspect of the vessel with ity and mortality associated with portal vein injury is high.
direct repair by gentle rotation of the vena cava. When pos- There is also a high frequency of major associated injuries,
sible, knots should be kept extraluminal to remove a nidus of especially in the region of the portal triad.3 In a multiinstitu-
thrombus formation. More proximally, rotation of the vessel tional review of 99 portal triad injuries, survival was only 20%
is usually not possible due to the tethering effect of the renal if more than one portal structure was damaged. Of patients
veins and the liver. In these situations, the anterior venotomy with portal triad injuries who died in the operating room,
can be extended to allow repair of the posterior rent from 85% had at least a portal vein injury.37
inside the vessel lumen (see Fig. 12-3). Knots will necessarily The portal vein is formed from the confluence of the
be intraluminal for the posterior repair. Transected vessels splenic vein and the SMV behind the neck of the pancreas
may be amenable to an end-to-end anastomosis, although it (Fig. 12-5). Contained within the hepatoduodenal ligament,
is rare that such a patient would be stable enough to tolerate the closely associated hepatic artery and bile ducts are fre-
more than ligation. End-to-end anastomosis is more difficult quently injured at the same time. The average diameter of
in the vena cava compared to an extremity vein. Due to the the portal vein is 2 cm. Despite a high flow rate, approaching
tethering of the visceral and lumbar tributaries, mobilization 1 L/min, pressures are low at approximately 10 mm Hg or
of the vena cava to increase length is difficult. This is especially less.3
 12  /  Inferior Vena Cava, Portal, and Mesenteric Venous Systems 133
Liver
Duodenum
Ascending
colon
FIGURE 12-5  Anatomy of the portal
vein in situ. IMV, Inferior mesenteric vein.
Exposure and Mobilization
The portal vein is best approached from the right. The ascend-
ing colon and hepatic flexure are reflected to the midline or
the patient’s left. A wide Kocher maneuver, with leftward
reflection of the duodenum and pancreatic head allows near
complete exposure of the portal vein and associated struc-
tures. The common bile duct may be isolated and retracted
leftward as well to provide additional access to the anterior
surface of the vein. Division of the pancreatic neck may be
necessary to access more distal portions of the portal vein. A
Pringle maneuver (an atraumatic clamp, vessel loop, umbilical
tape, or manual pressure is used to occlude the portal struc-
tures) is often needed to control hemorrhage while the portal
structures are being mobilized.11
Control of Hemorrhage
In the circumstance of massive hemorrhage, proximal control
will consist of supraceliac aortic control. This may be the only
way to reasonably control the inflow—both splenic flow from
the celiac axis and superior mesenteric flow. In less-dire cir-
cumstances, the Pringle maneuver is generally the most useful
method of controlling hemorrhage from suprapancreatic
portal vein injuries. However, this makes dissection and expo-
sure of the injury area quite difficult. Even in more limited
injuries, the occlusive tape or clamp prevents visualization of
the injury site. Indiscriminate clamping should be avoided to
prevent injury to delicate structures in the region.2,13,38 Local
Portal vein
Gastric vein
Splenic vein
Spleen
IMV
Pancreas
SMV
Descending
colon
proximal and distal control is obtained with the assistance of
direct compression while dissecting the vein free from the
hepatic artery and bile duct. Here again, working back from
the effective application of manual pressure with one’s fingers
or hand can be accomplished with gentle application of small
sponge sticks or lower-profile Kittner dissecting sponges.
Once the injury is visualized, it can be gently grasped with
Judd-Allis clamps and mobilized to allow suture closure or
passage of vascular tapes.
Repair of Portal Venous Injuries
Repair of the portal vein follows the general principles out-
lined for the vena cava. After the venous edges have been
débrided to healthy tissue, the surgeon must decide if a
primary repair is possible. Simple repairs should be performed
using 5-0 or 6-0 monofilament suture in an interrupted
fashion. If the portal vein has been divided, an end-to-end
anastomosis may be accomplished if there is minimal tension
between the two ends. Behind the pancreas, small medial
tributaries entering the portal vein may be ligated and divided
to achieve additional length. Additionally, if it has not already
been done to achieve control, partial division of the pancreas
and ligation of small medial tributaries may provide satisfac-
tory mobilization to make anastomosis possible. Reverse
saphenous vein interposition grafting is feasible, but few
patients are stable enough to permit this approach. In cases in
which repair is not feasible, the only alternative is ligation.
134 SECTION 3  /  DEFINITIVE MANAGEMENT
Portal Vein Ligation
As previously noted, patients with portal venous injuries
usually sustain massive blood loss, have multiple associated
injuries, and present in a state of extremis, which is not toler-
ant of prolonged repair. From a review of 18 patients present-
ing to the hospital with portal venous injuries between 1958
and 1980, survival was limited to 13% when ligation was used
as a last-ditch salvage option.11,39 However, when the portal
vein was ligated before cardiovascular collapse, survival
improved to 80%.39,40 Survival following portal vein ligation
is variably reported as 10% to 85%.3,37 Portal ligation is less
well tolerated than caval ligation. If portal vein ligation is
required, the anesthesia team must be made aware. Up to 50%
of the blood volume may be sequestered in the splanchnic
circulation.3 Ligation results in decreased venous return with
subsequent splanchnic hypertension but systemic hypoperfu-
sion. Aggressive fluid administration, both intraoperatively
and in the ICU, are required. Patients develop massive visceral
swelling due to the portal venous congestion.
The reported high mortality rates likely are partially related
to failure of appreciation of the tremendous fluid require-
ments. However, many reports of high mortality following
portal vein ligation were made before our appreciation of
abdominal compartment syndrome and the benefits of tem-
porary abdominal closure. Contemporary fluid and wound
management will likely improve outcomes with portal vein
ligation.
Delayed complications are common. Low mesenteric flow
combined with shock may lead to venous thrombosis, bowel
ischemia, and necrosis.15 The degree of bowel infarction may
vary from patchy necrosis to near total small bowel infarction.
Additionally, portal vein thrombosis and portal hypertension
may occur as sequelae in this setting. The complications of
Hepatic
proper a.
Portal v.
Bile duct
Duodenum
Right kidney
Pancreas
Ascending SMV
colon
SMA
IVC
IMA
FIGURE 12-6  Superior mesenteric vein in situ. a, Artery; IVC, inferior vena cava; SMA, superior mesenteric artery; SMV, superior mesenteric
vein; v, vein.
portal vein ligation are sobering but are unavoidable when
ligation is the only option to control hemorrhage and to
provide immediate patient survival.
The Superior Mesenteric Vein
The SMV is infrequently injured and is reported to account
for 0.1% of traumatic injuries.14 These injuries are most com-
monly produced by penetrating mechanisms. When injuries
result from blunt mechanisms, damage occurs due to shear
forces exerted on the mobile mesentery, resulting in avulsion
of the vessel. Due to its close association with the SMA, the
vessels are often injured in tandem. Found to the right of the
SMA, the vein provides outflow for the jejunum, the ileum,
the appendix, and the colon to the midtransverse segment.
Portions of the pancreas and duodenum are also dependent
on the SMV for outflow.
Due to the central location of the SMV, associated injuries
are common. In a study focusing on 51 patients with SMV
injuries, the average number of co-injuries was 3.5.15 As with
all the major abdominal veins, mortality is high with reported
rates varying between 50% and 71%, depending on the
number of associated vascular and solid organ injuries.1
Exposure and Mobilization
While relatively more accessible than the portal vein, the prox-
imal portions of the SMV may require division of the pancreas
for successful access. Anatomically intimate to the SMA and
the other major visceral and vascular structures, exposure is
further complicated when associated injuries are present in
the region.
The SMV is quite accessible in its distal portion compared
to the other major abdominal veins and is approached opera-
tively in the same manner as the SMA (Fig. 12-6). A direct
approach at the base of the mesentery may be appropriate if
Celiac
trunk
Splenic a.
Splenic v.
Spleen
Left kidney
IMV
Descending
colon
Aorta
 12  /  Inferior Vena Cava, Portal, and Mesenteric Venous Systems 135
injury occurs several centimeters below the inferior border of
the pancreas. Medial visceral rotation may be necessary to
access the root of the mesentery. If very proximal SMV control
is required, then exposure mirrors that used for the portal
vein. Colon mobilization and a Kocher maneuver are used to
provide access, and the body of the pancreas must be divided
to gain proximal control.2,15
Hemorrhage Control and Repair
Distal SMV injury may be controlled with manual occlusion.
Subsequent dissection will permit placement of tapes and
clamps for proximal and distal occlusion. A proximal SMV
injury will require pancreatic division to access, as noted
above. Hemorrhage is copious with proximal SMV injury, and
poor exposure can lead to visually impaired suture ligation,
resulting in compromised hemostasis and iatrogenic injury to
neighboring structures. Hemorrhage may be temporarily less-
ened by occlusion of the distal SMV and a Pringle maneuver,
though back-bleeding from the splenic vein may still compli-
cate the field to some extent. These maneuvers may be ade-
quate to slow hemorrhage and to allow adequate mobilization
of the proximal SMV. Primary repair of the SMV may be
accomplished with interrupted 5-0 or 6-0 monofilament
suture. In cases where significant tissue loss precludes primary
repair, a saphenous vein interposition graft may be required.
Ligation of the Superior Mesenteric Vein
Surgical literature suggests that patients with SMV ligation
fare better than those requiring portal vein ligation. Various
studies describe a 15% to 33% mortality for SMV ligation, as
opposed to a 36% to 43% mortality in the repair group.11,41
Asensio et al found no difference in mortality in 84 patients,
53 of whom underwent SMV ligation.42 Overall, these reports
indicate that patients requiring ligation of the SMV will likely
tolerate the procedure and may fare as well as those having
venous repair. The possibility of splanchnic hypertension and
late bowel ischemia exist with SMV ligation, as they do with
ligation of the portal vein. Those patients surviving SMV liga-
tion should undergo second look to evaluate viability of the
intestines before definitive abdominal closure. Whether it is
for the SMV, the portal vein, or the IVC, ligation should not
be left to a last-ditch option, by which time the patient has
crossed into irrecoverable shock. Judgment and composure
are required to recognize the need for ligation and to accom-
plish it quickly before loss of massive quantities of blood in
futile attempts at repair.
Temporary shunts should be considered for portal and
superior mesenteric venous injuries in a subset of unstable
patients whose injury anatomy is such that a shunt can be
inserted without causing further damage. The relative low
flow in the venous system in comparison to the arterial system
will result in a higher rate of thrombosis of those shunts.
However, this may provide additional options; and, if throm-
bosis occurs, the end result would be no different than with
ligation.
Alternative Management Options
Endovascular Techniques
The increasing experience with, and wide availability of, endo-
vascular techniques in elective vascular surgery provide excit-
ing opportunities for applications in the management of
vascular trauma. Except in cases of endovascular grafts for
aortic injuries, most published experience has come in the
form of case reports. However, the reports are increasing in
frequency and are thought provoking. The two main areas in
which endovascular techniques have been employed are
balloon occlusion control of hemorrhage and stent graft
repair of injuries.
While both interventional radiology and endovascular
surgery are widely available at most trauma centers, a number
of variables should be considered before a trauma surgeon
opts for this management strategy. First, practitioners who are
skilled in these techniques must be readily available. If not able
to respond shortly after patient presentation, the patient’s
hemodynamic status may preclude waiting for the specialist
to arrive. Secondly, a hybrid operative suite must be available
and must be able to accommodate the multiple demands of
the resuscitation, the operative exploration, and the fluoros-
copy needed for the endovascular approach. An extensive
inventory of guidewires, catheters, and grafts of various sizes
is required.43 Percutaneous options offer the greatest potential
for injuries to the IVC occurring in locations that are difficult
to access. The anatomy of the portal and superior mesenteric
veins preclude percutaneous access.
Occlusion Balloons
The use of occlusion balloons to control hemorrhage is one
of the most appealing applications of endovascular technol-
ogy. The balloon can be inserted via femoral vein access
following Seldinger technique of sheath insertion. A case
report by Bui and Mills in 2009 described using occlusive
endovascular balloons placed preoperatively to occlude an
IVC laceration, identified with CT, in order to stop ongoing
hemorrhage. Upon entry into the abdomen, identification of
the injury was rapid and blood loss was minimal, decreasing
operative time overall.4 A similar technique was reported
to control bleeding after an iatrogenic IVC injury during a
lumbar fusion.44
Balloon occlusion may be advantageous intraoperatively
when the vascular injury is not known preoperatively, as is
the case with penetrating trauma. Upon identification, the
injured vessel might be accessed at a site remote from the
injury or directly through the vessel laceration. As with stan-
dard proximal occlusion, there is immediate loss of vascular
return to the heart. The sequestration of blood volume may
lead to hypotension and, in some cases, to circulatory arrest.32
Large-bore vascular access in the upper extremities must be
secured.
Stent Grafts
Endovascular grafts provide an effective approach for manag-
ing retrohepatic and suprahepatic IVC injuries. Hommes et al
and Denton et al described using stent grafts in conjunction
with laparotomy to manage IVC injuries.45,46 Standard opera-
tive techniques to limit hemorrhage, including Pringle maneu-
ver and packing, were undertaken followed by stent deployment
in the retrohepatic cava to repair the injury. If the patient is
stable enough to undergo immediate endovascular access,
direct stent repair may be a superior option for retrohepatic
and suprahepatic IVC lacerations.44 Accommodations for
hepatic vein inflow by fenestrating the graft before placement
have been performed.47 However, the use of long-term antico-
agulation to prevent late graft stenosis is controversial.43,47
136 SECTION 3  /  DEFINITIVE MANAGEMENT
Right atrium
Chest tube
Damaged IVC
Rummel tourniquet
FIGURE 12-7  Atriocaval shunt. IVC, Inferior vena cava.
Venous Shunts
Atriocaval Shunt
First described by Schrock in 1968, this shunt functionally
bypasses the site of a retrohepatic caval injury. A large diam-
eter chest tube is introduced via a small incision in the right
atrial appendage. With the tube outflow protruding from the
right atrium and clamped, fenestrations in the tube are posi-
tioned in the intrapericardial IVC and below the site of injury,
usually the infrarenal cava (Fig. 12-7). Vessel loops or Rommel
tourniquets are used to secure the vessel around the tube.33,34,48
Unfortunately, survival following the atriocaval shunt is poor.
Burch, Feliciano, and Mattox had only 6 of 31 patients survive
with the shunt; all were gunshot wounds to the retroperitoneal
IVC.48 Advances in endovascular technology will likely make
atriocaval shunts obsolete.
Temporary Venous Shunts
The use of temporary prosthetic shunts in the management
of venous injuries has been limited. Recent military opera-
tions in Iraq and Afghanistan have again raised the profile of
temporary shunts used for damage control vascular surgery,
though the vast majority of this evidence is from extremity
injuries. A 2009 review of 64 extremity arterial injuries in
United States troops demonstrated 38% with concomitant
venous injuries. These authors note that several of the patients
in their study underwent venous shunting and subsequent
restoration of venous continuity.49 Though carotid shunts,
such as the Javid or Argyle shunt, are the most widely used for
arterial shunting, the larger luminal size of the major abdomi-
nal veins renders a small-caliber chest tube a better match. The
use of venous shunts for abdominal trauma may facilitate
damage control surgery via improved hemorrhage control and
by allowing time for patient resuscitation, operative planning,
or potential transfer to a higher level of care.
Most of the published data on long-term shunt patency
rates comes from the civilian trauma literature. In humans, a
temporary vascular shunt was employed in the SMA for 36
hours without shunt thrombosis.50 Another group utilized
temporary vascular shunts in two cohorts of trauma patients
with arterial injuries—those being shunted during orthopedic
stabilization and those requiring damage control surgery.
Patency was excellent in both groups, with 8 of 19 patients
(42%) requiring a shunt for 12 to 24 hours and with a longest
dwell time of 52 hours.51 None of these patients received sys-
temic anticoagulation. While the patency rates of temporary
arterial shunts are encouraging, reports of temporary venous
shunting remain largely limited to small series, and limited
objective data exists on patency rates in these cases. Rasmus-
sen et al note in a 2006 review that four venous injuries were
shunted in combat troops and all remained patent.52 Because
dwell times for shunts in theater are limited by transport
policy, however, it remains unclear how damage control
venous shunts would fare over longer time periods, in light of
lower flow rates and pressures. From a practical standpoint, if
hemorrhage is controlled but the patient’s physiologic status
mandates damage control surgery, a temporary prosthetic
shunt is a reasonable alternative to ligation. The shunt should
be secured with ligatures at both the proximal and the distal
ends to prevent dislodgment during transport and subsequent
ICU care. Definitive operative choices may then be made
during a second look, when the patient’s status accommodates
reconstruction. Venous shunts are an acceptable choice when
damage control is required, but surgeons must remain mindful
that patency times are not well defined.
The Use of Venovenous Bypass, Circulatory Arrest,
and Transplantation
The profound hemorrhage from major abdominal vein inju-
ries, combined with a young, otherwise-healthy trauma
patient, may place the trauma surgeon in the position of
attempting truly heroic measures. Definitely falling into the
camp of uncommon measures for hemorrhage control, both
venovenous bypass and circulatory arrest have intermittently
been described in case reports with marginal success. To enter-
tain these options, a trauma center must have personnel who
are experienced in placing patients on bypass and who are
experienced managing a pump, as well as cannula availabil-
ity.29 Cannula placement includes open approaches via the
right atrium or left pulmonary artery (beneficial in preventing
right heart overload and tricuspid regurgitation) or percuta-
neous placement in the femoral, subclavian, or internal jugular
veins.21,27 Once on bypass, repair in a fairly bloodless field may
commence. Following institution of bypass, intraoperative
blood loss is less; and renal function and 30-day survival are
improved with venovenous bypass, though these studies have
been done in liver transplant populations. Care must be taken
to avoid air embolism and to be wary of the hemodynamic
effects of large volume shifts associated with bypass circuits.29
Hypothermic circulatory arrest is appealing for the potential
tissue protective effects of profound hypothermia. However,
the requirement for a heparinized circuit in the polytrauma
patient may be prohibitive.
 12  /  Inferior Vena Cava, Portal, and Mesenteric Venous Systems 137
Box 12-1 Pitfalls and Points in Management
of IVC, Portal Vein and Mesenteric
Venous Systems
• Ligation of the infrarenal inferior vena cava (IVC) is well
tolerated and is the preferred management strategy for
patients in extremis.
• Suprahepatic IVC ligation, however, is uniformly lethal.
• Portal vein ligation is a reasonable bailout option when
catastrophic bleeding is present.
• Division of the head of the pancreas should not be delayed
when improved portal vein exposure is needed.
• Portal vein ligation will result in profound fluid requirements
during the postoperative phase of care.
• Ligation of either the IVC or portal vein requires second-look
laparotomy to ensure viability of bowel.
• Both the atriocaval shunt and resuscitative thoracotomy have
extremely poor outcomes and are to be avoided. Endovascular
options are increasingly preferred in these tenuous patients.
There are reports of liver explantation or transplantation
for severe IVC injuries, combined with profound hepatic dis-
ruption. Isolated reports of liver explantation with back-table
repair and autotransplantation exist, with poor survival. If
total hepatic isolation can be achieved, the liver is explanted
and repaired, bloodlessly, on a back table. Potentially, a second
team may address remaining vascular or other visceral injuries
in vivo. The transplant option is not feasible in any but the
most extraordinary of circumstances due to lack of ready
organ availability and associated patient injuries.53
Postoperative Care and
Complications
Of those surviving to a recovery phase in the ICU, there are a
few complications unique to major abdominal vein injuries
(Box 12-1). These include stenosis and/or thrombosis at the
venous repair sites. Lower extremity swelling, which is often
self-limited, occurs with IVC ligation. Splanchnic hyperten-
sion with portal and superior mesenteric venous narrowing
or occlusion may occur.27,30 Long-term outcomes from IVC
repair are generally favorable; however, concern remains
regarding the possibility of complications, primarily throm-
bosis and the potential for embolism. Though there are iso-
lated reports of sudden death from pulmonary embolism in
patients having undergone IVC ligation, the literature is scarce
regarding venous thromboembolism following repair. Postop-
erative screening with duplex ultrasonography is warranted to
monitor the cava following repair, especially in patients with
lower extremity edema or other symptoms. In symptomatic
or high-risk patients, consideration may be given to a caval
filter or extended anticoagulation.30 Finally, in some instances
of blunt caval injury, late development of thrombosis and
Budd-Chiari syndrome have been observed.20
Conclusion
Despite changes in prehospital care and patient transport,
open surgical and interventional repair, damage control
surgery, and ICU management, mortality from this triad of
highly lethal venous injuries has changed little over the last 3
decades.7,11,30 In comparison to large series compiled in the
1980s and 1990s, mortality has actually worsened. Rather than
representing a deterioration in technique or care, this likely
reflects maintenance and transport of evermore severely
injured patients to the hospital phase of management.7
Ongoing changes in resuscitation strategies, with a greater
emphasis on matched red blood cell to plasma ratios and
decreased crystalloid volumes, may prove especially beneficial
in low-pressure venous injuries. Each injury must be evaluated
on a case-by-case basis, as no single algorithm is adequate to
predict management in these cases. Adherence to excellent
vascular technique with rapid hemorrhage control and limited
operative times is the key to success. The use of temporary
vascular shunting and endovascular techniques provide tan-
talizing glimpses of the ever-evolving management options.
REFERENCES
1. Coimbra R, Filho AR, Nesser RA, et al: Outcome from traumatic injury
of the portal and superior mesenteric veins. Vasc Endovascular Surg
38(3):249–255, 2004.
2. Asensio JA, Forno W, Roldan G, et al: Visceral vascular injuries. Vasc
Trauma 82(1):1–20, 2002.
3. Pearl J, Chao A, Kennedy S, et al: Traumatic injuries to the portal vein:
case study. J Trauma 56(4):779–782, 2004.
4. Bui TD, Mills JL: Control of inferior vena cava injury using percutane-
ous balloon catheter occlusion. Vasc Endovascular Surg 43(5):490–493,
2009.
5. Duncan IA, Sher BJ, Fingleson LM: Blunt injury of the infrarenal inferior
vena cava—imaging and conservative management. S Afr J Surg 43(1):20–
21, 2005.
6. DeBakey ME, Simeone FA: Battle injuries of the arteries in World War II:
an analysis of 2,471 cases. Ann Surg 123(4):534–579, 1946.
7. Sullivan PS, Dente CJ, Patel S, et al: Outcome of ligation of the inferior
vena cava in the modern era. Am J Surg 199(4):500–506, 2010.
8. Feliciano DV, Bitondo CG, Mattox KL, et al: Civilian trauma in the 1980s.
A 1-year experience with 456 vascular and cardiac injuries. Ann Surg
199(6):717–724, 1984.
9. Mattox KL, Feliciano DV, Burch J, et al: 5,760 cardiovascular injuries in
4459 patients: epidemiologic evolution 1958 to 1987. Ann Surg 209(6):
698–707, 1989.
10. Huerta S, Bui TD, Nguyen TH, et al: Predictors of mortality and manage-
ment of patients with traumatic inferior vena cava injuries. Am Surg
72(4):290–296, 2006.
11. Fraga GP, Bansal V, Fortiage D, et al: A 20-year experience with portal and
superior mesenteric injuries: has anything changed? Eur J Vasc Endovasc
Surg 37:87–91, 2009.
12. Moore EE, Cogbill TH, Malangoni M, et al: Scaling systems for organ
specific injuries. Table 17, <http://www.aast.org/Library/TraumaTools/
InjuryScoringScales.aspx>.
13. Asensio JA, Petrone P, Garcia-Nunez L, et al: Superior venous mesenteric
injuries: to ligate or to repair remains the question. J Trauma 62(3):668–
675, 2007.
14. Petersen SR, Sheldon GF, Lim JRRC: Management of portal vein injuries.
J Trauma 19(8):616–620, 1979.
15. Asensio JA, Berne JD, Chahwan S, et al: Traumatic injury to the superior
mesenteric artery. Am J Surg 178:235–239, 1999.
16. Asensio JA, Chahwan S, Hanpeter D, et al: Operative management and
outcome of 302 abdominal vascular injuries. Am J Surg 180:528–534,
2000.
17. Broering DC, Al-Shurafa HA, Mueller L, et al: Total vascular isolation and
in situ cold perfusion for management of severe liver trauma. J Trauma
53(3):564–567, 2002.
18. Matsumoto S, Sekine K, Yamazaki M, et al: Predictive value of a flat
inferior vena cava on initial computed tomography for hemodynamic
deterioration in patients with blunt torso trauma. J Trauma 69(6):1398–
1402, 2010.
19. Spencer Netto FAC, Tien H, Hamilton P, et al: Diagnosis and outcome of
blunt caval injuries in the modern trauma center. J Trauma 61(5):1053–
1057, 2006.
20. Cole K, Shadis R, Sullivan TR, Jr: Retrohepatic hematoma causing caval
compression after blunt abdominal trauma. J Surg Educ 66(1):48–50,
2009.
138 SECTION 3  /  DEFINITIVE MANAGEMENT
21. Marino IR, di Francesco F, Doria C, et al: A new technique for successful
management of a complete suprahepatic caval transection. J Am Coll
Surg 206(1):190–194, 2008.
22. Graham M, Mattox KL, Beall AC, Jr, et al: Injuries to the visceral arteries.
Surgery 84(6):835–839, 1978.
23. Lucas AE, Richardson JD, Flint LM, et al: Traumatic injury of the proxi-
mal superior mesenteric artery. J Trauma 193(1):30–34, 1981.
24. Albert D, Sam AD, Frusha JD, et al: Fatal avulsion of inferior vena cava
following blunt abdominal trauma. Br J Hosp Med 71(6):352–353,
2010.
25. Posner MC, Moore EE, Greenholz SK, et al: Natural history of untreated
IVC injury and assessment of venous access. J Trauma 26:698–701,
1986.
26. Buckman RF, Jr, Miraliakbari R, Badellino MM: Juxtahepatic venous inju-
ries: a critical review of reported management strategies. J Trauma 48(5):
978–984, 2000.
27. Liao GP, Braslow B, Schwab CW, et al: Cavopulmonary bypass to facilitate
infrahepatic vena cava gunshot wound repair. Ann Thorac Surg 89:2026–
2028, 2010.
28. Feliciano DV: Abdominal vessels. In Ivatury RR, Cayten CG, editors: The
textbook of penetrating trauma, Baltimore, 1996, Williams & Wilkins,
pp 702–716.
29. Kaemmerer D, Daffner W, Niwa M, et al: Reconstruction of a total avul-
sion of the hepatic veins and the suprahepatic inferior vena cava second-
ary to blunt thoracoabdominal trauma. Langenbecks Arch Surg 396:
261–265, 2011.
30. Navsaria PH, de Bruyn P, Nicol AJ: Penetrating abdominal vena cava
injuries. Eur J Vasc Endovasc Surg 30(5):499–503, 2005.
31. Yilmaz TH, Ndofor BC, Smith MD, et al: A heuristic approach and heretic
view on the technical issues and pitfalls in the management of penetrating
abdominal injuries. Scand J Trauma Resusc Emerg Med 18(40):1–7, 2010.
32. Angeles AP, Agarwal N, Lynd C, Jr: Repair of a juxtahepatic inferior vena
cava injury using a simple endovascular technique. J Trauma 56(4):918–
921, 2004.
33. Clark JJ, Steinemann S, Lau JM: Use of an atriocaval shunt in a trauma
patient: first reported case in Hawai’i. Hawai’i Med J 69:47–48, 2010.
34. Rosenthal D, Wellons ED, Shuler FW, et al: Retrohepatic vena cava and
hepatic vein injuries: a simplified experimental methods of treatment by
balloon shunt. J Trauma 56(2):450–452, 2004.
35. Votanopoulos KI, Welsh FJ, Mattox KL: Suprarenal inferior vena cava
ligation: a rare survivor. J Trauma 67(6):E179–E180, 2009.
36. Mullins RJ, Lucas CE, Ledgerwood AM: The natural history following
venous ligation for civilian injuries. J Trauma 20(9):737–743, 1980.
37. Jurkovich GJ, Hoyt DB, Moore FA, et al: Portal triad injuries. J Trauma
39(3):426–434, 1995.
38. Emmiler M, Kocogullari CU, Yilmaz S, et al: Repair of the inferior vena
cava with autogenous peritoneo-fascial patch graft following abdominal
trauma: a case report. Vasc Endovascular Surg 42(3):272–275, 2008.
39. Stone HH, Fabian TC, Turkleson ML: Wounds of the portal venous
system. World J Surg 6(3):335–340, 1982.
40. English WP, Johnson MB, Borman KR, et al: Mesenteric ischemia: an
unusual presentation of traumatic intrahepatic arterioportal fistula. Am
Surg 67(9):865–867, 2001.
41. Donahue T, Strauch G: Ligation as definitive management of injury to
the superior mesenteric vein. J Trauma 28(4):541–543, 1988.
42. Asensio JA, Britt LD, Borzotta A, et al: Multiinstitutional experience with
the management of superior mesenteric artery injuries. J Am Coll Surg
193(4):354–365, 2001.
43. Sam IIAD, Frusha JD, McNeil JW, et al: Repair of blunt traumatic inferior
vena cava laceration with commercially available endografts. J Vasc Surg
43(4):841–843, 2006.
44. de Naeyer G, Degrieck I: Emergent infrahepatic vena cava stenting for
life-threatening perforation. J Vasc Surg 41(3):552–554, 2005.
45. Hommes M, Kazemier G, van Dijk L, et al: Complex liver trauma with
bilhemia treated with perihepatic packing and endovascular stent in the
vena cava. J Trauma 67(2):E51–E53, 2009.
46. Denton JD, Moore EE, Coldwell DM: Multimodality treatment for grade
V hepatic injuries: perihepatic packing, arterial embolization and venous
stenting. J Trauma 42(5):964–968, 1997.
47. Watarida S, Nishi T, Furukawa A, et al: Fenestrated stent graft for trau-
matic juxtahepatic inferior vena cava injury. J Endovasc Ther 9:134–137,
2002.
48. Burch JM, Feliciano DV, Mattox KL: The atriocaval shunt. Facts and
fiction. Ann Surg 207(5):555–568, 1988.
49. Gifford SM, Aidinian G, Clouse WD, et al: Effect of temporary shunting
on extremity vascular injury: an outcome analysis from the global war on
terror vascular injury initiative. J Vasc Surg 50(3):549–556, 2009.
50. Reilly PM, Rotondo MF, Carpenter JP, et al: Temporary vascular control
during damage control: intraluminal shunting for proximal superior
mesenteric artery injury. J Trauma 39(4):757–760, 1995.
51. Granchi T, Schmittling Z, Vasquez J, Jr, et al: Prolonged use of intralumi-
nal arterial shunts without systemic anticoagulation. Am J Surg 180:493–
497, 2000.
52. Rasmussen TE, Clouse WD, Jenkins DH, et al: The use of temporary
vascular shunts as a damage control adjunct in the management of
wartime vascular injury. J Trauma 61(1):8–15, 2006.
53. Boggi U, Vistoli F, Del Chiaro M, et al: Extracorporeal repair and liver
autotransplantation after total avulsion of hepatic veins and retrohepatic
inferior vena cava injury secondary to blunt abdominal trauma. J Trauma
60(2):405–406, 2006.
Neck and Thoracic Outlet
FRED A. WEAVER AND GABRIEL HERSCU
Introduction
Vascular trauma to the neck and thoracic outlet may result in
a catastrophic neurologic deficit or death if not recognized
and properly treated. The spectrum of vascular injuries ranges
from obvious life-threatening injuries that require immediate
treatment to subtle injuries that may appear innocuous on
initial examination and yet lead to a major neurologic event.
This wide variation in presentation and potentially devastat-
ing nature of certain neck and thoracic outlet vascular injuries
has led to a reappraisal of methods of diagnoses, imaging,
and surgical management. These refinements have prompted
changes in the management paradigm for both penetrating
and blunt neck- and thoracic-outlet vascular injuries.
The surgical management of carotid artery injuries dates
back to the 1500s. In 1552, Ambroise Paré authored the first
report of successful management of a carotid artery injury by
ligation.1 Both the common carotid artery and the jugular vein
were ligated. The patient survived but developed aphasia and
hemiplegia. Fleming later reported a successful outcome after
ligating an injured common carotid artery, and this became
the standard for surgical management until the Korean War.2
The Korean War marked the beginning of primary repair of
arterial injuries, and carotid repair was attempted with success.
Subsequently, these reconstructive techniques were applied to
civilian carotid artery injuries as well as to the subclavian and,
to a lesser extent, to the vertebral artery. More recently, endo-
vascular techniques have replaced operative repair for selected
injuries of the neck and thoracic outlet vessels.
Indications
Patients with either penetrating or blunt neck/thoracic outlet
vessel injury frequently have severe concomitant injuries as
well as nonvascular injuries remote from the site of injury.
Therefore, a careful application of ATLS protocol for stabiliza-
tion and treatment is crucial. Initial examination should
include a thorough neurologic examination, auscultation for
bruit, and palpation of the carotid and superficial temporal
pulses. Upper extremity pulses and blood pressure in both
arms should be evaluated, because pressure differentials or
decreased pulses may suggest an arch or thoracic outlet injury.
Patients with carotid injuries may exhibit a contralateral
neurologic deficit, aphasia, Horner’s syndrome, or evidence of
anterior neck soft tissue trauma. Vertebral artery injuries may
be associated with ataxia, dizziness, vomiting, facial and body
analgesia, or visual field deficit. Complaints of headache, neck,
13 
ear, face, or periorbital pain may indicate mural hemorrhage
or dissection.3 Because of the high association of blunt carotid
and vertebral injuries with closed head injury, many patients
have a decreased Glasgow Coma Scale (GCS) on arrival, which
can complicate the diagnostic process. Patients with blunt
carotid/vertebral injuries may also arrive at the emergency
department (ED) with minimal to no overt vascular findings
and yet develop a focal neurologic deficit 10 to 72 hours later.4
Penetrating subclavian artery injuries are particularly lethal.
Of the patients who survive to reach the hospital, over half are
hypotensive and require resuscitative thoracotomy.5-9 A pulse
may be present distally despite significant arterial injury due
to the robust collateral circulation of the shoulder. A brachial
plexus injury accompanies a subclavian arterial injury in a
third of patients and is a major cause of postoperative mor-
bidity.10,11 First rib fractures are frequently associated with a
blunt subclavian artery injury.
Physical examination is extremely important in the evalu-
ation of penetrating injuries. Multiple studies have confirmed
serial physical examination to be of value in the diagnosis of
carotid injuries requiring repair, particularly zone II injuries.
In addition, a negative physical examination decreases the
likelihood of significant carotid injury in zone I and III (Fig.
13-1) Available literature documents that the use of serial
physical examinations provides a sensitivity of greater than
95% for detecting penetrating injuries that require repair.11-19
Because most blunt carotid and vertebral injuries are clini-
cally occult, computed tomography angiography (CTA) or
catheter-based angiographic screening of patients at risk for
blunt vascular injuries of the neck is recommended.20 Patients
at risk for blunt carotid/vertebral injury include those with:
(a) head and neck trauma associated with severe neck hyper-
extension and rotation or hyperflexion; (b) a Lefort II or III
fracture; (c) a basilar skull fracture involving the carotid canal;
(d) a closed head injury consistent with diffuse axonal injury
presenting with GSC score <6; (e) a cervical vertebral body or
transverse foramen fracture, subluxation, or ligamentous
injury at any level or any fracture of C1-C3; (f) a seat-belt or
other clothesline-type injury with significant cervical pain,
swelling, or altered mental status.4
Most penetrating carotid injuries in neurologically intact
patients should be repaired. In patients with a neurologic
deficit, definitive repair should also be performed although
controversy has existed in the past over vascular repair in this
setting. In the 1970s, Cohen and Bradley raised the concern
that repair of a carotid injury in a patient with a neurologic
deficit may lead to intracranial hemorrhage.21 However, later
139
 13  /  Neck and Thoracic Outlet 139.e1

ABSTRACT
Vascular trauma to the neck and thoracic outlet may result
in a catastrophic neurologic deficit or death if not recog-
nized and properly treated. The spectrum of vascular inju-
ries ranges from obvious life-threatening injuries that
require immediate treatment to subtle injuries that may
appear innocuous on initial examination and yet lead to a
major neurologic event. This wide variation in presentation
and potentially devastating nature of certain neck and tho-
racic outlet vascular injuries has led to recent refinements
and changes in methods of diagnoses, imaging, and surgi-
cal management of this injury pattern.
Vascular injuries resulting from penetrating trauma to
the neck require efficient utilization of multiple imaging
modalities, comprehensive planning, and advanced opera-
tive skills. A detailed knowledge of vascular anatomy and
operative exposures along with keen surgical judgment is
crucial, especially in the unstable patient where immediate
surgical intervention is required. Blunt cerebrovascular
trauma may lead to a delayed, catastrophic neurologic
consequence in the setting of a seemingly innocuous exam.
Therefore a high level of suspicion for these injuries must
be maintained. Specific screening protocols along with
new therapeutic medical and surgical modalities for these
injuries have led to higher recognition and significant
improvement in a once-dismal prognosis.
As endovascular skills and technology continue to
improve, cerebrovascular injuries are increasingly managed
by these methods, relieving the patient of large incisions
and their accompanying operative morbidity. Knowledge
and experience with endovascular techniques have become
critical elements in the management of vascular trauma
and are being applied with increasing frequency for a
variety of neck and thoracic outlet vascular injuries.

Key Words:  carotid,

vertebral,
subclavian,
neurologic,
computed tomography angiography (CTA),
endovascular
140 SECTION 3  /  DEFINITIVE MANAGEMENT
III
II
I thrombotic therapy. Grade V injuries are frequently associ-
FIGURE 13-1  Carotid zones of the neck. Zone I extends from the
sternal notch to the cricoid cartilage. Zone II extends from the cricoid
cartilage to the angle of the mandible. Zone III extends from the angle
of the mandible to the base of the skull.
studies by a number of authors conclusively demonstrated
that regardless of the initial neurologic deficit, mortality and
final neurologic status was improved overall if carotid repair
was performed.22-25 Relative contraindications to repair include
surgically inaccessible lesions, a delay of more than 3 to 4
hours from establishment of coma, large areas of cerebral
infarct on admission MRI or CT studies and absence of ret-
rograde back-bleeding from the distal arterial segment after
operative exposure and open thrombectomy.26
Nonoperative management of neurologically intact patients
with specific penetrating injuries is occasionally warranted.
For patients with a carotid or vertebral artery occlusion and
normal neurologic exam, observation and anticoagulation
with heparin is an acceptable approach. Likewise, patients
diagnosed with a minimal arterial injury do not require repair.
Minimal injuries are defined as nonobstructive or adherent
intimal flaps and pseudoaneuryms less than 5 m in size. The
safety of observation in minimal penetrating arterial injuries
has been documented with data and follow-up extending to
10 years.27,28
The indications for repair of a blunt carotid artery injury
depend on the grade of injury on CTA or catheter-based angi-
ography as follows: grade I, intimal injury with less than 25%
luminal narrowing; grade II, dissection or hematoma with
>25% luminal narrowing; grade III, pseudoaneurysm; grade
IV, occlusion; and grade V, vessel transection. For patients
initially managed nonoperatively, a follow-up CTA or catheter-
based angiogram is recommended in 7 to 10 days because over
60% of injuries will change in grade or severity during this
time interval. This is particularly true for grade I and II blunt
injuries which often develop into grade III pseudoaneurysms.
Additionally imaging 3 to 6 months after the injury is war-
ranted in these cases to exclude the development of a pseu-
doaneurysm over time.
Fabian first demonstrated that anticoagulation improved
survival (p < 0.02) and neurologic outcome (p < 0.01) in
patients with blunt carotid injuries.29 Subsequent studies
have also documented a trend toward improved neurologic
outcome for asymptomatic patients undergoing antithrom-
botic therapy.30-32 Antithrombotic therapy for treatment of
cervical arterial injuries consists of either therapeutic antico-
agulation with heparin followed by Coumadin, or antiplatelet
therapy with aspirin or aspirin plus clopidogrel. A recent
Cochrane meta-analysis of antiplatelet therapy versus anti­
coagulation therapy for carotid dissection showed no signifi-
cant differences in stroke rate or hemorrhagic complications
between these two medical treatment regimens.33 However,
dual antiplatelet therapy may be preferred due to its safety and
cost profile.4
Current recommendations are that patients with grade I
and II blunt carotid injuries be treated with antithrombotic
therapy. Surgically accessible grade III injuries should be
repaired. Inaccessible grade III injuries, which are often the
scenario, should be managed by a covered stent or bare-metal
stent combined with coil placement within the aneurysm
(Fig. 13-2). Grade IV injuries should be treated with anti-
ated with nonvascular injuries and may require operative
intervention as a life-saving maneuver. These injuries should
be surgically repaired, if possible, but in most instances they
require ligation or embolization due to their location.4,34 In
patients with a blunt carotid injury for which endovascular
repair is being considered, repair should be delayed for at least
7 days because earlier intervention is associated with a higher
risk of stroke.35
The natural history of blunt vertebral artery injury dem-
onstrates that 90% of stenotic lesions will resolve and that
67% of occluded vessels will recanalize with antithrombotic
therapy only.36 Both anticoagulation with heparin followed by
Coumadin or antiplatelet therapy with aspirin or aspirin and
Plavix have been utilized. Both regimens appear to have
similar outcomes, and the optimal medical treatment for these
injuries is yet to be determined.37 Blunt vertebral artery inju-
ries tend to occur at junctions between fixed and mobile seg-
ments. The V2 segment is most commonly affected in adults
whereas the V3 and upper V2 segments are more commonly
affected in children (Fig. 13-3). Approximately one third of
patients have bilateral injuries.37 The need for operative inter-
vention or endovascular repair is rare for both blunt and
penetrating vertebral artery injuries.
Preoperative Preparation
The preoperative preparation of patients with a documented
neck and thoracic outlet vascular injury depends on the pres-
ence of active bleeding and the suspected location or zone of
injury. Patients who are actively bleeding or have an expand-
ing hematoma should go directly to the operating room (OR)
for exploration, vascular control, and repair. In these instances,
rapid establishment of an oral or nasotracheal airway is criti-
cal, especially for zone II penetrating injuries. Patients without
evidence of bleeding and in whom a suspicion of a vascular
injury exists require expeditious diagnostic imaging and, in
select circumstances, require formal catheter-based diagnostic

10.32*mm
FIGURE 13-2  A, Angiogram of right
internal carotid artery pseudoaneurysm
due to a shotgun blast to zones II and
51.69*mm
III. The arrow points to the pseudoan-
eurysm. B, Completion angiogram fol-
lowing endovascular treatment with a
bare-metal stent and coiling (arrow) of A B
the pseudoaneurysm.
V4
V3
V2
V1
FIGURE 13-3  Anatomic segments of the vertebral artery. V1 is from
the subclavian origin to the entry into the C6 transverse foramen. V2
is from the C6 transverse foramen to the exit from the bony canal at
the transverse process of C2. V3 is the extracranial segment between
the transverse process of C2 and the base of the skull. V4 is the intra-
cranial segment, terminating at its junction with the contralateral
vertebral artery.
angiography. This approach is especially applicable for patients
with zone I and III injuries in which access to the vessels in
question is difficult. Although traditional teaching was that
operative exploration of all penetrating zone II injuries is the
best approach, evidence now shows that, in the absence of
hemorrhage, initial CT imaging of this injury pattern is safe
and may reduce the number of negative explorations. Duplex
ultrasonography, if available in the ED, is particularly valuable
in providing a quick, accurate assessment of zone II neck and
13  /  Neck and Thoracic Outlet 141
thoracic outlet vasculature.38-40 Attention to and prioritization
of associated nonvascular injuries is essential. Patients with a
lateralizing neurologic deficit or altered mental status require
a head CT or MR scan before operative intervention.
In most institutions, CTA is employed as the definitive
diagnostic test. CTA findings, particularly for penetrating
injuries, have been shown to be quite accurate and may be
used as the basis for operative intervention.16,41,42 CTA is less
accurate for blunt carotid and vertebral injuries. Recently
published recommendations specify that a 16-slice or higher
CTA is required for assessment of a possible blunt vascular
injury.4,34 However, subsequent studies have documented a
sensitivity of 29% to 64% and 51% to 54% with 16-slice and
64-slice scanners, respectively.43-45 Most blunt trauma patients
receive a CT scan of some portion of their body, so adding a
CTA of the neck is easily accomplished. A low threshold for
the use of angiography should exist in patients at risk for
blunt vascular injury. Depending on the mechanism, location,
and type of injury, endovascular intervention at the time of
diagnostic angiography may be the appropriate and definitive
treatment.
Pitfalls and Danger Points
• CTA and catheter-based angiography: For stable patients
without evidence of hemorrhage, it is mandatory that
a CTA or a catheter-based angiogram be performed
before operative intervention in order to demonstrate the
extent and the zone of injury. This information guides
the surgical field and exposure required for proximal
control.
• Blunt carotid/vertebral injuries: Most of these injuries
are best managed by antithrombotic therapy with either
heparin followed by Coumadin or by antiplatelet therapy.
Dual antiplatelet therapy may be preferable due to a
better safety and cost profile.4 Failure to screen for these
injuries and failure to treat with antithrombotic therapy
increase the risk of neurologic deterioration and long-
term morbidity.
• Exit and entry wounds: Although an exit or entry
wound may be in a zone or segment of a neck/thoracic
142 SECTION 3  /  DEFINITIVE MANAGEMENT
outlet artery that is surgically accessible, the course and
trajectory of the penetrating object should be considered
when preparing the operative field. The surgeon must
anticipate the need for more proximal or distal exposure
depending on the trajectory and the course of the pen-
etrating object.
• Neurologic deficit: Careful neurologic examination of
patients with a suspected or known carotid/vertebral
injury is essential. Documentation of neurologic status
before any intervention is critical to anticipating and rec-
ognizing new neurologic changes postoperatively.
• Associated aerodigestive injuries: For neck arterial inju-
ries, aerodigestive tract violations must be anticipated
and investigated before arterial repair. If present, protec-
tion of the arterial repair by the interposition of muscle
between the arterial repair and aerodigestive tract injury
is mandatory.
• Brachial plexus injury: The brachial plexus is frequently
injured with thoracic outlet injuries. Consequently, a
careful preoperative neurologic examination of the
affected extremity is important to establish the degree
of neurologic compromise. This allows for detection of
new neurologic deficits postoperatively due to operative
trauma or due to the development of an upper extremity
compartment syndrome.
• Proximal vascular control: Essential to successful repair
and minimization of blood loss is proximal control of the
artery before exposure of the injury. This is particularly
important for proximal subclavian injuries and zone I
carotid injuries, where either a median sternotomy, a
proximal endovascular balloon occlusion or, in the case
of a left subclavian artery injury, a third–fourth inter-
space left thoracotomy may be required. The proximal
left subclavian artery cannot be controlled through a
median sternotomy.
• Venous injuries: Venous injuries are frequently associ-
ated with neck/thoracic outlet arterial injuries. In most
patients ligation is appropriate and contributes to mini-
mal morbidity. The more proximal the injury, the greater
the likelihood that the venous injury requires operative
repair. In the setting of bilateral internal jugular vein
injuries, repair of one is advisable to prevent intracranial
venous hypertension.
• Cranial and phrenic nerves: The anatomic relationship
of these nerves to the vasculature of the neck and tho-
racic outlet place them at risk during exposure and repair.
Identification and preservation are important to mini-
mize short- and long-term neurologic morbidity.
• Internal carotid repairs: Thrombosis of the internal
carotid artery due to either a blunt or penetrating injury
may extend intracranially. Gentle passage of a thrombec-
tomy catheter from the cervical carotid may be necessary
to evacuate distal internal carotid thrombus. In the
absence of back-bleeding, repair and reperfusion of the
distal internal carotid should not be performed. In
patients for whom back-bleeding is restored, intraopera-
tive angiography should be used to document complete
evacuation of all distal thrombus before repair and
reperfusion.
• Avoidance of hypotension and hypoxia: For patients
with a neurologic deficit secondary to cortical brain
injury, maintenance of normotension and avoidance of
hypoxemia are essential to preserve the ischemic penum-
bra surrounding the cortical injury. Failure intraopera-
tively and postoperatively to maintain normotension and
adequate oxygen saturation can extend the brain injury
with subsequent neurologic deterioration.
Operative Strategy and Technique
Carotid
In 1969, Monson divided the neck into three zones46 (Fig.
13-1). The zones of the neck were devised for guidance in
diagnosis and treatment of carotid artery trauma. Zone I
spans from the clavicle to the cricoid cartilage, zone II from
the cricoid cartilage to the angle of the mandible, and zone III
from the angle of the mandible to the skull base.47 The zone
II carotid artery travels within the carotid sheath, which con-
tains the vagus nerve and the jugular vein. The common
carotid artery divides into the internal and external carotid
within Zone II, in most instances one to two fingerbreadths
below the angle of the mandible. An awareness of carotid
bifurcation anatomy is important in preoperative planning,
particularly for those injuries at the junction of zones II and
III. It is also important to recognize that the zone classification
describes the entry or exit site of the wound only. The course
of a penetrating wound may traverse other zones of the neck
or the thorax or intracranially.
The operative field for repair of a carotid injury requires
surgical preparation of the neck and chest as well as a thigh
for saphenous vein harvest. Carotid injuries in zone I and zone
III are surgically challenging to access. For patients with a zone
I carotid injury, median sternotomy may be required for prox-
imal control. If the capability exists, endovascular techniques
such as proximal arterial balloon occlusion can be used to
establish rapid control of bleeding and to minimize the need
for sternotomy. As shown in Figure 13-4, if sternotomy is
required, longitudinal extension along the anterior border of
the ipsilateral sternocleidomastoid provides excellent expo-
sure of the cervical carotid. Opening of the carotid sheath and
retraction of the internal jugular vein laterally expose the
common carotid artery. Care should be taken to identify and
protect the vagus nerve within the carotid sheath.
For zone II injuries the facial vein, which typically is located
at the carotid bifurcation, should be ligated and divided allow-
ing for lateral retraction of the internal jugular vein and expo-
sure of the cervical carotid artery. Cephalad dissection along
the medial edge of the internal jugular vein exposes the proxi-
mal internal carotid artery. Dissection along the lateral border
of the internal carotid artery exposes the hypoglossal nerve,
which courses transversely across the superficial surface of the
internal and external carotid arteries. Identification of this
important nerve is facilitated by following the ansa hypoglossi
nerve to its junction with the hypoglossal trunk.
More distal exposure of the internal carotid artery at the
junction of zones II and III may require division of the occipi-
tal artery and mobilization of the posterior belly of the digas-
tric muscle by release of its posterior fascial investment. Care
should be taken to identify and preserve the glossopharyngeal
and spinal accessory nerves, which typically lie behind the
muscle fibers of the posterior belly of the digastric muscle and
are at risk during zone III exposure. Anterior displacement of
the mandible with fixation by intraoral wires may provide

additional exposure but requires preoperative planning as well
as establishment of a nasotracheal airway. This maneuver
expands the base of the operative field from a narrow- to
wider-based triangle, allowing 1 cm to 2 cm of additional
exposure along the internal carotid artery.48 Alternative tech-
niques such as mandibular subluxation and osteotomy impart
A
B enous repair with a vein graft is recommended, particularly in
FIGURE 13-4  A, Operative photograph of a left zone I common
carotid artery repair performed with a reversed greater saphenous vein
interposition graft. B, Note the position of the left common carotid
origin posterior to the innominate artery on the aortic arch. In this
approach, which was through a median sternotomy extended proxi-
mally in continuity with a left longitudinal cervical incision, the left
subclavian artery origin is not visible.
A B
FIGURE 13-5  Illustration of external carotid–internal carotid transposition. A, Proximal ICA injury is depicted in. B, Transposition is accomplished
by proximal mobilization of ECA with transposition and end-to-end anastomosis of the proximal ECA and ICA distal to the injury.
13  /  Neck and Thoracic Outlet 143
little additional advantage and are associated with greater
morbidity. A preoperative cervical and cerebral angiogram is
essential to successful operative treatment of zone III neck
injuries.
Arterial repair involves securing proximal and distal
control, followed by exposure of the injured segment. A 2 or
3 French Fogarty™ balloon thrombectomy catheter should be
passed gently both proximally and distally to remove throm-
bus. It is important to use an appropriately small thrombec-
tomy catheter and to not overinflate the balloon in the internal
carotid artery in order to avoid arterial spasm, thrombosis or
perforation. Both proximal and distal arterial lumens should
be flushed with heparinized saline solution (1000 units
heparin/1 L saline); and systemic heparin, if not contraindi-
cated, should be administered to decrease the risk of throm-
bosis and clot propagation. Intraluminal temporary vascular
shunts such as the Sundt or Argyl rapidly reestablish prograde
arterial flow and should be used for zone II internal carotid
artery or carotid bifurcation injuries. Proximal common
carotid injuries can be repaired without the use of a shunt in
most instances.
The type of repair is dictated by the extent of injury.
Primary repair or patch angioplasty is possible if the injury is
a simple, small laceration as might occur with a stab wound.
For more extensive injuries, it is important to identify and
débride the injured arterial segment back to normal artery.
Repair of more extensive injuries will require either an end-
to-end anastomosis, an interposition graft or, when adjacent
soft injury is extensive, a bypass graft. If necessary, an autog-
the presence of aerodigestive tract injuries. However, pros-
thetic grafts can be utilized if needed, especially for common
carotid injuries. For proximal internal carotid injuries, trans-
position of the external carotid to internal carotid provides
another option when autogenous conduit is not available (Fig.
13-5). Zone III internal carotid artery injuries may extend to
the skull base, thereby precluding direct operative repair. In
this situation, depending on the type of injury, nonoperative
management or an endovascular approach may be the better
option. In selected circumstances, ligation may be necessary;
but this is associated with a high incidence of stroke.49 All
144 SECTION 3  /  DEFINITIVE MANAGEMENT
completed repairs should be tension free and covered by viable
soft tissue. Intraoperative completion arteriography or duplex
scanning is mandatory to document technical perfection of
the vascular repair and patency of distal arterial segments.50
Figure 13-2 depicts a successful endovascular treatment of an
internal carotid artery pseudoaneurysm caused by a gunshot
wound to zones II and III of the neck.
Endovascular management permits repair of injuries that
are difficult or impossible to surgically expose (distal zone III)
or lesions that would require extensive operative exposure
(proximal zone I). Initially used for treatment of small arte-
riovenous fistulas and short-segment dissections, covered and
uncovered stents are being used for more significant injuries
as the technology improves and as experience is accrued.
Endovascular treatment of carotid injuries should be consid-
ered, especially in high-risk patients with multiple concomi-
tant injuries. Vascular access can be achieved with a femoral
approach and with the use of long (>70 cm) sheaths or guide
catheters. An array of small- to medium-sized covered and
uncovered stents are now commercially available to manage
proximal and distal injuries. As more ORs are transformed
into high-resolution fluoroscopic units and surgeons become
more adept in endovascular treatment modalities, the endo-
vascular management of traumatic carotid injuries is certain
to expand.
For zone III injuries not amenable to open or endovascular
repair, proximal ICA ligation and extracranial–intracranial
bypass can be considered. The outcome of carotid ligation
alone for selected zone III injuries can be predicted based on
preligation provocative temporary balloon occlusion testing.
In patients who remain neurologically intact, ligation alone is
acceptable with extracranial–intracranial bypass reserved for
those who develop a deficit.
Vertebral
The vertebral artery arises as the first branch of the subclavian
artery, usually at the C6-C7 level. In up to 6% of individuals,
the left vertebral artery arises directly from the arch of the
aorta between the origins of the left common carotid and left
subclavian arteries.51 The vertebral artery is divided into four
anatomic segments (Fig. 13-3). V1 spans from the origin until
entry into the C6 transverse foramen. The V2 segment extends
from entry into the C6 transverse foramen until exit from the
transverse process of C2. V3 is the extracranial segment
between the transverse process of C2 and the base of the
skull. V4 describes the intracranial segment, beginning at
the entrance to the foramen magnum and terminating at the
junction with the contralateral vertebral artery, by which the
basilar artery is formed. The redundancy of the vertebral cir-
culation is unique and permits the ligation of an injured,
nondominant vertebral artery if necessary.52,53 Unilateral
hypoplasia of the vertebral artery occurs in approximately
10% of individuals and can be identified on preoperative CT
or catheter-based angiography.37
Management of a vertebral artery injury depends on which
anatomic segment is injured and on the condition of the con-
tralateral vertebral artery. Vertebral arteries are more difficult
to surgically access than the carotid artery, making direct sur-
gical repair challenging. Consequently, for most penetrating
or blunt injuries, regardless of the segment injured, ligation,
embolization or nonoperative management is appropriate.
When considering a nonoperative or ablative approach to an
injured vertebral artery, it is important to determine, if pos-
sible, which of the vertebral arteries is larger or dominant. If
it is determined that the injured artery is the dominant verte-
bral artery, a greater need to attempt a repair (e.g., endovas-
cular stent or open revascularization) is indicated. In selected
circumstances, depending on the quality of imaging and the
location of the injury, it may not be possible to determine
which vertebral artery is dominant or to attempt or complete
a repair on the dominant vertebral artery injury. In such cases
ligation or embolization of the artery, thus accepting a higher
risk of posterior circulation stroke, is acceptable. Stents or
embolization using coils, detachable balloons, liquid tissue
adhesives, and other hemostatic agents have been used for
pseudoaneurysms and selected arteriovenous fistulas. Most
vertebral artery occlusions require antithrombotic therapy.
Indications for operative management of a vertebral artery
injury include patients with active hemorrhage and those who
have failed endovascular management.
For the rare blunt or penetrating injury requiring open
surgical repair, exposure of the V1 segment of the vertebral
artery is via a medial transverse supraclavicular incision over
the two heads of the sternocleidomastoid. Dividing the heads
or splitting the two heads longitudinally exposes the carotid
sheath. Opening the sheath, retracting the carotid medially,
retracting the vagus nerve and internal jugular vein laterally,
and dividing the vertebral vein directly posterior allows direct
access to the vertebral artery and proximal subclavian artery.
Exposure of the V2-V5 segment of the vertebral artery is
rarely necessary and is extremely challenging. The V2 segment
requires exposure through the bony transverse foramina.
Through the same exposure discussed for the V1 segment, the
longus coli muscle is encountered in the deep posterior aspect
of the neck. Once this muscle is swept off of the underlying
bony structure, the anterior tubercle of the transverse process
and the vertebral bodies are visualized. A bone rongeur is used
to remove the anterior rim of the vertebral foramen to expose
the vertebral artery. Moderate to severe bleeding may occur
during this part of the dissection due to the venous plexus of
the bony canal. Care should be taken not to injure the cervical
nerve roots, which lie directly posterior to the artery. A poste-
rior auricular approach is required to expose the V3 segment
of the artery, and the V4 segment can only be exposed with a
craniotomy. Exposure of V3 and V4 segments is best done
with the assistance of a neurosurgeon.
Subclavian
The left subclavian artery arises as the third and final great
vessel from the aortic arch. The right subclavian artery arises
from the innominate artery. The subclavian artery extends
from its origin to the lateral border of the first rib. It is divided
into three segments based on the relationship of the anterior
scalene muscle (Fig. 13-6). The first portion, medial to the
anterior scalene muscle contains the most important branches,
including the vertebral artery, the internal mammary artery,
and the thyrocervical trunk. The second segment lays poste-
rior to the anterior scalene, and the short third segment
extends from the lateral border of the anterior scalene muscle
to the lateral edge of the first rib, where it becomes continuous
with the axillary artery. The phrenic nerve lies either directly
on or medial to the anterior scalene muscle and can be injured
during exposure of the first and second segments of the artery.
The artery anatomically is posterior to the subclavian vein, the

Anterior scalene
muscle
Vertebral artery
III II I
FIGURE 13-6  Anatomic segments of the subclavian artery. Segment
I extends from the subclavian origin to medial border of the anterior
scalene muscle. Segment II is posterior to the anterior scalene muscle.
Segment III extends from the lateral edge of the anterior scalene
muscle to the lateral edge of the first rib.
vertebral vein, the anterior scalene muscle and the thoracic
duct on the left.52
Penetrating subclavian injuries are commonly associated
with hemodynamic instability which requires immediate
treatment. For injuries that are actively bleeding, temporizing
measures including resuscitative thoracotomy in the ED may
be necessary. Rapid control has also been achieved by inserting
a Foley catheter in the wound tract and inflating the balloon.6
Stable patients require catheter-based angiography or CTA for
further delineation of the penetrating wound and of the extent
of vessel injury.
The injured anatomic segment of the subclavian artery
dictates the exposure required. For all operative repairs of
subclavian injuries, the neck and chest should be included in
the operative field. For injuries of the first segment, median
sternotomy is necessary for proximal control of the right sub-
clavian artery. The sternotomy incision may be combined with
a supraclavicular extension to allow for full exposure of the
right subclavian artery. On the left side, proximal control
requires a third or fourth space anterolateral thoracotomy due
the left subclavian’s origin from the more-posterior distal
arch. Following proximal control, a supraclavicular incision
can be made for exposure; and, if necessary, the two incisions
may be connected by an upper-median sternotomy, creating
a “trapdoor” or “book” thoracotomy. If the capability is
present, proximal control of either subclavian artery can also
be achieved by endovascular balloon occlusion at the time of
diagnostic angiography or operation.
If the vessel injury is localized to the second or third seg-
ments of the subclavian artery on the left or right, a supracla-
vicular incision may be all that is needed to access and repair
the injury. Injuries associated with significant cervical or
supraclavicular swelling, mediastinal widening, or intratho-
racic bleeding may need intrathoracic proximal control. Distal
control may be obtained bilaterally by exposure of the axillary
artery through an infraclavicular incision. Resection of the
medial half of the clavicle or division and retraction of the
medial half of the clavicle, although rarely necessary, may
provide additional exposure and confers minimal morbidity.6
13  /  Neck and Thoracic Outlet 145
Open surgical treatment of subclavian artery injuries
includes débridement of vessel edges and primary repair if
possible. Otherwise, interposition grafts of vein or prosthetic
are acceptable. When extensive repair is required, ligation can
be considered because the robust collateral network of the
shoulder and supraclavicular fossa can usually provide enough
upper extremity perfusion to maintain a viable arm and hand.
Concomitant venous injuries are common; and lateral repair,
when possible, may be performed. More-complex repairs are
not necessary because subclavian vein ligation is usually well
tolerated, although it can be associated with minimal to mod-
erate arm swelling. More proximal venous injuries involving
the brachiocephalic veins or the superior vena cava should be
repaired whenever possible.
Endovascular repair of subclavian artery injuries has
been performed in the stable patient with success rates over
93%.54-57 Endovascular therapy can be utilized as definitive
treatment or as a means to stabilize the patient and to provide
a bridge to definitive therapy. It is estimated that approxi-
mately 50% of penetrating subclavian artery injuries are ame-
nable to endovascular treatment.55,58,59 The procedure is
performed in conjunction with a diagnostic arteriogram via
femoral access and long sheaths or guide catheters. Alterna-
tively ipsilateral brachial artery access can be used or may be
necessary to facilitate the wire, and stent crossing of selected
subclavian artery injuries. Once the guidewire traverses the
injured segment, a covered stent can be delivered and deployed.
If coverage of the vertebral artery is necessary, a patent normal
or dominant contralateral vertebral artery should be docu-
mented by catheter-based angiography or CTA. Successful
endovascular treatment of subclavian artery occlusions and
transections has been reported.60
Postoperative Care, Complications,
and Outcomes
Patients who undergo operative or endovascular repair should
be monitored postoperatively in the intensive care unit (ICU)
for vascular or neurologic changes. Cerebral edema and on
rare occasions hemorrhagic conversion of an infarct may be
preceded by headache and a deterioration in neurologic
status.61 Cerebral injury and swelling may be associated with
bradycardia and hypertension. Continuous drip medications
such as intravenous calcium channel blockers may be used to
normalize blood pressure in patients who are hypertensive.
With injury to extracranial cerebral vessels with or without
clinical neurologic change, the injured brain may be acutely
sensitive to loss of perfusion. Strict maintenance of a normal
mean arterial pressure (80 mm Hg to 100 mm Hg) and sub-
sequent cerebral perfusion pressure and avoidance of hypox-
emia are crucial to limiting extension of neurologic damage
in the ischemic penumbra.62
For vascular injuries in the cervical region, postoperative
coagulopathy and soft tissue swelling may lead to airway com-
promise. To protect the airway, endotracheal intubation should
be maintained until the hematoma and edema have subsided.
For zone I carotid and proximal subclavian injuries, monitor-
ing of chest tube or drain output and daily chest x-rays are
required to promptly detect ongoing bleeding. Chest CT may
also be helpful in identifying patients who are bleeding. Clear
clinical signs of bleeding, refractory hypotension and falling
146 SECTION 3  /  DEFINITIVE MANAGEMENT
hemoglobin, should prompt a return to the OR for definitive
control.
Patients who have undergone axillary or subclavian artery
repairs run the risk of upper extremity reperfusion injury and
subsequent compartment syndrome. Although this phenom-
enon is much less common in the upper than in the lower
extremity, patients should be monitored closely in the post-
operative period for increased forearm or hand pain or for the
development of neurologic deficits in the forearm or hand. In
such patients, evaluation of compartment pressures and/or
performance of a forearm fasciotomy is indicated.
In injuries or repairs involving the thoracic outlet on the
left, injury to the thoracic duct may occur. A drain should be
left in place in the event that a thoracic duct injury has
occurred. If drainage is persistent, evaluation for a duct injury
should be performed by examining the drainage fluid for
elevated triglycerides and the presence of chylomicrons.63
In the absence of contraindications, postoperative anti-
thrombotic therapy should consist of aspirin following the
use of vein or prosthetic for arterial reconstruction and
should be continued for a minimum of 30 days. Patients
undergoing stent placement should be placed on dual anti-
platelet therapy for a minimum of 30 days and up to 6 months
after intervention. This has been recommended in patients
undergoing stenting for atherosclerotic carotid disease64 and
has been confirmed to be of benefit in the trauma literature
as well.65-67 Repeat imaging using CTA or duplex ultrasound
of the stent is recommended during follow-up to evaluate for
restenosis.64
The development of a postoperative lateralizing neurologic
deficit after carotid reconstruction is an ominous develop-
ment. In most patients, this is due to either progressive cere-
bral edema or occlusion of the arterial repair. Cerebral edema
should be managed by measures to limit brain swelling and,
on occasion, craniectomy. If an occluded arterial repair is
documented, the decision for carotid exploration and repair
depends on the degree of neurologic deficit, the head CT scan
findings, and the hemodynamic stability of the patient. For
stable patients with minimal to no evidence of cerebral injury
on brain CT, a rapid return to the OR for thrombectomy and
repair is indicated. As was the case with the primary repair,
gentle passage of a thrombectomy catheter distally with the
reestablishment of back-bleeding from the internal carotid is
required before proceeding with formal repair and reperfu-
sion. Intraoperative angiography to document complete evac-
uation of distal internal carotid thrombus is also advisable.
For patients with a large cerebral injury shown on the head
CT, nonoperative management is probably indicated; and the
prognosis is poor.
Penetrating carotid artery trauma is associated with high
mortality and morbidity with all-cause mortality occurring in
greater than 60%.68 Most studies quote a mortality rate due to
the carotid injury of approximately 20%, although it has been
reported to be as high as 42%.69 Worse outcomes are associ-
ated with hypotension or coma on arrival at the ED. As would
be expected, penetrating internal carotid artery injuries have
a higher stroke rate than penetrating common carotid inju-
ries.70 Operative management of patients with a neurologic
deficit leads to stabilization or improvement in the neurologic
deficit in up to 92%.25 Worse operative outcomes are associ-
ated with a gunshot wound versus a stab wound and with
more complex operative repairs. Penetrating isolated vertebral
artery injuries are associated with minimal neurologic
morbidity.
Endovascular therapy has been focused on the manage-
ment of carotid and vertebral pseudoaneurysms that are sur-
gically inaccessible. A report concerning stent placement for
carotid artery pseudoaneurysms following penetrating injury
documented no strokes or occlusions at a mean follow-up of
2.5 years.71 A recent study incorporated endovascular therapy
into the treatment of grades II, III, and V blunt carotid and
vertebral injuries. This study reported a postmanagement
stroke rate of 4% and a mortality rate of 11%.65 Another
simultaneous study reported 13 patients with traumatic pseu-
doaneurysms treated by a covered stent with a 93% success
rate and no postprocedure strokes or stent occlusions at a
mean follow-up of 20 months.66 Herrera reported 94% injury
resolution and 97% clinical improvement in 36 patients with
extracranial carotid artery injuries treated by endovascular
intervention.50
The value of aggressive screening and treatment for clini-
cally occult blunt carotid and vertebral artery injuries can-
not be overemphasized. Blunt carotid and vertebral injuries
recognized and treated with antithrombotic therapy and
selective endovascular intervention have a decreased neuro-
logic event rate. In a retrospective review of 147 patients
with blunt carotid and vertebral artery injuries, the stroke
rate was 25.8% for untreated patients versus 3.9% for those
receiving any mode of therapy.72 Blunt carotid artery injuries
tend to have an increasing stroke rate with increasing grade.
However, blunt vertebral artery injuries have a more consis-
tent stroke rate of approximately 20% for all grades of
injury.3
A 2005 review of the National Trauma Data Bank docu-
mented that blunt carotid artery trauma leads to more severe
functional disability at discharge than penetrating carotid
trauma.73 Seventy-eight percent of penetrating carotid artery
injury patients were fully independent at discharge versus 37%
of blunt carotid artery injury patients. The main cause of dis-
ability was concomitant stroke and other associated nonvas-
cular injuries.
Open repair of a subclavian artery injury is often per-
formed in an unstable patient with life-threatening concomi-
tant injuries. For those patients who reach the hospital, the
mortality is approximately 34%, and those that survive to
reach the OR have a mortality of approximately 15%.11 Open
repair is associated with early failure rates of approximately
5%.55
Endovascular management of a subclavian arterial injury
avoids the morbidity of extensive open exposures; but
long-term durability, infection, and the possibility of stent
fracture are a concern. The overall incidence of reported
complications following endovascular subclavian artery
repair is 12% and includes arm claudication, stent thrombo-
sis, and stent fracture.74 However, in most reports, these com-
plications have been successfully managed by additional
endovascular techniques. A study of 27 patients who had
subclavian and axillary artery injuries and who were selec-
tively treated with open or endovascular techniques demon-
strated endovascular repair to be associated with significantly
shorter operative time and blood loss, with similar 1-year
patency.58 These results suggest that an endovascular approach
is preferred in stable patients, particularly those with subcla-
vian pseudoaneurysms.

REFERENCES
1. Watson WL, Silverstone SM: Ligature of the common carotid artery in
cancer of the head and neck. Ann Surg 109(1):1–27, 1939.
2. Fleming D: Case of rupture of the carotid artery and wounds of several
of its branches, successfully treated by tying the common trunk of the
carotid itself. Med Chir J Rev 3(2):1817.
3. Burlew CC, Biffl WL: Blunt cerebrovascular trauma. Curr Opin Crit Care
2010.
4. Biffl WL, Cothren CC, Moore EE, et al: Western Trauma Association
critical decisions in trauma: screening for and treatment of blunt cere-
brovascular injuries. J Trauma 67(6):1150–1153, 2009.
5. Sobnach S, Nicol AJ, Nathire H, et al: An analysis of 50 surgically managed
penetrating subclavian artery injuries. Eur J Vasc Endovasc Surg 39(2):
155–159, 2009.
6. Demetriades D, Chahwan S, Gomez H, et al: Penetrating injuries to the
subclavian and axillary vessels. J Am Coll Surg 188(3):290–295, 1999.
7. Bricker DL, Noon GP, Beall AC, Jr, et al: Vascular injuries of the thoracic
outlet. J Trauma 10(1):1–15, 1970.
8. Lin PH, Koffron AJ, Guske PJ, et al: Penetrating injuries of the subclavian
artery. Am J Surg 185(6):580–584, 2003.
9. Graham JM, Feliciano DV, Mattox KL, et al: Management of subclavian
vascular injuries. J Trauma 20(7):537–544, 1980.
10. Hyre CE, Cikrit DF, Lalka SG, et al: Aggressive management of vascular
injuries of the thoracic outlet. J Vasc Surg 27(5):880–884, discussion
884–885, 1998.
11. Demetriades D, Asensio JA: Subclavian and axillary vascular injuries. Surg
Clin North Am 81(6):1357–1373, xiii, 2001.
12. Sekharan J, Dennis JW, Veldenz HC, et al: Continued experience with
physical examination alone for evaluation and management of penetrat-
ing zone 2 neck injuries: results of 145 cases. J Vasc Surg 32(3):483–489,
2000.
13. Beitsch P, Weigelt JA, Flynn E, et al: Physical examination and arteriog-
raphy in patients with penetrating zone II neck wounds. Arch Surg
129(6):577–581, 1994.
14. Jarvik JG, Philips GR, 3rd, Schwab CW, et al: Penetrating neck trauma:
sensitivity of clinical examination and cost-effectiveness of angiography.
AJNR Am J Neuroradiol 16(4):647–654, 1995.
15. Demetriades D, Theodorou D, Cornwell E, 3rd, et al: Penetrating inju-
ries of the neck in patients in stable condition. Physical examination,
angiography, or color flow Doppler imaging. Arch Surg 130(9):971–975,
1995.
16. Inaba K, Munera F, McKenney M, et al: Prospective evaluation of screen-
ing multislice helical computed tomographic angiography in the initial
evaluation of penetrating neck injuries. J Trauma 61(1):144–149, 2006.
17. Rivers SP, Patel Y, Delany HM, et al: Limited role of arteriography in
penetrating neck trauma. J Vasc Surg 8(2):112–116, 1988.
18. Eddy VA: Is routine arteriography mandatory for penetrating injury to
zone 1 of the neck? Zone 1 Penetrating Neck Injury Study Group.
J Trauma 48(2):208–213, discussion 213–214, 2000.
19. Tisherman SA, Bokhari F, Collier B, et al: Clinical practice guideline:
penetrating zone II neck trauma. J Trauma 64(5):1392–1405, 2008.
20. Biffl WL, Moore EE, Ryu RK, et al: The unrecognized epidemic of blunt
carotid arterial injuries: early diagnosis improves neurologic outcome.
Ann Surg 228(4):462–470, 1998.
21. Cohen CA, Brief D, Mathewson C, Jr: Carotid artery injuries. An analysis
of eighty-five cases. Am J Surg 120(2):210–214, 1970.
22. Liekweg WG, Jr, Greenfield LJ: Management of penetrating carotid arte-
rial injury. Ann Surg 188(5):587–592, 1978.
23. Robbs JV, Baker LW, Human RR, et al: Cervicomediastinal arterial inju-
ries. A surgical challenge. Arch Surg 116(5):663–668, 1981.
24. Ledgerwood AM, Mullins RJ, Lucas CE: Primary repair vs ligation for
carotid artery injuries. Arch Surg 115(4):488–493, 1980.
25. Weaver FA, Yellin AE, Wagner WH, et al: The role of arterial reconstruc-
tion in penetrating carotid injuries. Arch Surg 123(9):1106–1111, 1988.
26. Demetriades D, Asensio JA, Velmahos G, et al: Complex problems in
penetrating neck trauma. Surg Clin North Am 76(4):661–683, 1996.
27. Stain SC, Yellin AE, Weaver FA, et al: Selective management of nonoc-
clusive arterial injuries. Arch Surg 124(10):1136–1140, discussion 1140–
1141, 1989.
28. Frykberg ER, Vines FS, Alexander RH: The natural history of clinically
occult arterial injuries: a prospective evaluation. J Trauma 29(5):577–583,
1989.
29. Fabian TC, Patton JH, Jr, Croce MA, et al: Blunt carotid injury. Impor-
tance of early diagnosis and anticoagulant therapy. Ann Surg 223(5):513–
522, discussion 522–525, 1996.
13  /  Neck and Thoracic Outlet 147
30. Cothren CC, Moore EE, Biffl WL, et al: Anticoagulation is the gold stan-
dard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg
139(5):540–545, discussion 545–546, 2004.
31. Miller PR, Fabian TC, Bee TK, et al: Blunt cerebrovascular injuries: diag-
nosis and treatment. J Trauma 51(2):279–285, discussion 285–286, 2001.
32. Prall JA, Brega KE, Coldwell DM, et al: Incidence of unsuspected blunt
carotid artery injury. Neurosurgery 42(3):495–498, discussion 498–499,
1998.
33. Lyrer P, Engelter S: Antithrombotic drugs for carotid artery dissection.
Cochrane Database Syst Rev (10):CD000255, 2010.
34. Bromberg WJ, Collier BC, Diebel LN, et al: Blunt cerebrovascular injury
practice management guidelines: the Eastern Association for the Surgery
of Trauma. J Trauma 68(2):471–477, 2010.
35. Biffl WL, Ray CE, Jr, Moore EE, et al: Treatment-related outcomes from
blunt cerebrovascular injuries: importance of routine follow-up arteriog-
raphy. Ann Surg 235(5):699–706, discussion 706–707, 2002.
36. Lee YJ, Ahn JY, Han IB, et al: Therapeutic endovascular treatments for
traumatic vertebral artery injuries. J Trauma 62(4):886–891, 2007.
37. Desouza RM, Crocker MJ, Haliasos N, et al: Blunt traumatic vertebral
artery injury: a clinical review. Eur Spine J 20(9):1405–1416, 2011.
38. Cogbill TH, Moore EE, Meissner M, et al: The spectrum of blunt injury
to the carotid artery: a multicenter perspective. J Trauma 37(3):473–479,
1994.
39. Bynoe RP, Miles WS, Bell RM, et al: Noninvasive diagnosis of vascular
trauma by duplex ultrasonography. J Vasc Surg 14(3):346–352, 1991.
40. Fry WR, Dort JA, Smith RS, et al: Duplex scanning replaces arteriography
and operative exploration in the diagnosis of potential cervical vascular
injury. Am J Surg 168(6):693–695, discussion 695–696, 1994.
41. Munera F, Soto JA, Palacio D, et al: Diagnosis of arterial injuries caused
by penetrating trauma to the neck: comparison of helical CT angiography
and conventional angiography. Radiology 216(2):356–362, 2000.
42. Munera F, Soto JA, Palacio DM, et al: Penetrating neck injuries: helical
CT angiography for initial evaluation. Radiology 224(2):366–372, 2002.
43. Goodwin RB, Beery PR, 2nd, Dorbish RJ, et al: Computed tomographic
angiography versus conventional angiography for the diagnosis of blunt
cerebrovascular injury in trauma patients. J Trauma 67(5):1046–1050,
2009.
44. Sliker CW, Shanmuganathan K, Mirvis SE: Diagnosis of blunt cerebro-
vascular injuries with 16-MDCT: accuracy of whole-body MDCT com-
pared with neck MDCT angiography. AJR Am J Roentgenol 190(3):
790–799, 2008.
45. DiCocco JM, Emmett KP, Fabian TC, et al: Blunt cerebrovascular injury
screening with 32-channel multidetector computed tomography: more
slices still don’t cut it. Ann Surg 253(3):444–450, 2011.
46. Monson DO, Saletta JD, Freeark RJ: Carotid vertebral trauma. J Trauma
9(12):987–999, 1969.
47. Feliciano DV, Mattox KL, Moore EE: Trauma, ed 6, New York, 2008,
McGraw-Hill Medical.
48. Mock CN, Lilly MP, McRae RG, et al: Selection of the approach to the
distal internal carotid artery from the second cervical vertebra to the base
of the skull. J Vasc Surg 13(6):846–853, 1991.
49. Nishioka H: Results of the treatment of intracranial aneurysms by occlu-
sion of the carotid artery in the neck. J Neurosurg 25(6):660–704, 1966.
50. Herrera DA, Vargas SA, Dublin AB: Endovascular treatment of penetrat-
ing traumatic injuries of the extracranial carotid artery. J Vasc Interv
Radiol 22(1):28–33, 2011.
51. Schwarzacher SW, Krammer EB: Complex anomalies of the human aortic
arch system: unique case with both vertebral arteries as additional
branches of the aortic arch. Anat Rec 225(3):246–250, 1989.
52. Leonard RJ: Human gross anatomy : an outline text, New York, 1995,
Oxford University Press.
53. Cronenwett JL, Johnston KW, Rutherford RB: Rutherford’s vascular
surgery, ed 7, Philadelphia, 2010, Saunders/Elsevier.
54. Castelli P, Caronno R, Piffaretti G, et al: Endovascular repair of traumatic
injuries of the subclavian and axillary arteries. Injury 36(6):778–782,
2005.
55. du Toit DF, Lambrechts AV, Stark H, et al: Long-term results of stent graft
treatment of subclavian artery injuries: management of choice for stable
patients? J Vasc Surg 47(4):739–743, 2008.
56. White R, Krajcer Z, Johnson M, et al: Results of a multicenter trial for the
treatment of traumatic vascular injury with a covered stent. J Trauma
60(6):1189–1195, discussion 1195–1196, 2006.
57. Patel AV, Marin ML, Veith FJ, et al: Endovascular graft repair of penetrat-
ing subclavian artery injuries. J Endovasc Surg 3(4):382–388, 1996.
58. Xenos ES, Freeman M, Stevens S, et al: Covered stents for injuries of
subclavian and axillary arteries. J Vasc Surg 38(3):451–454, 2003.
148 SECTION 3  /  DEFINITIVE MANAGEMENT
59. Danetz JS, Cassano AD, Stoner MC, et al: Feasibility of endovascular
repair in penetrating axillosubclavian injuries: a retrospective review.
J Vasc Surg 41(2):246–254, 2005.
60. Shalhub S, Starnes BW, Tran NT: Endovascular treatment of axillosubcla-
vian arterial transection in patients with blunt traumatic injury. J Vasc
Surg 53(4):1141–1144, 2011.
61. Towne JB, Hollier LH: Complications in vascular surgery, ed 2, New York,
2004, Marcel Dekker.
62. Owens WB: Blood pressure control in acute cerebrovascular disease.
J Clin Hypertens (Greenwich) 13(3):205–211, 2011.
63. Valentine VG, Raffin TA: The management of chylothorax. Chest
102(2):586–591, 1992.
64. Brott TG, Halperin JL, Abbara S, et al: 2011. ASA/ACCF/AHA/AANN/
AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on
the management of patients with extracranial carotid and vertebral artery
disease: executive summary: a report of the American College of Cardiol-
ogy Foundation/American Heart Association Task Force on Practice
Guidelines, and the American Stroke Association, American Association
of Neuroscience Nurses, American Association of Neurological Surgeons,
American College of Radiology, American Society of Neuroradiology,
Congress of Neurological Surgeons, Society of Atherosclerosis Imaging
and Prevention, Society for Cardiovascular Angiography and Interven-
tions, Society of Interventional Radiology, Society of NeuroInterven-
tional Surgery, Society for Vascular Medicine, and Society for Vascular
Surgery. Vasc Med 16(1):35–77, 2011.
65. DiCocco JM, Fabian TC, Emmett KP, et al: Optimal outcomes for patients
with blunt cerebrovascular injury (BCVI): tailoring treatment to the
lesion. J Am Coll Surg 212(4):549–557, discussion 557–559, 2011.
66. Wang W, Li MH, Li YD, et al: Treatment of traumatic internal carotid
artery pseudoaneurysms with the Willis covered stent: a prospective
study. J Trauma 70(4):816–822, 2011.
67. Cothren CC, Moore EE, Ray CE, Jr, et al: Screening for blunt cerebrovas-
cular injuries is cost-effective. Am J Surg 190(6):845–849, 2005.
68. Demetriades D, Skalkides J, Sofianos C, et al: Carotid artery injuries:
experience with 124 cases. J Trauma 29(1):91–94, 1989.
69. Richardson R, Obeid FN, Richardson JD, et al: Neurologic consequences
of cerebrovascular injury. J Trauma 32(6):755–758, Discussion 758–760,
1992.
70. du Toit DF, van Schalkwyk GD, Wadee SA, et al: Neurologic outcome after
penetrating extracranial arterial trauma. J Vasc Surg 38(2):257–262, 2003.
71. Coldwell DM, Novak Z, Ryu RK, et al: Treatment of posttraumatic inter-
nal carotid arterial pseudoaneurysms with endovascular stents. J Trauma
48(3):470–472, 2000.
72. Stein DM, Boswell S, Sliker CW, et al: Blunt cerebrovascular injuries: does
treatment always matter? J Trauma 66(1):132–143, discussion 143–144,
2009.
73. Martin MJ, Mullenix PS, Steele SR, et al: Functional outcome after blunt
and penetrating carotid artery injuries: analysis of the National Trauma
Data Bank. J Trauma 59(4):860–864, 2005.
74. Hershberger RC, Aulivola B, Murphy M, et al: Endovascular grafts for
treatment of traumatic injury to the aortic arch and great vessels.
J Trauma 67(3):660–671, 2009.
Upper Extremity and
Junctional Zone Injuries
AARON C. BAKER AND W. DARRIN CLOUSE
Epidemiology of Upper Extremity
Vascular Injury
Reports from both the civilian and military settings have
shown the distribution and outcomes of major vascular inju-
ries going as far back as the Civil War (Table 14-1).1-22 While
some publications comment on and provide details related to
vascular injury in the upper extremity, it is often difficult to
discern specific epidemiology and outcomes of upper extrem-
ity vascular injuries in many series. Regardless, some clear
patterns concerning upper extremity vascular injury can be
observed across these available studies, and several general
comments pertaining to upper extremity vascular injury can
be made.
First, upper extremity vascular trauma is less common than
that in the lower extremity, in both military and civilian envi-
ronments. In several of the most recent civilian series, as well
as in the Balad Vascular Registry (BVR) and Joint Theater
Trauma Registry (JTTR) in Iraq and Afghanistan, upper
extremity arterial injury constitutes 30% to 40% of extremity
arterial trauma. Second, penetrating mechanisms of injury are
more commonly reported than blunt-force mechanisms, espe-
cially in the military setting. However, blunt mechanisms are
associated with a higher morbidity and mortality compared
to penetrating injury, especially in civilian series. This is
mostly attributable to the effects of concomitant injuries.
Third, the most commonly injured vessel of the upper extrem-
ity is the brachial artery, which is most likely related to its
rather superficial anatomical location. The next most com-
monly injured vessels are those of the forearm, while the axil-
lary and subclavian arteries in the junctional zone are the most
infrequently injured vessels of the upper extremity. Fourth,
primary repair, patch angioplasty, and autologous vein graft-
ing are the most common techniques used to repair traumatic
vascular injuries in the arm.
Finally, associated limb loss with upper extremity arterial
injury ranges from 1% to 28% with more recent reports dem-
onstrating an amputation rate of less than 10%. It has been
suggested that in modern military settings, the rate of early
limb loss with upper extremity vascular injury may be more
pronounced than in the lower extremity.1,2 Multimechanistic
etiology with blast, penetration, and burn are common. This,
along with the smaller surface area and soft tissue structure of
the arm, may perhaps lead to coverage and revascularization
difficulties. Reported mortality rates are low for upper extrem-
ity vascular injury, but not negligible, and range from 0% to
34% in contemporary series. This is most significantly related
to concomitant injuries with exsanguination occurring rarely.
14 
Indications, Presentations,
and Diagnoses
While hemorrhage and critical ischemia are the key determi-
nants indicating the need for intervention and repair, a deeper
understanding of the presentation and diagnostic nuances of
the different upper extremity arterial segments is essential.
This knowledge allows one to optimize management deci-
sions, including situations where nonoperative management
may be applied. Unstable patients should be taken to the oper-
ating room. Stable patients may undergo further diagnostic
imaging to better prepare for treatment. Chest x-ray can reveal
fractured ribs and clavicles and hemopneumothoraces, and it
may provide information about the mediastinum. Bilateral
arm blood pressure using continuous wave-Doppler (i.e.,
measurement of an injured extremity index) is a quick and
easy extension of the physical examination that allows diag-
nosis of an inflow or arterial injury. In a hemodynamically
stable patient, CT angiography has proven itself and offers the
opportunity for determining the location and nature of upper
extremity vessel injury; and it defines other concomitant inju-
ries and allows optimization of operative planning. Duplex
ultrasound can be helpful in diagnosis beyond the subclavian
artery. Arteriography remains useful, particularly when
catheter-based endovascular repair is considered.
Subclavian Artery Injuries
The relatively short extent of the subclavian vessels, along with
their surrounding and protective bony structures and muscu-
lature, makes injuries to these proximal upper extremity
vessels rare. While injury to the subclavian arteries is more
common in penetrating trauma, reports from military and
civilian descriptions of vascular trauma show the prevalence
of subclavian artery injuries to range from 1% to 10%.
Subclavian vascular injury should be considered when the
bony structures of the thoracic outlet, such as the first rib or
the clavicle are fractured. Subclavian artery injury may not
present with critical ischemia given the robust collateral cir-
culation around the shoulder. Absence of a distal pulse in an
upper extremity, reduction in the injured extremity index
(<0.9), or the presence of hemodynamic collapse with appar-
ent mechanism should be considered highly suspicious for
occult subclavian artery injury. In fact, many patients with a
subclavian artery injury will present in shock. Hemopneumo-
thorax is common. Other physical signs can include signifi-
cant supraclavicular and low cervical swelling or tracheal
compression from an expanding hematoma. Steps to gain
immediate control include direct manual pressure to the
149
 14  /  Upper Extremity and Junctional Zone Injuries 149.e1

ABSTRACT
Injuries to blood vessels in the thoracic inlet and shoulder
or junctional zone and in the upper extremity continue to
present significant challenges to trauma and vascular sur-
geons. As with other vascular injuries, there is a severity
spectrum dependent on mechanism, anatomic location,
temporal circumstances, and concomitant injuries. Vascular
trauma in the upper limb may result not only in life-
threatening hemorrhage but also in tissue ischemia, leading
to ischemic neuropathy/plexopathy, compartment syn-
dromes, and muscular contracture. Associated injuries to
the nerves, bones, and soft tissues may also contribute to
dysfunction. In some instances, amputation is the result,
either in the acute setting or in the chronic phase. Injuries
leading to loss of function or amputation can be devastat-
ing and life-altering events for the patient. The best chance
of successful management lies in early clinical review,
correct application of damage control principles, proper
use of diagnostic technologies, and efficient judgment
as to the optimal treatment strategy. Junctional trauma
requires early proximal control to stop bleeding; this may
mean control from within the chest. As in other areas of
vascular trauma, the use of endovascular technologies is
becoming ever-more feasible to stop hemorrhage and to
restore vessel perfusion, even beyond the root of the limb.
Military experience has shown that, with better prehospital
and in-hospital protocols, death rates from isolated upper
limb vascular injury can be effectively reduced, placing the
emphasis on functional outcomes as better benchmarks of
care.

Key Words:  junctional zone injuries,

upper extremity vascular injuries,
subclavian artery,
axillary artery,
brachial artery,
radial artery,
ulnar artery,
upper extremity venous injury
150 SECTION 3  /  DEFINITIVE MANAGEMENT

Table 14-1 Select Civilian and Military Series Reporting Upper Extremity Arterial Injuries
Number Injured Artery Distribution
of Injured
Penetrating: Arteries
Series Setting Year Blunt (UE:LE) Subclavian Axillary Brachial Radial Ulnar
Graham et al Civilian 1955-1978 93%:8% 93 93 NR NR NR
Mattox et al Civilian 1958-1988 NR 859 : 4901‡ 168 143 446 261
Hardin et al Civilian 1967-1979 84%:16% 100 NR 21 43 36
Fitridge et al Civilian 1969-1991 55%:45% 114 16 12 62 24
Graham et al Civilian 1970-1980 95%:5% 85† 9 51 13 NR
Humphrey et al Civilian 1970-1990 59%:41%‡ 115 : 56 3 9 30 36 37
Pasch et al Civilian 1979-1984 100%:0%* 48 : 91 NR 15 33 NR
Costa et al Civilian 1981-1987 0%:100% 15 15 NR NR NR
Shaw et al Civilian 1983-1992 78%:12% 43 15 28 NR
Lin et al Civilian 1991-2001 100%:0% 54 54 NR NR NR
Demetriades et al Civilian 1993-1997 100%:0% 79† 59 NR NR
Brown et al Civilian 1992-1998 70%:30% 64 6 13 26 5 6
Menakruru at al Civilian 1996-2002 16%:84%* 67 : 63 6 4 38 11 8
Zellweger et al Civilian 1999-2002 97%:3% 124 NR NR 124 NR
Shanmugam et al Civilian 2000-2002 55%:44% 27 0 2 13 7 5
Dragas et al Civilian/Military 1992-2006 77%:23% 189 3 41 104 40
Peck et al Civilian 2004-2006 88%:3%* 40 : 150 NR 4 25 11
DeBakey et al Military WWII NR 864 : 1607 21 74 601 99 69
Hughes Military KW NR 112 : 192 3 20 89 NR
Rich et al Military 1965-1968 95%:1.1%* 350 : 650 8 59 283 NR
Clouse et al Military 2004-2005 85%:15% 43 10 25 23
Clouse et al Military 2004-2006 94%:6%* 76 : 225 11 42 23

AVAG/P, Autologous vein or artery graft or patch angioplasty; KW, korean war; LE, lower extremity; NR, not reported; UE, upper extremity.
*Data combines upper and lower extremity artery injury data.
†
Data combines upper extremity artery and venous injury data.
‡
Data combines all cardiovascular injuries.
§
Data is for upper extremity artery injury only.

supraclavicular area or Foley catheter tamponade. Concomi-
tant injuries to the cervical or thoracic spine may be present,
and brachial plexus injuries along with associated venous
injury will commonly be present. Meticulous assessment for
these injuries should be performed as soon as the patient’s
status permits.
Axillary Artery Injuries
Axillary artery injuries are more common than subclavian
artery injuries because they lack the protection of the struc-
tures of the thoracic outlet. Similar to subclavian trauma,
penetrating trauma is the most common mechanism of axil-
lary artery injury. However, in contrast to isolated subclavian
artery injuries—in which the patient will present in shock—
isolated injuries to the axillary artery rarely present with
hemodynamic collapse. More common hallmarks include
absent distal pulse or reduced injured extremity index (<0.9),
pulsatile bleeding, and/or an expanding hematoma. The rich
collateral network may preclude the development of critical
ischemia, and an axillary artery injury may not be readily
recognized without the aid of the continuous-wave Doppler
and measurement of the injured extremity index. As with
other forms of vascular trauma, arteriography is a useful diag-
nostic tool in certain situations including those in which an
endovascular therapy is being considered.7 However, with
good physical examination, continuous-wave Doppler use,
and other noninvasive imaging modalities, most axillary
artery injuries can be diagnosed without arteriography. Ante-
rior dislocation of the humeral head or fractures of the
humerus can result in axillary artery injury, and concomitant
injuries to the nearby nerves of the brachial plexus and axillary
vein are common.
Brachial Artery Injuries
Patients with brachial artery injury, especially those with inju-
ries sustained from a penetrating mechanism, will typically
present with hard signs of vascular injury. In some instances,
however, critical ischemia may not develop due to the robust
collateral network around the elbow. The degree of ischemia
resulting from a brachial artery injured will depend on the
following two factors:
1. Whether or not the injury occurred proximal or distal
to the origin of the deep brachial artery
2. The degree of muscle and soft-tissue injury associated
with the trauma. This second factor relates to injury or
interruption of the deep brachial artery network and
makes significant ischemia more likely in cases of pen-
etrating injury with larger soft-tissue defects.
Most brachial artery injuries can be diagnosed with physical
examination, use of the continuous-wave Doppler, and mea-
surement of an injured extremity index (normal index >0.90).
Other findings such as a supracondylar fracture or elbow dis-
location increase the suspicion for a concomitant brachial
artery injury.23 Additionally, recent use of the brachial artery
 14  /  Upper Extremity and Junctional Zone Injuries 151

Operative Repair Technique Associated Injuries Outcomes

Series Limb Series

Primary AVAG/P Prosthetic Ligation Nerve Bone Vein Loss Mortality
33 8 17 0 18 (19%) 17 (18%) 38 (40%) NR 12 (13%)
NR NR NR NR NR NR NR NR NR
69 19 0 19 46 (46%) 6 (6%) 14 (14%) 2 (2%) NR
39 45 1 14 47 (41%) 35 (30%) NR 9 (7%) 3 (2%)
20 13 18 0 23 (35%) NR 20 (30%) 1 (1%) 2 (3%)†
126‡ 40‡ 15‡ 47‡ 63 (29%)‡ 70 (32%)‡ NR 26 (11.4%)‡ 10 (4.8%)‡
14 34 0 0 38%§ NR 62 (45%)* 1 (0.7%)* 0*
NR NR NR NR 8 (53%) 12 (80%) NR 2 (13%) 1 (7%)
NR NR NR NR 13 (30%) 3 (6%) NR 3 (10%) NR
38 10 3 3 17 (31%) NR 23 (44%) NR 39%
19 18 22 0 26 (32%) NR 20 (25%) NR 27 (34%)†
27 32 6 6 12 (19%) 8 (13%) 20 (31%) 4 (5%) 2 (3%)
103* 32* 4* NR 16 (10%)* 90 (60%)* 13 (9%)* 9 (6%) 12 (8%)
47 73 2 2 77 (62%) 17 (14%) 12 (10%) NR NR
5 12 2 6 6 (22%) 10 (37%) 10 (37%) 1 (3%) 0
57 99 2 6 91 (55%) 45 (27%) 62 (37%) 10 (6%) 4 (2.4)%
4 25 2 9 NR NR 15 (38%) 4 (3%)* 2 (1.5%)*
81* 40* 14* 1639* NR NR NR 214 (24%)§ NR
77 20 0 15 NR NR 192 (63%)* 13%* NR
464* 462* 4* 15* 424 (42%)* 285 (29%)* 377 (38%)* 19 (2%)§ 17 (1.7%)*
7 26 2 1 38 (88%) 10 (23%) 5 (11%) 4 (9.3%) NR
15* 47* 1* 13* NR NR NR 7 (8.5%)* 14 (4.3%)*

for vascular access either for invasive hemodynamic monitor-
ing or endovascular procedures should also increase the sus-
picion for iatrogenic brachial artery thrombosis or injury. As
with the other vascular injuries of the upper extremity, a thor-
ough sensorimotor exam should be performed and docu-
mented before any operative intervention.
Radial and Ulnar Artery Injuries
Forearm artery injury is commonly reported in extremity vas-
cular trauma series. The most common mechanism, as with
the more proximal arteries of the upper extremity, is penetrat-
ing trauma. Hypothenar eminence hammer syndrome is a
rare manifestation of repeated blunt trauma to the hypothe-
nar eminence and distal ulnar artery. This can result in aneu-
rysmal dilation, thrombosis, or distal embolization. Hematoma
formation can result in development of compartment syn-
drome of the forearm and ultimately in a Volkmann flexure
contracture. Signs of a tense hematoma with sensation, motor,
or perfusion abnormalities should prompt consideration of a
forearm fasciotomy.
Scapulothoracic Dissociation
This is a blunt injury of the upper extremity and shoulder
girdle, resulting in complete musculoskeletal separation of the
shoulder attachments from the torso with stretch and avulsion
injuries to the brachial plexus and vasculature. Physical signs
on presentation demonstrate chest wall hematoma, absent
pulses, and loss of continuous-wave Doppler signals, along
with complete upper extremity motor and sensory loss below
the shoulder. X-ray imaging can show a laterally displaced
scapula, distracted clavicle fracture, sternoclavicular disrup-
tion, or acromioclavicular disruption. This injury is rare; and
one of the larger series, which reported 52 cases, showed that
poor outcome is mostly related to neurologic injury, suggest-
ing that there are no benefits to revascularization.24 Arterial
ligation should be considered as a damage control option in
a patient who is actively bleeding. When associated nerve tran-
section and arterial injury are confirmed in the setting of
musculoskeletal disruption, early amputation is generally rec-
ommended.24 This should be undertaken with consideration
of the level of soft-tissue viability and the prospects for recon-
struction, with a staged approach often being useful. Even in
cases of successful limb salvage, scapulothoracic dissociation
has been shown to result in significant short-term and long-
term disability compared to isolated brachial plexus injury.25
Preoperative Preparation
Unpredictable arterial injury patterns often require that the
surgeon be able to apply a diverse armamentarium of tech-
niques. Efficient application requires adequate foresight of
potential intraoperative and postoperative issues during the
diagnostic and assessments stage. Failure to correctly prepare
can prolong operative time and can inadvertently result in
152 SECTION 3  /  DEFINITIVE MANAGEMENT
suboptimal outcomes. Intravenous access should be obtained
in another uninjured extremity, and central venous access may
be helpful. As detailed in previous chapters of this text, atten-
tion to resuscitation must be diligent.
General Considerations in Addressing
Complex Upper Extremity Vascular Trauma
Orthopedic and soft-tissue injuries often occur in tandem
with upper extremity vascular injuries. This is especially
germane in current combat given the increased use of high-
energy improvised explosive devices. When faced with arte-
rial injury in conjunction with bone and/or nerve injuries,
several broad concepts should be reviewed. Orthopedic long
bong injuries should be brought to length with either perma-
nent or temporary fixation before definitive vascular repair.
In most instances, when vascular and orthopedic injuries
occur together, wound concerns require external fixation of
the fracture with permanent internal fixation kept as an
option, if needed, once other aspects of injury are optimized.
Temporary vascular shunts should be considered to expedi-
tiously restore perfusion to the distal extremity before place-
ment of external fixation devices in these situations. This
proven strategy or sequence allows for expedited perfusion
to the extremity, a more thoughtful and well-done fixation,
and an easier platform for definitive arterial and/or venous
reconstruction.
Débridement of all clearly devitalized tissue should be per-
formed when extensive, primary amputation needs to be con-
sidered. In our experience, routing of vascular bypass grafts
through deep anatomic planes is possible in the great majority
of injuries in which limb salvage is pursued. In the cases where
large, cavitary soft-tissue defects are present, extraanatomic
routes are needed and deep intermuscular or subcutaneous
planes can be utilized depending on which path provides the
best graft course and protection. Consideration must be given
to primary repair of concomitant nerve injuries verses tagging
the nerve ends for delayed neurorrhaphy once the wound has
been stabilized. As described further in the following sections,
repair of venous injury may improve limb outcomes and
should be entertained particularly in axillosubclavian injuries
and when other life-threatening injuries do not require atten-
tion. We give serious consideration to reconstruction of at
least one vein in the upper arm when brachial, cephalic, and
basilic vein disruption coexists (Fig. 14-1). The brachial or
basilic veins are favored for reconstruction because these lie
within the exposures required to deal with colocated arterial
injury and are more easily covered with soft tissue.
Approach to Tourniquets in Upper
Extremity Trauma
Use of tourniquets in the modern civilian trauma setting has
not been systematically endorsed, but the effectiveness of
tourniquets has been demonstrated in the combat environ-
ment. Early application of tourniquets in Operation Iraqi
Freedom (OIF)/Operation Enduring Freedom (OEF) has
proven effective and life-saving in patients with extremity
injuries. In 2009, Kragh et al reported that application of a
tourniquet in the absence of shock in a prehospital setting had
a significant survival advantage as compared to application of
the tourniquet in the emergency department (ED) after the
patient had developed shock (90% vs. 10%; p < 0.001).26,27
A small percentage (1.7%) experienced nerve palsy at the
B
C
D A
FIGURE 14-1  View from the patient’s head. A high-energy gunshot
injury to the left inner arm resulted in a “blowout” injury at the bullet
exit site. A greater saphenous vein (GSV) brachial artery to radial artery
bypass was performed to address the brachial artery injury, and a GSV
interposition graft was used to repair the basilic vein injury. Fasciotomy
was performed. Arrows indicate cavitation injury, brachioradial GSV
bypass, basilic vein interposition, and median nerve. A, Cavitation
injury. B, Brachioradial GSV bypass. C, Basilic vein. D, Median nerve.
level of application, but no amputations resulted from tour-
niquet use.
In another study by the Israeli Defense Forces, the use of
combat tourniquets was evaluated over 4 years. In all, 110
tourniquets were applied to for extremity injury, of which 34
were used to treat upper limb trauma. In that study, 94% of
upper limb injuries were controlled by tourniquet, as com-
pared to only 74% of lower extremity injuries.28 Neurologic
complications developed in, seven limbs and four of these
involved nerve palsies of the upper extremity.
Injuries distal to the axillary artery are most amenable to
control by tourniquet. Designs include windlass tourniquets,
such as the Combat Application Tourniquet (CAT) and the
Special Operations Forces Tactical Tourniquet (SOFTT),
which are commonly issued to combat troops, and pneumatic
compression designs such as the Emergency and Military
Tourniquet (EMT). One study of volunteers who self-applied
the CAT, SOFTT, or EMT found each design to consistently
interrupt distal perfusion as assessed by Doppler.29
While there has been a historical apprehension for the use
of tourniquets in the prehospital setting, these and other
recent studies from the combat arena have shown tourniquets
to be important means of preventing hemorrhage and saving
lives.30,31 It is difficult to generalize this data to settings outside
of military combat trauma systems which, through extensive
training and rapid medical transport, have created the circum-
stances and successful outcomes observed with tourniquet
application.32 Thus, while widespread recommendation for
civilian prehospital tourniquet use may be somewhat prema-
ture, selected upper extremity injuries may be prudently
treated by tourniquet assuming that the goal of early removal
is achieved.
Considerations for success are as follows:
1. Tourniquets for hemorrhage control, temporary shunts
for early restoration of perfusion, and low threshold
for fasciotomy are important adjuncts to consider
when facing delayed or complex upper extremity vas-
cular injury.
2. Prepare and drape the patient to allow for appropriate
proximal and distal control of the injury, as well as
harvesting of autologous conduit such as saphenous
vein.

3. Exposure in the upper extremity junctional zone is
difficult. Be prepared for sternotomy and thoracotomy.
4. Long bong fractures should be brought to length
before definitive vascular repair. (Consider immediate
temporary vascular shunt placement followed by
placement of fixation devices.)
5. Liberal use of interposition grafting and patching
avoids the arterial narrowing that often results from
primary repair.
6. Prosthetic conduit is an acceptable option in upper
extremity junctional zone injuries where size match is
important and where infectious complications are less
common than in the groin.
7. Repair of venous injury may improve limb outcomes
and should be entertained, particularly in the upper
extremity junctional zone.
8. Endovascular repair of upper extremity vascular injury
is now commonplace with reasonably early results,
particularly in central junctional zone injuries.
9. Liberal use of duplex ultrasound as a surveillance
mechanism for vascular repair is recommended.
10. Elevation of the extremity, early and aggressive reha-
bilitation, and antithrombotic therapy are important
in the postoperative care after revascularization for
upper extremity trauma.
Operative Strategy
Traditionally, the operative strategy for complex extremity
vascular injury was guided by the dictum “life over limb.” in
the wars in Afghanistan and Iraq, experience with damage
control resuscitation and damage control surgical strategies
have shown that in many instances of mangled extremity it is
now possible to save both life and limb. An understanding of
damage control adjuncts such as temporary vascular shunts
and a methodical evaluation of complex extremity injuries can
assist in minimizing morbidity and mortality while attempt-
ing to maximize functional outcomes in these formidable
scenarios.
Temporary Vascular Shunts in Upper
Extremity Vascular Injury
Temporary intravascular shunts can allow for rapid restora-
tion of distal limb perfusion when immediate vascular recon-
struction is not possible (Fig. 14-2). This may be due to delays
involving orthopedic fixation, wound débridement and defi-
nition, vein harvest, lack of clinical expertise at the initial
treating facility, or the need to address more life-threatening
injuries. A full discussion on the use of vascular shunts follows
in Chapter 17. The use of intravascular shunting has been
specifically applied within the military setting as a method to
stabilize and temporize peripheral vascular injuries, to avoid
vascular reconstructions in austere and forward environments
with limited resources and time, and to allow for restitution
and preservation of extremity perfusion during transport to
definitive care. Further, shunting has been used during mass
casualty events and during damage control in those with sig-
nificantly adverse physiology or concomitant injuries. As such,
robust and systematic evaluations of use have been performed
during OIF and OEF.33-35
Chambers et al reported the use of 27 temporary vascular
shunts in a U.S. Marine Forward Resuscitative Surgical System
14  /  Upper Extremity and Junctional Zone Injuries 153
FIGURE 14-2  Brachial artery temporary vascular shunt used to main-
tain distal perfusion while orthopedic fixation was performed to bring
the humerus to length.
(FRSS) during OIF. Six (22%) of the shunts clotted during
transport, but this did not impact early limb outcome.33 Only
three of the shunts reported in this series were placed in upper
extremity vascular injury (one brachial artery, one brachial
vein, one ulnar artery), and none were reported to have
resulted in early amputation. The one complication reported
from upper extremity shunting involved a single shunt placed
in the brachial artery, which clotted due to arm angulation
and shunt kinking during transport. Another Navy FRSS
report from OIF illustrated similar results with 96% shunt
patency and 100% early limb salvage. Mean time to arrival at
definitive Level III care was 5 hours 48 minutes (ranging from
3 hours 40 minutes to 10 hours 49 minutes), indicating the
relative importance of reperfusion abilities forward.35 Ras-
mussen and colleagues chronicled descriptive data from the
Balad Vascular Registry, a major Level III facility in Iraq, dem-
onstrating shunts placed for proximal vascular injuries (at or
proximal to the knee or elbow) had a significantly greater
patency (86%, n = 22) than shunts placed in distal vascular
injuries (distal to the knee or elbow) (12%, n = 8).34 However,
no difference in early limb viability was identified between the
groups (95% and 88%, respectively; p = NS), and thus failure
of the distal shunts did not result in decreased limb viability.
In 2009, Gifford et al presented a longer-term outcome
analysis in a case-controlled fashion with a time-to-event
analysis portraying the impact of temporary vascular shunting
on freedom from amputation, using data collected from the
Joint Theater Trauma Registry (JTTR), including the Balad
Vascular Registry (BVR) and the Walter Reed Vascular Regis-
try (WRVR) from 2003 to 2007.36 Cases and controls consist-
ing of 64 and 61 extremity arterial injuries, respectively, had a
mean follow-up of 22 months. While the shunted group
showed significantly higher mean injury severity scores when
compared to the control group (18 versus 15, p = 0.05) after
propensity score adjustment, use of TVS suggested a reduced
risk of amputation but was not statistically significant (RR =
0.47; 95% CI [0.18 to 1.19]; p = 0.11). Interestingly, venous
repair was associated with limb salvage (RR = 0.2; 95% CI
[0.04 to 0.99], P = 0.05), whereas elevated mangled extremity
severity scores ([MESS 8 to 12]; RR 16.4; 95% CI [3.79 to
154 SECTION 3  /  DEFINITIVE MANAGEMENT

70.79], P < 0.001) and fracture (RR = 5.0; 95% CI [1.45 to Table 14-2 Mangled Extremity Severity Score
17.28], P = 0.01) predicted amputation. Similar freedom from (MESS)
amputation was identified in both shunted and nonshunted
extremities after definitive reconstruction (78% versus 77%; Variable Injury Assessment Points
p = –0.5), but relative, graduated improvement in limb salvage Skeletal Low energy 1
with shunting was identified as the severity of the extremity (stab; simple fracture; civilian GSW)
injury increased. Medium energy 2
While the above studies support the use of shunting for (open or multiple fractures,
dislocation)
extremity injury in a combat setting, several case series High energy 3
describing use of shunts in the civilian setting have also been (close-range shotgun or military
accomplished.37-42 These series report similar results and con- GSW; crush injury)
siderations regarding the use of shunts. Controversies regard- Very high energy 4
(above + gross contamination;
ing the use and theoretic benefit of venous shunts and soft-tissue avulsion)
therapeutic (or pharmacologic) shunting remain to be further Limb ischemia Pulse reduced or absent but 1*
studied and defined, along with the proper posture of shunt- perfusion intact
ing during transport in civilian settings. Pulseless; paresthesias; diminished 2*
Collectively, these experiences have defined the feasibility capillary refill
and usefulness of temporary shunting in the upper extremi- Cool; paralyzed; insensate; numb 3*
ties, particularly with injuries to the brachial artery and Shock SBP always >90 mm Hg 0
Transient hypotension 1
more proximally. Certainly, there appears to be no harm in Persistent hypotension 2
early reperfusion using shunts. The potential drawbacks— Age (years) <30 0
unrecognized vessel injury by shunts or the necessity for more 30-50 1
extensive repairs owing to shunts and securing mechanisms— >50 2
seem negligible overall. Even when faced with primary upper
Adapted from Johansen et al: Objective criteria accurately predict
extremity vascular injury at the time of definitive manage- amputation following lower extremity trauma.”
ment, the authors find that initial shunt use can be quite *Score doubled for ischemia time >6 hours.
effective in providing time for operative planning and autolo-
gous vein harvest. Arterial injury identification, thrombec-
tomy, regional heparin, and temporary shunt placement
provide reperfusion while orthopedic lengthening and fixa-
tion is secured and/or autogenous vein harvest occurs. This
simple strategy allows for earlier flow restoration, allows time
for better definition of the vascular injury, and may create a Table 14-3 Mangled Extremity Syndrome
more precise final revascularization with improved neuro- Index (MESI)
muscular outcome.
Variable Injury Assessment Points
Application of Mangled Extremity Scores in Injury 0-25 1
Upper Extremity Vascular Trauma severity 25-50 2
A mangled extremity is defined as a complex injury involving score >50 3
soft tissue, bone, nerve, and vasculature. Determining which Integument Guillotine 1
Crush/burn 2
patients and mangled upper extremities will benefit from Avulsion/degloving 3
aggressive attempts at limb salvage and which would be better Nerve Contusion 1
served with primary amputation in the early stages of man- Transection 2
agement can be challenging. Exhaustive efforts at limb salvage Avulsion 3
in severely injured patients may result in misdirection of care, Vascular Artery transection 1
whereas premature extremity amputation may preclude Artery thrombosed 2
Artery avulsed 3
optimal functional outcome. Venous injury 1
Scoring systems have been developed to take into consid- Bone Simple fracture 1
eration concomitant injuries, as well as the degree and nature Segmental fracture 2
of the bony, soft tissue; the nerve features, and the vessel Segmental-comminuted fracture 3
features of extremity injury. These systems are designed to Segmental-communited with bone 4
assist the surgeon in decision making during the early phases loss <6 cm
Segmental fracture intra-extra articular 5
of mangled limb management and also to provide a mecha- Segmental fracture intra-extra articular 6
nism to do a comparative retrospective study of extremity with bone loss >6 cm
injury.43,44 These systems could theoretically discern between Bone loss >6 cm Add 1
those extremities in which aggressive salvage would be suc- Lag time 1 point for every hour >6 hrs
cessful and those in which up-front amputation would be Age 40-50 1
most rational. Application of different scoring systems, 50-60 2
60-70 3
such as the Mangled Extremity Severity Score (MESS) (Table
Preexisting 1
14-2), Mangled Extremity Syndrome Index (MESI) (Table disease
14-3), Predictive Salvage Index (PSI), and Limb Salvage Index Shock Systolic blood pressure <90 2
(LSI), have been evaluated regarding their abilities to predict

limb-salvage and long-term functional outcome.45-47 Only the
MESI was proposed to evaluate mangled upper extremities,
but the MESS has also been retrospectively applied to upper
extremity injuries.43,47-49
The most robust validation studies of mangled extremity
scores focused on the lower extremity, and caution was pro-
posed in applying MESS to upper extremity injury by the
original authors and others.44,49 However, the simplicity of
determining MESS (evaluation of four clinical variables—
skeletal/soft-tissue injury, limb ischemia, shock, and age) has
likely resulted in its application in assessing mangled upper
extremities for viability. Slauterbeck et al reported on 43
mangled upper extremities, and found all 9 arms with a MESS
of greater than or equal to 7 were primarily amputated,
whereas a score of less than 7, found in 34 upper extremities,
resulted in salvage.48 Durham et al also retrospectively evalu-
ated the application of limb-salvage scores independently for
both upper and lower mangled extremities and concluded
MESS and MESI both decently predicted upper limb salvage
(MESI Sn = 100%, Sp = 67%, PPV = 90%, NPV = 100%; MESS
Sn = 78%, Sp = 100%, PPV = 100%, NPV = 60%).47 Interest-
ingly, the authors concluded that these scores did not accu-
rately predict functional outcome, iterating limb viability and
function are related but not identical.
Recently, the application of MESS to combat-related upper
extremity injury has been published from Iraq and Afghani-
stan. In a combination of 17 upper and 43 lower extremity
injuries, Rush and colleagues suggested a MESS of 7 or greater
predicted limb loss.50 In a propensity-adjusted, multivariate
analysis of 64 shunted versus 61 matched, unshunted arterial
extremity injuries with a nearly 2-year mean follow-up,
Gifford confirmed the seeming fidelity of MESS.36 This case-
control study included 35 upper extremity injuries and 90
lower extremity injuries. No difference in amputation-free
survival was seen in extremities with MESS scores less than 4.
However, graduated, significant reductions were seen in
amputation-free survival for those with MESS 5 to 7 (RR 3.5;
95% CI 0.97 to 12.4; p = 0.06) and MESS 8 to 12 (RR16.4;
95% CI 3.79 to 70.98; p < 0.001).
Collectively, we believe data regarding mangled extremity
scores suggest they serve as objective reminders of subjective
clinical experience. They provide cues to the nuances leading
to either limb salvage, or limb loss in significantly injured
extremities, and provide general guidelines. Yet, their clear and
unquestioned use as indicators of whether an upper extremity
should be primarily amputated remains to be proven; and the
expertise and opinion of the evaluating surgeon remains most
essential in the approach to management.
Upper Extremity Venous Injury
The optimal management of upper extremity venous injury
remains a controversial topic. Ligation of the named veins of
the upper extremity can be performed in austere conditions
or when another life-threatening injury takes precedence with
relatively low morbidity. It has been previously recommended
that upper extremity venous injuries should be repaired when
the patient’s condition permits.51,52 Extremity venous repair
gained popularity during the Vietnam War with Rich report-
ing 377 venous injuries, in which 124 (32.9%) were repaired.
Lateral suture was the most common repair performed (n =
106) followed by end-to-end anastomosis (n = 10), vein inter-
position graft (n = 5), and vein patch graft (n = 3).53 This
14  /  Upper Extremity and Junctional Zone Injuries 155
report noted that the concern for thromboembolic complica-
tions did not materialize with venous repair, as was historically
expected. Rich also suggested that extremity venous repair
may be important for limb salvage; and, although many
repairs fail, a proportion of these may recanalize.53 How mean-
ingful recanalization is in terms of venous return or insuffi-
ciency has not been defined.
In another large, more-recent military series, Quan et al
retrospectively reviewed 82 patients with 103 venous injuries
sustained in combat operations.54 The majority of patients
(63%) were treated with ligation; no significant difference
in postoperative thromboembolic complications was seen
between the ligated and repaired groups. In 2009, Gifford and
colleagues identified venous repair as independently protec-
tive against amputation (RR = 0.2; 95% CI [0.04 to 0.99], P =
0.05) during evaluation of 135 extremity vascular injuries, 35
of which were in the upper extremity.36 This has led to the
authors’ relatively aggressive stance to repair upper extremity
veins, particularly in the proximal arm where the larger veins
represent watershed areas of venous drainage. Upper extrem-
ity vein repair should also be considered in instances where
this is a multimechanistic injury resulting in soft-tissue defect
likely to compromise venous return through damaged col-
lateral networks. In these instances, the authors observed that
maintenance or reestablishment of the main axial venous
outflow is important in quality limb salvage.
Few civilian series evaluate upper extremity venous repair
in addition to lower extremity venous injury. Meyers et al
reported 34 patients with venous injury (26 lower extremity,
8 upper extremity), and showed 61% early patency for all
venous repairs with a 40% early patency for interposition vein
graft. This report did not specifically detail the differences
between the upper and lower extremity outcomes.55 Nypaver
and colleagues reviewed longer-term follow-up (mean 49
months; range 6 to 108 months) for 32 patients who had
venous reconstruction, and found long-term patency to be
90% as determined by duplex ultrasound.56 However, only 6
upper extremity vein reconstructions (1 axillary, 5 brachial)
were performed in this series, and 60% of the brachial vein
repairs occluded.
Endovascular Management of Upper
Extremity Vascular Injuries
As endovascular technologies have emerged for elective treat-
ment of vascular disease, the application of these techniques
in the diagnosis and management of vascular trauma has also
become more common in the civilian setting.57 Endovascular
techniques have now been applied also in the combat setting.
Several descriptions of endovascular therapies in Iraq and
Afghanistan can be found in the literature. Documented
development and successful implementation of endovascular
capability in a Level III surgical facility from 2004 to 2007
during OIF has been described by Rasmussen and colleagues.58
During this period, 150 catheter-based procedures were per-
formed of which 12 included angiographic evaluation of the
upper extremity vasculature, and 2 patients underwent cov-
ered stent placement for axillosubclavian artery injury.
Specific application of catheter-based techniques to proxi-
mal upper extremity and junctional zone injuries may offer
advantages in acute vessel injury, as well as in less-urgent
traumatic sequelae such as arteriovenous fistula and pseudoa-
neurysm (Fig. 14-3). Endovascular techniques also avoid an
156 SECTION 3  /  DEFINITIVE MANAGEMENT
A B
emergent operative dissection adjacent to the brachial plexus
and the venous structures. Furthermore, use of covered stents
is becoming recognized as a feasible alternative in definitive
management in both penetrating and blunt trauma (Fig.
14-4).59,60 Even in the presence of hard signs of vascular injury
(pulsatile bleeding, absent distal pulses, expanding hematoma,
bruit or thrill) and hemodynamic instability, patients may
now be considered for endovascular repair or control in the
operating room. Endovascular management requires that
catheter-wire expertise is available and that the operating
room is capable of timely endovascular proficiency. Today, as
fixed hybrid operating room technology, with state-of-the-art
imaging becomes more commonplace, this possibility becomes
increasingly realistic and such rooms allow open conversion
when needed.
When the patient is stable and there are soft signs of vas-
cular injury, the use of CTA or Duplex ultrasound allows for
confirmation of injury definition and triage for endovascular
treatment. When there are hard signs of vascular injury, the
patient may be taken directly for angiography and endovascu-
lar therapy without preliminary imaging.
Rapid control of the proximal brachial and axillosubcla-
vian segments can be achieved endovascularly via balloon
occlusion, with follow-on definitive endovascular manage-
ment or open operative repair. Endovascular control and
repair of axillosubclavian injury may require antegrade
femoral access, retrograde ipsilateral brachial access, or both.
Passing the wire under fluoroscopic guidance across the vessel
disruption from either the antegrade femoral or retrograde
brachial approach may be challenging. Because of the shorter
distance from the access site to the injury, many consider the
retrograde brachial approach preferable. Directional catheters
and balloon centering and guidance are other endovascular
techniques used to achieve wire access across the injured
vessel.
Self-expanding and balloon-expandable covered stents
have been reported to be effective in managing select innomi-
nate and axillosubclavian injuries. In contrast, bare metal
stents have been more commonly reported for the treatment
of small dissections or intimal flaps. One multicenter trial
evaluating the use of the self-expanding Wallgraft Endoproth-
esis (Boston Scientific; Natick, MA) for the treatment of 62
iliac, femoral or subclavian arterial injuries showed the
FIGURE 14-3  A, A 21-year-old (with
multiple injuries after improvised ex-
plosive device including bilateral lower
extremity long bone fractures) under-
went “clamshell” thoracotomy for bi-
lateral hilar injuries and subsequent
laparotomy with multiple enteric inju-
ries. A large 6-cm pseudoaneurysm
of the axillary brachial junction was
identified on CT angiogram postop-
eratively. B, A retrograde left brachial
artery endovascular approach allowed
for deployment of covered stents.
endoprosthesis achieved exclusion of the injury in 93.5% of
cases and in 90% of subclavian artery injuries.61 Freedom from
bypass was achieved in 100% of injured subclavian arteries.
No procedure-related mortalities were reported and the most
common postprocedure complication involved stenosis or
occlusion. While the data support the use of endovascular
management of arterial injury, most of the procedures in this
series were performed for iatrogenic injury (78%), and com-
parison of this study group with a standard trauma popula-
tion should be done with caution.
Du Toit and colleagues reported 57 patients with penetrat-
ing subclavian artery injury that underwent stent graft treat-
ment during a 10-year period.62 One patient in this series
died due to other injuries, and 3 (5%) developed early, non–
limb-threatening stent graft occlusion. Complete follow-up
data was available for 16 patients at a mean of 61 months
(range 8 to 104 months), which showed that 5 patients had
claudication; and more than 50% exhibited in-stent stenosis
on arteriogram. These patients were successfully treated with
balloon angioplasty. Three additional asymptomatic patients
in the follow-up cohort had stent occlusion, but they did not
require reintervention. There are also multiple case reports
exhibiting the use of endografts in the setting of upper extrem-
ity arterial trauma.63-70 Hershberger et al reviewed 195 studies
published between 1995 and 2007 and suggested the overall
treatment success rate for supradiaphragmatic arterial injury
was 96%.71 When all reports reviewing endovascular treat-
ment of innominate (n = 7), subclavian (n = 91), and axillary
(n = 12) artery injuries were assessed, technical success rates
were 85.7%, 96.7% and 100%; periprocedural morbidity was
0%, 12.1% and 8.3%; and mortality was 0%, 3% and 0%,
respectively, for each segment. The rare complications that
were reported following endovascular repair of upper extrem-
ity vascular injury in these reports included access-site pseu-
doaneurysm, arm claudication, stent fracture, and thrombosis.
While short-term durability has been suggested to be
equivalent to operative repair, long-term durability of endo-
vascular stents in upper extremity traumatic injuries has not
been completely defined.59,60,62,72-74 Despite these concerns,
results to date are encouraging. Specifically, patency rates
appear to be acceptable with few authors reporting the need
to revascularize following upper extremity stent-graft occlu-
sion. The possibility of infection is a legitimate concern, but

FIGURE 14-4  A, A 30-year-old
woman sustained a high-impact blunt
injury to her right shoulder with a
clavicle fracture. Active extravasation
was seen from the subclavian artery.
B, Covered stent endovascular repair
was performed from a femoral access A B
approach.
there is no suggestion that the use of covered stents in trauma
patients poses an undue risk. In fact, the authors have not been
made aware of, or experienced any upper extremity stent
graft–related infectious complications in grafts placed in Iraq,
in Afghanistan, or in their civilian trauma practice in the U.S.
It is likely that case selection plays a meaningful role in deter-
mining infectious outcomes in endovascular repair. The upper
extremity/junctional zone may be prone to fewer infections
than other body regions, and the avoidance of morbid open
incisions may provide a protective effect. Given the overall
younger age of the trauma population, noncompliance with
follow-up and the impact of life-long, antiplatelet therapy
remain legitimate issues. However, the acute use of endovas-
cular stents does not preclude either future open repair or
catheter-based reintervention. Additional studies evaluating
longer follow-up periods and different technologies are
needed before the durability of these interventions can be
definitively assessed. As endovascular techniques and capabili-
ties continue to evolve, application in distal vascular beds is
becoming more feasible. Reports of endovascular intervention
for successful management of brachial artery transection are
appearing although the long-term results remain unclear.75
Operative Technique
Anatomy of the Junctional Zone and
Subclavian Artery
The junctional zone of the upper extremity is composed
of the thoracic outlet and shoulder. The articulations between
the first rib, the sternum, and spinal column create the bony
boundaries of the thoracic outlet. The clavicle connects to the
manubrium superior to the first rib, and these bony relation-
ships make direct access to the vasculature, including the sub-
clavian vessels and their branches, quite challenging. The
musculature surrounding the thoracic outlet can be best visu-
alized as an inverted cone with the anterior and posterior
scalenes attaching to the first and second ribs, respectively, the
sternothyroid; the sternohyoid attaching to the sternum; and
the sternocleidomastoid attaching to the medial clavicle and
sternum. While the complexity of the anatomy in this area
creates a protective cage for the underlying vessels and nerves,
obtaining proximal control in rushed emergency situations
14  /  Upper Extremity and Junctional Zone Injuries 157
can easily result in inadvertent damage to adjacent critical
structures.
The major arterial structure of the thoracic outlet is the
subclavian artery (Fig. 14-5). The right subclavian originates
from the innominate artery posterior to the costoclavicular
joint, and the left subclavian artery originates from the aortic
arch at roughly the level of the 4th left interspace. The subcla-
vian artery is divided into three sections based on the relation-
ship to the anterior scalene, and the branches provide
important collateral pathways around the shoulder (Fig. 14-6).
The first portion is proximal to the muscle; and branches
include the vertebral artery, the thyrocervical trunk, and the
internal thoracic artery. The phrenic and vagus nerves cross
anterior to the artery, and the internal jugular and subclavian
vein join together anterior to the nerves. On the left, the tho-
racic duct courses across the proximal subclavian artery and
drains into the junction of the left internal jugular and left
subclavian vein. The mid portion of the subclavian artery is
posterior to the anterior scalene, abuts the brachial plexus
trunks located posteriorly and superiorly to the artery, and
gives off the dorsalscapular branch. The third portion is
located lateral to the anterior scalene and remains in close
proximity to the brachial plexus as the cords form from the
trunks. These cords are intimately associated with the third
part of the subclavian artery, which does not have any side
branches.
Operative Management of Junctional Zone
and Subclavian Artery
The proximal portion of the right subclavian artery can be
readily exposed via a median sternotomy. Further exposure
may require a clavicular extension of the incision, with or
without resection of the clavicular head. The origin of the left
subclavian artery is in a more-posterior location on the aortic
arch and must be exposed through a high left anterolateral
thoracotomy (Fig. 14-7). The mid to distal left subclavian
artery may be controllable through a median sternotomy with
a supraclavicular or cervical extension. When the goal is to
expose the mid portion of the subclavian artery, a combined
supraclavicular/infraclavicular two-incision technique has
been described; but in the authors’ experience a single-incision
approach with subperiosteal clavicular resection (with or
without simultaneous reconstruction of the clavicle) seems
158 SECTION 3  /  DEFINITIVE MANAGEMENT
Vagus nerve
Brachial plexus
Phrenic nerve
Subclavian vein
Anterior scalene
Subclavian artery muscle
A
FIGURE 14-5  A, Anterior view of the thoracic outlets. B, Angiogram of the left subclavian artery with branches.
Right axillary artery
Level of
tourniquet
FIGURE 14-6  Angiogram demonstrating collateral circulation in
the shoulder. The important collateral vessels are the thoracoacromial,
the lateral thoracic, the subscapular, and the anterior and posterior
humeral circumflex arteries.
most expeditious and flexible. A distal left subclavian/proximal
axillary vessel injury can be exposed by a separate supracla-
vicular incision. Alternatively, the clavicle can be resected in a
subperiosteal fashion to expose the subclavian vessels. The
distal subclavian artery and proximal axillary artery is poten-
tially treatable from a two-incision approach, but injury man-
agement may require a lateral clavicular resection, again with
or without bony replacement.
Dissection in the area of the subclavian artery and vein should
be performed with care given the abundance of adjacent nerve
structures (Fig. 14-8). Aside from the brachial plexus and the
vagus nerve, the phrenic nerve sits on the anterior scalene
muscle and should be identified and preserved. The abun-
dance of collaterals around the shoulder and neck may allow
for ligation of the subclavian artery in emergency situations
with modest upper extremity ischemia. Temporary shunting,
however, may be considered and, in the authors’ opinions,
B
provides a better expeditious alternative to ligation. Tension-
free repair of the subclavian artery cannot be overemphasized
as the vessel is relatively thin, nonmuscular, and delicate.
Because of this, primary repair and patch angioplasty is chal-
lenging. If these are entertained, use of pledgets is recom-
mended. Prosthetic material can be used as an interposition
graft for these larger, more-proximal great vessel and upper
extremity reconstructions. Autologous conduit such as saphe-
nous vein, paneled saphenous vein, internal jugular vein, or
even femoral vein can be used depending on size and length
considerations. The choice is dependent on patient condition
and associated soft-tissue injury. In more extensive injuries,
ligation and revascularization using bypass with inflow based
more proximally such as from the ascending aorta, the innom-
inate artery, or the carotid systems may also be options.
Axillary Artery Anatomy
The axillary artery is the continuation of the subclavian artery
and extends from the lateral border of the first rib, becoming
the brachial artery at the lateral border of the teres major
muscle. The three parts of the axillary artery are defined by
the relationship to the anteriorly located pectoralis minor
(Fig. 14-9, A). The first part has only one branch—the supe-
rior thoracic artery. The second part contains two branches—
the thoracoacromial and lateral thoracic artery. The third part
contains three branches—the subscapular branch, the ante-
rior humeral circumflex, and the posterior humeral circum-
flex arteries. The axillary artery is bordered medially by the
axillary vein and posteriorly by the cords of the brachial plexus
proximally. Moving distally, the cords of the brachial plexus
surround the axillary artery, and ultimately these form the
named nerves of the arm at the level of the distal axillary and
proximal brachial artery (Fig. 14-9, B).
Operative Management of Axillary  
Artery Injuries
The skin of the ipsilateral neck, the chest, the supraclavicular
fossa, and the circumferential arm should be prepared and
draped into the sterile field in order to allow for proximal
control. It is a mistake to try to obtain control by incising into

Supraclavicular
incision
FIGURE 14-7  Surgical exposure of the junctional
zone vessels can be obtained by supraclavicular
and infraclavicular incisions (also see Fig. 14-9), by
left anterolateral thoracotomy and by median
sternotomy.
any obvious hematoma because this will be associated with
excessive blood loss and damage to poorly adjacent nerves.
An infraclavicular incision, made two fingerbreadths below
and parallel to the clavicle, will allow access to the proximal
axillary artery (Fig. 14-7, A). The clavipectoral fascia is divided
through the superior aspect of this incision, opening a space
which allows visualization of the proximal axillary artery.
Identification and division of the pectoralis minor muscle
through this exposure is frequently necessary to show the
entire axillary artery. In the case of more proximal axillary
artery injuries, the use of supraclavicular and infraclavicular
counterincisions allow for exposure and control of the subcla-
vian and axillary arteries; but be prepared to undertake cla-
vicular resection if adequate visualization is not obtained.
Clamps should be applied with care and precision, given the
proximity of these structures to the axillary vein and brachial
plexus.
A primary end-to-end repair of the axillary artery can be
performed, with ligation and division of side branches to
enable mobilization of the artery and provision of a tension-
free anastomosis. However, most axillary artery injuries
require more complex repair in the form of interposition graft
14  /  Upper Extremity and Junctional Zone Injuries 159
Infraclavicular
incision
Median
sternotomy
Left anterolateral
thoracotomy
reconstruction. As is the case with subclavian artery injury, the
use of autologous vein as a simple interposition or paneled
graft is a reasonable option—particularly in the setting of a
significant soft-tissue injury. Prosthetic graft is a rational alter-
native should there be size mismatch or should the patient’s
injuries preclude vein harvest. Although some suggest that the
rich collateral supply of the upper extremity allows for ligation
of the axillary artery with minimal consequence, the presence
of associated soft-tissue trauma indicates probable disruption
to these collaterals and prejudice to limb survival. Temporary
intravascular shunting is a good alternative to ligation and
allows limb perfusion, patient stabilization, and deferred
definitive repair.
Brachial Artery Anatomy
The brachial artery is the continuation of the axillary artery
and extends from the inferior border of the teres major to its
bifurcation in the antecubital fossa (Fig. 14-10). It resides
medial to the humerus and is closely associated with the
median, ulnar, and radial nerves. The radial nerve courses
away via the triangular interval with the profunda brachii
artery. The ulnar nerve courses posterior to the brachial artery,
160 SECTION 3  /  DEFINITIVE MANAGEMENT

A B

Junction innominate artery bifurcation

Internal jugular Vagus nerve
Phrenic nerve

Subclavian artery primary repair with pledgets

C
FIGURE 14-8  A, A gunshot wound sustained to the left sternoclavicular region is shown. B, A view from the patient’s head. A supraclavicular
incision was performed, and a subclavian artery and vein injury were identified. A subclavian artery GSV interposition graft was performed as
well as a subclavian vein to internal jugular GSV bypass. C, The complexity of the anatomy in the area of the subclavian artery and vein neces-
sitates meticulous dissection during operative exposure.

then toward the posterior medial humeral epicondyle in the
ulnar groove. As the brachial artery approaches the elbow
joint, the median nerve travels from lateral to medial by cross-
ing anterior to the artery. Following its exit from the axilla
the course of the brachial artery is fairly superficial, and it is
the most commonly injured vessel in the upper extremity. The
three main branches of the brachial artery are (from proximal
to distal) the profunda brachii artery, the superior ulnar col-
lateral artery, and the inferior ulnar collateral artery. The pro-
funda brachii artery passes posteriorly with the radial nerve
and runs between the medial and lateral heads of the triceps.
The branches of the profunda brachii form important col-
lateral networks with the axillary artery proximally and the
forearm vessels distally. Distal branches form the superior
radial collateral network, along with branches from the proxi-
mal radial artery. The superior and inferior ulnar arteries
accompany the ulnar nerve medially and also provide a col-
lateral network around the elbow.
Operative Management of Brachial   Brachial artery injuries resulting from low-energy stabbing
Artery Injuries
If the vessel is bleeding, proximal control can be obtained
by manual compression of the brachial artery against the
humerus. Bleeding may have ceased due to vessel contraction
and local thrombosis. As with other upper extremity vascular
injuries, the ipsilateral neck and chest should be widely
prepped and draped in case more proximal exposure is
required. The hand and wrist should be freely accessible to
allow for palpation of pulses and Doppler interrogation.
A longitudinal incision is made in the palpable groove on
the medial side of the upper arm between the biceps and the
triceps (Fig. 14-11). This incision can be extended proximally
and distally as needed. With retraction of the pectoralis
muscles exposure as high as the distal axillary artery is pos-
sible. The close proximity of the basilic vein, the median nerve,
and the ulnar nerve to the artery requires the dissection to be
performed with care and without excessive retraction. The
basilic vein should be preserved if possible, and ligating tribu-
taries will allow mobilization and easier retraction. Distally,
the bicipital aponeurosis must be divided to expose the bra-
chial artery. The median nerve will be located deep and lateral
to the artery.
mechanisms may be repaired primarily if the artery is not
devitalized. As expected, this type of repair is rarely employed
in injuries resulting from high-energy blunt and penetrating
 14  /  Upper Extremity and Junctional Zone Injuries 161

Infraclavicular
incision

C5

C6
Subclavian Brachial
C7
artery plexus
Lateral C8
A cord
T1
Axillary artery

Musculocutaneous
nerve
Median nerve

Anterior circumflex artery

Radial nerve

Pectoralis minor muscle B

(cut)
FIGURE 14-9  A, An infraclavicular incision made two fingerbreadths below and parallel to the clavicle can expose the proximal axillary artery.
Surgical anatomy of the axillary artery and six branches with the three parts defined by the relationship to the anteriorly located pectoralis
minor. B, The cords of the brachial plexus are located posteriorly to the proximal axillary artery, but surround the distal axillary artery. This close
relationship explains the high incidence of nerve injuries with axillary artery trauma.

mechanisms, which require prudent use of vein patches or,
more commonly, autogenous vein interposition grafting (Fig.
14-1). Spatulation of the ends of the anastomosis is always
necessary to avoid narrowing; and, in some instances, an inter-
rupted suture technique can be useful given the relatively
small size of the brachial artery and its tendency to spasm.
Injuries to the brachial artery distal to the origin of the
profunda brachii will be associated with a variable degree of
ischemia depending on the amount of associated damage to
the collateral circulation. Use of a temporary vascular shunt
is recommended when reconstruction of the brachial artery is
not feasible due to patient physiology or lack of available
expertise.
Radial and Ulnar Artery Anatomy
After the brachial artery crosses the antecubital fossa, it bifur-
cates into the radial and ulnar arteries. While the radial artery
is the more direct continuation of the brachial artery, the ulnar
artery is typically the larger of the two (Fig. 14-12).
The ulnar artery gives off two branches, the anterior and
posterior ulnar recurrent arteries, which form the distal com-
ponents of the collateral circulation around the elbow. The
other branch of the ulnar artery—the common interosseous
artery—passes posterolaterally toward the interosseous mem-
brane, where it bifurcates into the anterior and posterior inter-
osseous arteries that run on opposing sides of the membrane.
The superficial palmar arch is most commonly the terminal
end of the ulnar artery. In the forearm the ulnar artery courses
with the ulnar nerve.
The radial artery contains only one branch in the proximal
portion responsible for collateral circulation around the
elbow; it is the radial recurrent artery. In the forearm, the
radial artery travels with the radial nerve. The radial artery
most commonly becomes the deep palmar arch in the hand.
Operative Management of Radial  
and Ulnar Artery Injuries
Typically, forearm hemorrhage can be controlled with direct
pressure. The proximal portion of the arm, the entire hand,
and fingers should be prepped and draped in a circumferential
manner in order to allow for adequate proximal and distal
control and operative exposure and assessment of the radial
and ulnar arteries.
An S-shaped incision over the antecubital fossa will allow
for proximal exposure of both the radial and ulnar arteries.
Identifying the brachial artery as described above and tracing
it distally may aid in identifying the ulnar and radial arteries.
The radial artery follows the medial border of the brachiora-
dialis muscle, and the medial groove of this muscle can be
used as a landmark to make an incision in the mid forearm
(Fig. 14-13). In the distal wrist, the radial artery can be exposed
by a longitudinal incision slightly lateral to the artery.
162 SECTION 3  /  DEFINITIVE MANAGEMENT

Brachial
plexus

Subclavian artery
Brachiocephalic vein
Cephalic vein

Aortic arch
Axillary artery

Subclavian vein
Brachial artery Axillary vein

Brachial vein
Humerus

Teres major muscle

Basilic vein

Antecubital fossa

Radial artery Median cubital vein

Ulnar artery
FIGURE 14-10  The brachial artery is the continuation of the axillary artery and extends from the inferior border of the teres major muscle to
its bifurcation in the antecubital fossa. Important anatomic relationships include three main artery branches, three associated veins, three associ-
ated nerves, and three associated muscles.

Posterior branch of
profunda brachii artery
Biceps brachii
muscle Superior ulnar
Radial collateral branch collateral artery
of profunda brachii artery
Inferior ulnar
Brachialis muscle Radial nerve collateral artery
Radial recurrent artery Anterior ulnar
Brachioradialis
Deep br. of radial nerve recurrent artery
muscle
Brachial Superficial br. Posterior ulnar
Pronator artery of radial nerve recurrent artery
teres muscle Interosseous Common
Median recurrent artery interosseous artery
nerve Volar Dorsal
interosseous artery interosseous artery
Median nerve
Anterior
interosseous nerve
Radial artery Ulnar nerve
Ulnar artery

FIGURE 14-11  Surgical exposure of the brachial artery is obtained

rapidly by a longitudinal incision along the course of the artery with
an extension as an S curve either across the axilla proximally or across
the antecubital fossa distally. The median nerve and basilic vein are in
close proximity to the artery.

FIGURE 14-12  The radial and ulnar arteries have close relationships
with the radial nerve and ulnar nerve in the forearm.

Ulnar nerve
Flexor digitorum
Ulnar artery
superficialis muscle
Flexor digitorum Flexor carpi
profundus muscle ulnaris muscle
A B
FIGURE 14-13  A, The ulnar artery can be exposed through a longitudinal incision made on the medial arm about four fingerbreadths distal
to the medial epicondyle. The artery can be identified between the flexor carpi ulnaris and flexor digitorum superficialis. B, The medial groove
can be used as a landmark to expose the radial artery, which follows the medial border of the brachioradialis muscle.
The ulnar artery dives deep to the pronator teres slightly
beyond the bifurcation and remains deep to the flexor muscles
of the proximal forearm before emerging into a more super-
ficial position, approximately at the midpoint of the forearm,
which makes proximal exposure more difficult. A longitudinal
incision is made on the medial side of the arm about four
fingerbreadths distal to the medial epicondyle, and the artery
can be identified between the flexor carpi ulnaris and the
flexor digitorum superficialis (see Fig. 14-13). In the wrist, the
ulnar artery can be exposed through a longitudinal incision
on the radial side of the flexor carpi ulnaris muscle in order
to avoid the ulnar nerve, which runs lateral to the ulnar artery.
Typically, the management of forearm artery injury is
dependent on whether or not there is a satisfactory continuous-
wave Doppler signal at the wrist and/or in the hand. Should
a reasonable signal in the palmar arches be maintained—
despite outflow occlusion of the injured vessel—ligation is a
viable alternative to repair. Primary repair of simple lacera-
tions using fine permanent sutures is also reasonable. Spatula-
tion with interrupted technique is required when undertaking
end-to-end anastomosis. When the hand is acutely ischemic
as a result of significant forearm vascular injury, vein graft
interposition or bypass originating from the brachial artery is
required. For reconstruction, at the wrist it is helpful to have
a hand surgeon present. Conduits for wrist/hand level recon-
struction can include forearm or foot vein as well as various
other arterial conduits.76
Nonoperative Management in Upper
Extremity Injury
Nonocclusive arterial injuries, including pseudoaneurysms,
initimal flaps, stenosis/spasm, and arteriovenous fistulas may
14  /  Upper Extremity and Junctional Zone Injuries 163
Superficial radial
nerve
Brachioradialis
muscle
Radial artery
be managed nonoperatively if the disruption is not flow limit-
ing.77,78 Use of anticoagulants or antiplatelet therapy should
be considered in contained flap or dissection-type injuries,
and prompt arteriogram with endovascular or open interven-
tion should be performed if there is development of ischemic
symptoms. Follow-up at regular intervals is advisable for this
patient population, and evaluation utilizing noninvasive
imaging such as duplex ultrasound offers a reasonable method
for determining progression or resolution of the nonocclusive
injury. The place of endovascular methods for treatment of
minimal injuries in the upper extremity is not well defined.
Postoperative Care
Monitoring
Patients in the immediate perioperative period require close
monitoring of the injured limb and its circulation. The deci-
sion to locate the patient in the intensive care unit or in an
intermediate care ward is institution-specific and depends on
blood loss and the need for ongoing volume resuscitation,
rewarming, and correction of physiology. Continuous-wave
Doppler is used to help assess the adequacy of the vascular
repair before return of a palpable pulse, although mere pres-
ence of a signal does not necessarily denote patency. Further
evaluation of perfusion includes extremity warmth, presence
of sensorimotor function, and capillary refill. Duplex ultra-
sound can also be used to assess the patency of a repaired
vascular segment, and in some cases this identifies technical
defects that may benefit from early reintervention.
If a fasciotomy has not been performed, or has been
incompletely performed, the development of compartment
164 SECTION 3  /  DEFINITIVE MANAGEMENT
syndrome should be vigilantly guarded against through fre-
quent and regular review. Compartment syndrome is dis-
cussed in greater detail later in the chapter.
Wound Care
Negative pressure dressings (V.A.C.) can be particularly ben-
eficial in dressing open wounds when primary skin closure is
not feasible, between serial evaluations of soft-tissue viability
or following fasciotomy pending definitive wound closure.
Negative pressure therapy may promote wound healing79,80;
but vascular reconstructions must be properly covered with
soft tissue or muscle flaps in order to prevent communication
between the vacuum dressing and the vascular space, graft
desiccation, and anastomotic breakdown. Similarly, while
wound closure may be delayed in some types of injury by the
need for serial irrigation and débridement, soft-tissue integ-
rity should be restored as soon as possible—whether through
delayed primary closure, skin graft, or muscle flap (Fig. 14-14).
Wounds treated through delayed primary closure should be
tension-free with minimal compression in order to avoid del-
eterious consequences. Extremity elevation will help decrease
edema.
Rehabilitation
Physical and occupational therapy should be employed as
soon as possible after upper extremity injury in order to help
prevent contractures and muscular atrophy. A meticulous
evaluation for sensorimotor deficits is a prerequisite for
therapy aimed at regaining, or learning to compensate for, lost
function. Appropriate coordination regarding timing and
weight-bearing status should be coordinated with other spe-
cialists involved in the patients care.
Typically, rehabilitation after upper extremity injury can be
a challenging process when compared to the lower extremity,
which is a testament to the more intricate and complex tasks
required of the hand and arm. Technologies have advanced
beyond esthetic prosthetics to body-powered, and even myo-
electric and neural, controlled bioprosthetics.
A B
FIGURE 14-14  A, Wound VAC placement after a forearm fasciotomy was performed. B, Maintenance of domain allowed for a delayed primary
closure to be performed. Full closure was achieved post injury day 6.
Outcomes and Complications
Outcomes After Upper Extremity  
Vascular Injury
Commonly accepted outcomes after treatment of upper
extremity and junctional zone arterial injuries are presented
in Table 14-1. In general, it is observed that the more distal
the injury, the lower the chance that it will be fatal or lead to
limb loss. Outcomes after upper extremity vascular injury
have evolved beyond measurements of mortality alone, largely
because advancements in prehospital and early resuscitative
care mean that injury to an upper extremity artery is rarely
the sole contributor to death. Furthermore, limb salvage in
and of itself is perhaps a poor indicator of successful treat-
ment, as many limbs may be painful or poorly performing,
even though the tissue remains viable after revasculariza-
tion.81,82 Ultimately these issues may lead to delayed upper
extremity amputation, rehabilitation, and fitting of a prosthe-
sis. Function-related outcomes after upper extremity vascular
injury and arterial reconstruction serve as more relevant
modern benchmarks, and several studies have evaluated
these.
In a retrospective study spanning 13 years, Hardin et al
reviewed 99 upper extremity arterial injuries involving 21 axil-
lary, 43 brachial, 12 radial, 13 ulnar, and 10 combined radial
and ulnar vessels.8 Ultimately only 5 patients required ampu-
tation. Complete return of function occurred in 49 (49%) of
these patients, whereas the remaining 50 patients were left
with some degree of permanent functional impairment.
Injury to the axillary artery was associated with the highest
incidence of severe neurological impairment, attributed of the
close proximity of the brachial plexus to the artery and to a
higher burden of tissue ischemia. Shotgun and gunshot inju-
ries were more often associated with long-term functional
disability, whereas lacerations, stab wounds, and blunt injury
were more often associated with recovery.
Brown et al performed a retrospective review of 71 patients
who underwent operative management of upper extremity

arterial injury.19 The limb-salvage rate was 94%, and follow-up
after injury was 6.3 months (ranging from 0 to 33 months).
Patients who sustained blunt injury were more likely to have
severe disability than patients with a penetrating injury. Those
with concomitant orthopedic trauma were as likely to have a
full functional recovery as those without such injury. The
importance of associated nerve damage was highlighted; and
patients who had a concomitant nerve injury, whether com-
bined with an orthopedic injury or not, were less likely to
regain function. Additionally, patients who had delayed repair
of nerves were more likely to have severe disability or late
amputation. These authors found that those patients with
injuries deemed severe enough to require fasciotomy did not
gain functional recovery and were left with the most severe-
disability. It seems clear from the available data that while
restoration of arterial perfusion and stabilization of bony
injuries is often feasible, the ability to treat the formidable
functional sequelae of nerve and soft-tissue disruption deter-
mines outcome in many cases.
Complications After Upper Extremity
Vascular Injury
Complications after upper extremity arterial injury and
repair include reperfusion injury, thrombosis, anastomotic
hemorrhage, infection, and pseudoaneurysm. The risk of
complications varies according to type and severity of injury
but has not been well defined in the literature, with most
series focusing on mortality and limb salvage rather than
repair-related complications. The authors’ experience, re-
ported in an analysis of upper extremity vascular injuries
from OIF involving 45 patients, showed that the rate of early
complications after repair was significant and included infec-
tion (4.7%), thrombosis (9.3%), anastomotic hemorrhage
(2.3%), and early amputation (9.3%).2 A high index of suspi-
cion for postoperative complications, with close and repeated
clinical evaluation, and early use of Duplex ultrasound or CT
angiography are recommended to enable early diagnosis and
mitigation to thereby reduce associated morbidity and
mortality.
Upper Extremity Compartment Syndrome
Although less commonly observed in the upper extremity
compared to the lower extremity, compartment syndrome
may affect the forearm or, less frequently, the upper arm
(triceps/deltoid). The diagnosis should always be considered
in any patient with blunt or penetrating extremity trauma,
particularly in patients who have endured prolonged isch-
emia or transport times and in those that require sizable fluid
resuscitation. The earliest symptom of compartment syn-
drome is increasing pain. As the syndrome progresses, find-
ings on physical examination will be pronounced and include
tense compartments, pain on passive extension, progressive
loss of sensation, and weakness. Loss of a distal pulse is a late
finding.
Direct pressure measurement of the compartments can
help confirm the diagnosis, with normal compartment pres-
sures ranging from 0 to 9 mm Hg. While debatable, a com-
partment pressure over 30 mm Hg is considered elevated and
warrants prompt fasciotomy. Some use the pressure difference
between the diastolic blood pressure and the compartment
pressure as a marker for compartment syndrome. When this
difference in pressure is 30 mm Hg or less, compartment syn-
14  /  Upper Extremity and Junctional Zone Injuries 165
Box 14-1 Indications for Fasciotomy in the
Combat Setting
• >4- to 6-hour evacuation delay to revascularization
• Combined arterial and venous injuries
• Crush injuries
• High–kinetic energy mechanism
• Vascular repair
• Arterial or venous ligation
• Comatose, closed head injury, or epidural analgesia
• Tense compartments
• Prophylactic
Adapted from Starnes BW et al: Extremity vascular injuries on the
battlefield: tips for surgeons deploying to war. J Trauma 60:432-
442, 2006.
drome is suggested. However, the finding of normal pressure
does not preclude the presence of compartment syndrome or
its development at a future time point, and prophylactic fas-
ciotomy should be considered. This is particularly important
if prolonged transport to definitive care is anticipated. In
austere environments such as military combat, where com-
partment pressure measurements are not easily performed,
the threshold to perform a prophylactic fasciotomy is much
lower than in an urban civilian setting. Indications for fasci-
otomy in the combat setting are shown in Box 14-1. Further,
in one study from Iraq and Afghanistan of air-evacuated
patients with extremity injuries, the need for fasciotomy revi-
sion predicted mortality and tissue loss, while delayed fasci-
otomy predicted mortality, tissue loss, and amputation.83
Kim et al reviewed 139 patients with brachial artery injury
and found that 29 patients (20.9%) were diagnosed with
upper extremity compartment syndrome. Multiple arterial
injuries, total intraoperative blood loss, and open fractures
were found to be significant independent risk factors for the
development of compartment syndrome in this series (OR
1.12, 5.79, and 2.68, respectively).84 In a follow-up study, Kim
et al developed a prognostic score for compartment syndrome
after upper extremity vascular injury based on the three afore-
mentioned variables (1 point for every 100 mL of intraopera-
tive blood loss, 6 points for the presence of multiple arterial
injuries, 3 points for the presence of open fracture).85 A score
of less than 2.5 had 97% sensitivity and 37% specificity for
development of compartment syndrome, whereas a score of
20 had 97% specificity and 38% sensitivity. While this scoring
system may offer an adjunct to the clinical decision making of
whether or not to perform a fasciotomy of the upper extremity
after arterial injury, it is important to keep in mind this score
has not been prospectively validated.
The skin and fascial incision for upper extremity forearm
fasciotomy extends from the lower medial aspect of the upper
arm, becoming sinusoidal from medial to lateral at the ante-
cubital fossa, incorporating the bicipital aponeurosis (Fig.
14-15). The incision extends sufficiently lateral to open the
forearm fascia over the extensor wad. The incision then curves
gently back to the volar aspect to release the fascia, with con-
comitant carpal tunnel release dependent on the injury type
and extent of tissue compromise. In instances with penetrat-
ing trauma, the injury itself may provide partial compartment
release.
166 SECTION 3  /  DEFINITIVE MANAGEMENT
A 24. Sampson LN, Britton JC, Eldrup-Jorgensen J, et al: The neurovascular
B niquets to stop bleeding in major limb trauma. J Trauma 64:S38–S49,
FIGURE 14-15  A, Fasciotomy of the upper extremity should begin
medially in the arm, and become sinusoidal from medial to lateral at
the antecubital fossa, incorporating the bicipital aponeurosis. Exten-
sion must be sufficiently lateral to open the fascia over the extensor
wad. Gentle incision back to the volar fascia will help to also release
this aspect. B, Extensor counterincision is rarely necessary.
REFERENCES
1. Clouse WD, Rasmussen TE, Peck MA, et al: In-theater management of
vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg
204:625–632, 2007.
2. Clouse WD, Rasmussen TE, Perlstein J, et al: Upper extremity vascular
injury: a current in-theater wartime report from Operation Iraqi
Freedom. Ann Vasc Surg 20:429–434, 2006.
3. Costa MC, Robbs JV: Nonpenetrating subclavian artery trauma. J Vasc
Surg 8:71–75, 1988.
4. Debakey ME, Simeone FA: Battle injuries of the arteries in World War II:
an analysis of 2,471 cases. Ann Surg 123:534–579, 1946.
5. Demetriades D, Chahwan S, Gomez H, et al: Penetrating injuries to the
subclavian and axillary vessels. J Am Coll Surg 188:290–295, 1999.
6. Graham JM, Feliciano DV, Mattox KL, et al: Management of subclavian
vascular injuries. J Trauma 20:537–544, 1980.
7. Graham JM, Mattox KL, Feliciano DV, et al: Vascular injuries of the axilla.
Ann Surg 195:232–238, 1982.
8. Hardin WD, Jr, O’Connell RC, Adinolfi MF, et al: Traumatic arterial inju-
ries of the upper extremity: determinants of disability. Am J Surg 150:
266–270, 1985.
9. Hughes CW: Arterial repair during the Korean war. Ann Surg 147:555–
561, 1958.
10. Humphrey PW, Nichols WK, Silver D: Rural vascular trauma: a twenty-
year review. Ann Vasc Surg 8:179–185, 1994.
11. Lin PH, Koffron AJ, Guske PJ, et al: Penetrating injuries of the subclavian
artery. Am J Surg 185:580–584, 2003.
12. Mattox KL, Feliciano DV, Burch J, et al: Five thousand seven hundred
sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution
1958 to 1987. Ann Surg 209:698–705, Discussion 6–7, 1989.
13. Menakuru SR, Behera A, Jindal R, et al: Extremity vascular trauma in
civilian population: a seven-year review from North India. Injury 36:400–
406, 2005.
14. Pasch AR, Bishara RA, Lim LT, et al: Optimal limb salvage in penetrating
civilian vascular trauma. J Vasc Surg 3:189–195, 1986.
15. Peck MA, Clouse WD, Cox MW, et al: 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 45:1197–1204, Discussion 204–5, 2007.
16. Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam:
1,000 cases. J Trauma 10:359–369, 1970.
17. Shanmugam V, Velu RB, Subramaniyan SR, et al: Management of upper
limb arterial injury without angiography—Chennai experience. Injury
35:61–64, 2004.
18. Shaw AD, Milne AA, Christie J, et al: Vascular trauma of the upper limb
and associated nerve injuries. Injury 26:515–518, 1995.
19. Brown KR, Jean-Claude J, Seabrook GR, et al: Determinates of functional
disability after complex upper extremity trauma. Ann Vasc Surg 15:43–48,
2001.
20. Zellweger R, Hess F, Nicol A, et al: An analysis of 124 surgically managed
brachial artery injuries. Am J Surg 188:240–245, 2004.
21. Blaisdell FW: Civil War vascular injuries. World J Surg 29(Suppl 1):
S21–S24, 2005.
22. Dragas M, Davidovic L, Kostic D, et al: Upper extremity arterial injuries:
factors influencing treatment outcome. Injury 40:815–819, 2009.
23. Endean ED, Veldenz HC, Schwarcz TH, et al: Recognition of arterial
injury in elbow dislocation. J Vasc Surg 16:402–406, 1992.
outcome of scapulothoracic dissociation. J Vasc Surg 17:1083–1088, Dis-
cussion 8–9, 1993.
25. Riess KP, Cogbill TH, Patel NY, et al: Brachial plexus injury: long-term
functional outcome is determined by associated scapulothoracic dissocia-
tion. J Trauma 63:1021–1025, 2007.
26. Kragh JF, Jr, Walters TJ, Baer DG, et al: Survival with emergency tourni-
quet use to stop bleeding in major limb trauma. Ann Surg 249:1–7, 2009.
27. Kragh JF, Jr, Walters TJ, Baer DG, et al: Practical use of emergency tour-
Discussion S–50, 2008.
28. Lakstein D, Blumenfeld A, Sokolov T, et al: Tourniquets for hemorrhage
control on the battlefield: a 4-year accumulated experience. J Trauma
54:S221–S225, 2003.
29. Walters TJ, Wenke JC, Kauvar DS, et al: Effectiveness of self-applied tour-
niquets in human volunteers. Prehosp Emerg Care 9:416–422, 2005.
30. Kotwal RS, Montgomery HR, Kotwal BM, et al: Eliminating preventable
death on the battlefield. Arch Surg 146:1350–1358, 2011.
31. Moore FA: Tourniquets: another adjunct in damage control? Ann Surg
249:8–9, 2009.
32. Walters TJ, Mabry RL: Issues related to the use of tourniquets on the
battlefield. Mil Med 170:770–775, 2005.
33. Chambers LW, Green DJ, Sample K, et al: Tactical surgical intervention
with temporary shunting of peripheral vascular trauma sustained during
Operation Iraqi Freedom: one unit’s experience. J Trauma 61:824–830,
2006.
34. Rasmussen TE, Clouse WD, Jenkins DH, et al: The use of temporary
vascular shunts as a damage control adjunct in the management of
wartime vascular injury. J Trauma 61:8–12, Discussion 12–5, 2006.
35. Taller J, Kamdar JP, Greene JA, et al: Temporary vascular shunts as initial
treatment of proximal extremity vascular injuries during combat opera-
tions: the new standard of care at Echelon II facilities? J Trauma 65:595–
603, 2008.
36. Gifford SM, Aidinian G, Clouse WD, et al: Effect of temporary shunting
on extremity vascular injury: an outcome analysis from the Global War
on Terror vascular injury initiative. J Vasc Surg 50:549–555, Discussion
55–6, 2009.
37. Granchi T, Schmittling Z, Vasquez J, et al: Prolonged use of intraluminal
arterial shunts without systemic anticoagulation. Am J Surg 180:493–496,
Discussion 6–7, 2000.
38. Nichols JG, Svoboda JA, Parks SN: Use of temporary intraluminal shunts
in selected peripheral arterial injuries. J Trauma 26:1094–1096, 1986.
39. Reber PU, Patel AG, Sapio NL, et al: Selective use of temporary intravas-
cular shunts in coincident vascular and orthopedic upper and lower limb
trauma. J Trauma 47:72–76, 1999.
40. Sriussadaporn S, Pak-art R: Temporary intravascular shunt in complex
extremity vascular injuries. J Trauma 52:1129–1133, 2002.
41. Johansen K, Bandyk D, Thiele B, et al: Temporary intraluminal shunts:
resolution of a management dilemma in complex vascular injuries.
J Trauma 22:395–402, 1982.
42. Subramanian A, Vercruysse G, Dente C, et al: A decade’s experience with
temporary intravascular shunts at a civilian level I trauma center.
J Trauma 65:316–324, Discussion 24–6, 2008.
43. Gregory RT, Gould RJ, Peclet M, et al: The mangled extremity syndrome
(M.E.S.): a severity grading system for multisystem injury of the extrem-
ity. J Trauma 25:1147–1150, 1985.
44. Johansen K, Daines M, Howey T, et al: Objective criteria accurately
predict amputation following lower extremity trauma. J Trauma 30:568–
572, Discussion 72–3, 1990.
45. Bonanni F, Rhodes M, Lucke JF: The futility of predictive scoring of
mangled lower extremities. J Trauma 34:99–104, 1993.
46. Bosse MJ, MacKenzie EJ, Kellam JF, et al: A prospective evaluation of the
clinical utility of the lower-extremity injury-severity scores. J Bone Joint
Surg Am 83-A:3–14, 2001.
47. Durham RM, Mistry BM, Mazuski JE, et al: Outcome and utility of
scoring systems in the management of the mangled extremity. Am J Surg
172:569–573, Discussion 73–4, 1996.
48. Slauterbeck JR, Britton C, Moneim MS, et al: Mangled extremity severity
score: an accurate guide to treatment of the severely injured upper
extremity. J Orthop Trauma 8:282–285, 1994.

49. Togawa S, Yamami N, Nakayama H, et al: The validity of the mangled
extremity severity score in the assessment of upper limb injuries. J Bone
Joint Surg Br 87:1516–1519, 2005.
50. Rush RM, Jr, Kjorstad R, Starnes BW, et al: Application of the Mangled
Extremity Severity Score in a combat setting. Mil Med 172:777–781, 2007.
51. Timberlake GA, Kerstein MD: Venous injury: to repair or ligate, the
dilemma revisited. Am Surg 61:139–145, 1995.
52. Timberlake GA, O’Connell RC, Kerstein MD: Venous injury: to repair or
ligate, the dilemma. J Vasc Surg 4:553–558, 1986.
53. Rich NM, Hughes CW, Baugh JH: Management of venous injuries. Ann
Surg 171:724–730, 1970.
54. Quan RW, Gillespie DL, Stuart RP, et al: The effect of vein repair on the
risk of venous thromboembolic events: a review of more than 100 trau-
matic military venous injuries. J Vasc Surg 47:571–577, 2008.
55. Meyer J, Walsh J, Schuler J, et al: The early fate of venous repair after
civilian vascular trauma. A clinical, hemodynamic, and venographic
assessment. Ann Surg 206:458–464, 1987.
56. Nypaver TJ, Schuler JJ, McDonnell P, et al: Long-term results of venous
reconstruction after vascular trauma in civilian practice. J Vasc Surg 16:
762–768, 1992.
57. Starnes BW, Arthurs ZM: Endovascular management of vascular trauma.
Perspect Vasc Surg Endovasc Ther 18:114–129, 2006.
58. Rasmussen TE, Clouse WD, Peck MA, et al: Development and implemen-
tation of endovascular capabilities in wartime. J Trauma 64:1169–1176,
Discussion 76, 2008.
59. Danetz JS, Cassano AD, Stoner MC, et al: Feasibility of endovascular
repair in penetrating axillosubclavian injuries: a retrospective review.
J Vasc Surg 41:246–254, 2005.
60. du Toit DF, Strauss DC, Blaszczyk M, et al: Endovascular treatment of
penetrating thoracic outlet arterial injuries. Eur J Vasc Endovasc Surg
19:489–495, 2000.
61. White R, Krajcer Z, Johnson M, et al: Results of a multicenter trial for the
treatment of traumatic vascular injury with a covered stent. J Trauma
60:1189–1195, Discussion 95–6, 2006.
62. du Toit DF, Lambrechts AV, Stark H, et al: Long-term results of stent graft
treatment of subclavian artery injuries: management of choice for stable
patients? J Vasc Surg 47:739–743, 2008.
63. Babatasi G, Massetti M, Le Page O, et al: Endovascular treatment of a
traumatic subclavian artery aneurysm. J Trauma 44:545–547, 1998.
64. Brandt MM, Kazanjian S, Wahl WL: The utility of endovascular stents in
the treatment of blunt arterial injuries. J Trauma 51:901–905, 2001.
65. Janne d’Othee B, Rousseau H, Otal P, et al: Noncovered stent placement
in a blunt traumatic injury of the right subclavian artery. Cardiovasc
Intervent Radiol 22:424–427, 1999.
66. Jeroukhimov I, Altshuler A, Peer A, et al: Endovascular stent-graft is a
good alternative to traditional management of subclavian vein injury.
J Trauma 57:1329–1330, 2004.
67. Renger RJ, de Bruijn AJ, Aarts HC, et al: Endovascular treatment of a
pseudoaneurysm of the subclavian artery. J Trauma 55:969–971, 2003.
68. Stecco K, Meier A, Seiver A, et al: Endovascular stent-graft placement for
treatment of traumatic penetrating subclavian artery injury. J Trauma
48:948–950, 2000.
14  /  Upper Extremity and Junctional Zone Injuries 167
69. Teso D, Bloch R, Pohlman T, et al: Simultaneous endovascular repair of
traumatic rupture of the right subclavian artery and thoracic aorta. Ann
Thorac Surg 91:281–283, 2011.
70. Lonn L, Delle M, Karlstrom L, et al: Should blunt arterial trauma to the
extremities be treated with endovascular techniques? J Trauma 59:1224–
1227, 2005.
71. Hershberger RC, Aulivola B, Murphy M, et al: Endovascular grafts for
treatment of traumatic injury to the aortic arch and great vessels.
J Trauma 67:660–671, 2009.
72. Bates MC, Campbell J: Emergent stent graft isolation of a knife-related
subclavian arterial venous fistula: lessons learned during long-term
follow-up. Catheter Cardiovasc Interv 66:483–486, 2005.
73. Carrick MM, Morrison CA, Pham HQ, et al: Modern management of
traumatic subclavian artery injuries: a single institution’s experience in
the evolution of endovascular repair. Am J Surg 199:28–34, 2010.
74. Xenos ES, Freeman M, Stevens S, et al: Covered stents for injuries of
subclavian and axillary arteries. J Vasc Surg 38:451–454, 2003.
75. Maynar M, Baro M, Qian Z, et al: Endovascular repair of brachial artery
transection associated with trauma. J Trauma 56:1336–1341, discussion
41, 2004.
76. McClinton MA: Reconstruction for ulnar artery aneurysm at the wrist.
J Hand Surg [Am] 36:328–332, 2011.
77. Dennis JW, Frykberg ER, Veldenz HC, et al: Validation of nonoperative
management of occult vascular injuries and accuracy of physical exami-
nation alone in penetrating extremity trauma: 5- to 10-year follow-up.
J Trauma 44:243–252, discussion 2–3, 1998.
78. Stain SC, Yellin AE, Weaver FA, et al: Selective management of nonoc-
clusive arterial injuries. Arch Surg 124:1136–1140, Discussion 40–1, 1989.
79. Labler L, Rancan M, Mica L, et al: Vacuum-assisted closure therapy
increases local interleukin-8 and vascular endothelial growth factor levels
in traumatic wounds. J Trauma 66:749–757, 2009.
80. Jacobs S, Simhaee DA, Marsano A, et al: Efficacy and mechanisms of
vacuum-assisted closure (VAC) therapy in promoting wound healing: a
rodent model. J Plast Reconstr Aesthet Surg 62:1331–1338, 2009.
81. Burkhardt GE, Gifford SM, Propper B, et al: The impact of ischemic
intervals on neuromuscular recovery in a porcine (Sus scrofa) survival
model of extremity vascular injury. J Vasc Surg 53:165–173, 2011.
82. Hancock HM, Stannard A, Burkhardt GE, et al: Hemorrhagic shock
worsens neuromuscular recovery in a porcine model of hind limb vascu-
lar injury and ischemia-reperfusion. J Vasc Surg 53:1052–1062, Discus-
sion 62, 2011.
83. Ritenour AE, Dorlac WC, Fang R, et al: Complications after fasciotomy
revision and delayed compartment release in combat patients. J Trauma
64:S153–S161, Discussion S61–2, 2008.
84. Kim JY, Buck DW, 2nd, Forte AJ, et al: Risk factors for compartment
syndrome in traumatic brachial artery injuries: an institutional experi-
ence in 139 patients. J Trauma 67:1339–1344, 2009.
85. Kim JY, Schierle CF, Subramanian VS, et al: A prognostic model for the
risk of development of upper extremity compartment syndrome in the
setting of brachial artery injury. Ann Plast Surg 62:22–27, 2009.
 Lower Extremity
15  Vascular Trauma
NEIL G. KUMAR, BRIAN S. KNIPP, AND DAVID L. GILLESPIE
Introduction
Vascular injury to the lower extremity is a common pattern of
vascular trauma. Injuries to junctional zone vessels are espe-
cially challenging and potentially lethal. Foremost, injury to
the distal iliac and proximal femoral arteries and veins poses
a challenge with hemorrhage control. The term junctional
vascular injury was a product of the military’s recognition
during the wars in Afghanistan and Iraq that, although tour-
niquets were effective in controlling lower extremity hemor-
rhage, they did not work if the penetrating wounds were too
proximal on the lower extremity (i.e., the junctional zone
between the torso and the lower extremity). Furthermore,
injury to the distal iliac and proximal femoral arteries result-
ing in hemorrhage is often very difficult for a medic or
bystander to control with manual pressure because the vessels
are either large or deep under the inguinal ligament and the
distal pelvic outlet. Because of this injury pattern’s propensity
for exsanguinating hemorrhage, the military has coined the
term “junctional lower extremity vascular injury” to facilitate
study and to improve management strategies. More distal
injuries such as those to the femoral, popliteal, and tibial seg-
ments may also lead to lethal hemorrhage; but from a practical
standpoint these injuries are amenable to tourniquet control.
Lower extremity vascular trauma at any anatomic level poses
challenges not only related to control of bleeding but also with
regard to decisions related to restoration of perfusion and
reconstruction of the vascular injury.
History and Background
When considering those who died of combat wounds from
2001 to 2009, nearly 41% had potentially survivable injuries
if hemorrhage had been controlled in a more prompt and
effective manner.1 In this context, potentially survivable death
means mortality that occurred in the absence of a lethal head
or cardiac wound or body disruption from explosive injury.
The body regions accounting for death with otherwise surviv-
able injuries include trauma to the torso (48%), to the extrem-
ities (31%), and to the junctional region (21%). Table 15-1
shows the incidence of lower extremity vascular injury in mili-
tary conflicts, past and present. The rate of exsanguination
from torso trauma has decreased over the years possibly due
to the use of body armor. Similarly, the rate of extremity
hemorrhage has decreased likely due to the broad distribution,
training, and use of tourniquets.2-4 With improvements in
body armor, which protects from central torso trauma, injury
to the extremity vessels has contributed a larger percentage of
168
overall vascular injuries. Lower extremity vascular injuries will
likely continue to be common due to practical limitations
associated with extremity and junctional zone armor.5
Lower extremity vascular injury is also common in the
civilian setting where injuries to the iliac artery and vein have
a higher incidence than in the military setting. Mattox et al
documented 232 iliac artery injuries and 289 vein injuries,
representing 4% and 5%, respectively, of all vascular injuries
in a single-center civilian registry.13 Femoral and popliteal
vessel injuries are more common than iliac vessel injuries in
civilian trauma centers, which likely reflects their longer extent
and exposed position. In a report by Branco et al femoral
vessel injury comprised approximately 25% of all extremity
vascular injuries.14 Comparatively, Asensio et al reported
femoral vessel injuries to be even more common, accounting
for nearly 70% of peripheral vascular injuries.15 However, in
isolated lower extremity trauma, the most commonly injured
artery is the popliteal, with the majority of injuries resulting
from blunt mechanism.16 Blunt injuries are more likely to be
associated with orthopedic fractures or dislocations and likely
to result in longer hospital stays and higher rates of amputa-
tion than other lower forms of extremity arterial injury.17
Similarly, the number of tibial artery injuries and the pro-
portion of all vascular injuries they represent have increased
in the past number of years. A recent single institution study
of lower extremity vascular trauma reported that the tibial
arteries were the most commonly injured vessels and accounted
for 36% of cases. The most common mechanism of tibial
artery injury is gunshot wound (37%) with motor-vehicle
accidents (26%) contributing a significant portion as well.13,18
Presentation and Diagnosis
Assessment of a patient with a potential lower extremity injury
or a junctional zone vascular injury follows a standard
approach outlined in the Advanced Trauma Life Support
(ATLS) program developed by the American College of Sur-
geons (ACS) and its Committee on Trauma (COT).19 Fore-
most, control of bleeding with a tourniquet or manual pressure
is necessary to prevent exsanguination. Depending on the
location, if a standard Combat Application Tourniquet (C-A-
T’ North American Rescue, LLC, Greer, SC) is not available, a
manual blood pressure cuff may be inflated proximal to the
injury to act as a tourniquet to control bleeding. As described,
the vexing problem lies with junctional vascular injuries which
are not amenable to tourniquet application and are difficult
to control with manual pressure. In these instances, manual
pressure with or without a topical hemostatic agent such as
 15  /  Lower Extremity Vascular Trauma 168.e1

ABSTRACT
Vascular trauma of the lower extremities is associated with
high rates of morbidity and mortality and is especially chal-
lenging when it involves the junctional zone between the
torso and the lower extremities. Lower extremity junctional
injuries are those that occur to the distal iliac and proximal
femoral vessels. In the absence of hard signs of injury, lower
extremity junctional vascular trauma may be challenging
to diagnose; and, in the presence of hard signs, they may
be hard to control, expose, and repair. The successful man-
agement of lower extremity vascular injury is dependent
on early diagnosis and control of hemorrhage, resuscitation
of the patient, and prompt intervention to minimize associ-
ated ischemia. The most important factors in life- and limb-
saving interventions relate to prompt control of hemorrhage
and time to reperfusion in the setting of ischemia. The
anatomic level of lower extremity vascular injury (iliac-
femoral, femoral-popliteal, tibial), the severity of the
mangled extremity, and the presence of associated injuries
are also important factors influencing patient outcomes.

Key Words:  lower extremity trauma,

mangled extremity,
tourniquet,
vascular shunt,
venous injury,
arterial injury,
amputation

Table 15-1 Incidence of Lower Extremity
Vascular Injury
Iliac Femoral Popliteal Tibial
War Vessels Vessels Vessels Vessels
World War I 1% 35% 12% 11%
World War II 2% 21% 20% 20%
Korean War 2% 31% 26% 18%
Vietnam War 3% 35% 22% 0%
Iraq and 2% 28% 9% 10%
Afghanistan
Data compiled from the following references 5-12.
Combat Gauze (Z-Medica Corporation, Wallingford, CT) and
rapid operative control may be necessary.
In the absence of significant hemorrhage, one has time to
examine the lower extremity including assessing the femoral,
popliteal, and pedal pulses. Palpation in the resuscitation
room or intensive care unit is subjective and prone to false
positive or negative recordings, and this portion of the exami-
nation should be augmented with continuous-wave Doppler.
The utility of Doppler ultrasound in the diagnosis of extrem-
ity vascular injury is detailed in Chapter 5 of this textbook. At
the time of palpation of pulses, the injured lower extremity
should be assessed for hard or soft vascular injury. Hard signs
are grouped as clear or obvious indicators of blood vessel
disruption or occlusion and include pulsatile bleeding,
expanding hematoma, palpable thrill, audible bruit or pro-
found ischemia distal to the point of injury. Soft signs are
suggestive of vascular injury but less obvious. These include
reports of bleeding at the scene of injury, the presence of a
peripheral nerve deficit, an injury pattern (including long-
bone fracture or dislocation, indicative of vascular compro-
mise), and injury in close proximity to a main or axial
extremity vessel.
In nearly all cases, the presence of hard signs of extremity
vascular injury indicates the need for prompt operative inter-
vention. In the presence of confounding factors such as pen-
etrating wounds to multiple levels of the lower extremity,
arteriography or other imaging such as duplex or computed
tomographic angiography (CTA) may be appropriate even in
the setting of hard signs. In the presence of soft signs of vas-
cular injury, using the continuous-wave Doppler to calculate
the injured extremity index (IEI) is necessary. Initially, the
quality of the audible arterial signal in the distal aspect of the
injured extremity (wrist, ankle and foot) gives the examiner
information regarding the nature of perfusion to the limb. For
example, a strong, clearly audible, bi- or triphasic arterial
signal is typically normal and noticeably different than a weak
monophasic signal, which may be an indicator of vascular
injury. However, the quality of the audible signal is also some-
what subjective and may be influenced by a patient who is cold
and hypotensive. A more objective modality using the
continuous-wave Doppler and a manual blood pressure cuff
is the IEI.
The IEI is a measure of the arterial occlusion pressure of
the audible Doppler signal in the distal aspect of the injured
limb compared to the occlusion pressure in one of the other
noninjured extremities. This measurement or ratio is the same
as the ankle-brachial index (ABI) that is used in the diagnosis
of arterial occlusive disease in the lower extremity. In the
15  /  Lower Extremity Vascular Trauma 169
FIGURE 15-1  Junctional zone penetrating injury with concomitant
bowel injury.
setting of trauma and because the comparison may be between
the occlusion pressure in an injured upper extremity to that
in the noninjured upper extremity, this ratio is also referred
to as the IEI. In the absence of vascular injury, the ratio of the
occlusion pressures between the injured and noninjured
extremities should be 0.9 or greater. An IEI of less than 0.9,
especially in a patient with a normal contralateral IEI, indi-
cates a flow-limiting abnormality and has been shown to cor-
relate with identifiable arterial injury.
Importantly, the IEI should be repeated in patients who are
hypothermic and/or hypotensive as these factors may result in
initial false negative ratios. The IEI should also be repeated in
patients who have an extremity fracture or dislocation after
the orthopedic injury has been reduced or aligned with trac-
tion. In patients with these types of extremity injuries, the
Doppler signal and therefore the IEI may improve with resus-
citation, warming, and fracture reduction. However, an IEI
that is persistently less than 0.9 should be considered to indi-
cate arterial injury, and one should pursue further imaging or
operative exploration. In most cases in which there are soft
signs of vascular injury and a persistently diminished IEI
further diagnostic imaging such as duplex ultrasound, CTA,
or conventional arteriography is performed.20-23 In complex
cases, arteriography should be performed in the operating
room (OR) using a mobile or fixed fluoroscopic imaging
system to provide access to all options including definitive
operative exploration if necessary. In cases of extremity frac-
ture or dislocation, performance of arteriography in the OR
may be combined with procedures such as fracture reduction
or fixation.
Junctional Distal Iliac and Proximal  
Femoral Injuries
Injury to the external iliac vessels should be suspected in all
penetrating injuries to the junctional zone including wounds
to the lower quadrants of the abdomen, hips, buttocks, and
groins (Fig. 15-1). Symptoms of iliac vessel injury are the same
as those to the more commonly recognized lower extremity
vessels but may also include abdominal distension, evidence
of bowel injury (e.g., rectal blood), or a suggestion of genito-
urinary injury (e.g., hematuria, blood in the vagina or at the
170 SECTION 3  /  DEFINITIVE MANAGEMENT

penile meatus). In the setting of penetrating lower abdominal it may not be possible to determine the location of operation
or pelvic injury, the absence of femoral pulse(s) or a discrep- without contrast imaging. Physical examination alone has
ancy between the femoral pulses should alert the provider to been shown to be associated with a false positive rate as high
the likelihood of an iliac artery injury. as 87%.26 The amputation rate for patients with blunt extrem-
The soft sign of a junctional vascular injury may initially ity trauma has been reported to be extremely high due to
be proximity of a lower abdominal or pelvic wound to the missed injuries. Surgeons must maintain a high index of sus-
external iliac vessels. In these cases, the provider must have a picion for popliteal artery injuries in any patient with anterior
high index of suspicion to pursue additional imaging or oper- or posterior knee dislocations, distal femur fractures or tibial
ative exploration.24 Further imaging is not generally indicated plateau fractures. In some situations, the diagnostic adjunct
in patients who are hemodynamically unstable with penetrat- of intraoperative arteriography may reduce the rate of nega-
ing lower abdominal or pelvic injury. Instead, these patients tive surgical exploration.25 Recent studies support a practice
should be managed with operative exploration in conjunction of selective arteriography and operative exploration based on
with balanced, blood component-based resuscitation. In cases IEI, duplex ultrasound, and CTA. The uses of this strategy
of penetrating lower abdominal trauma, exploration will contrast arteriography and operative exploration are reserved
require exploratory laparotomy to achieve vascular control for instances in which one or more of these noninvasive
and hemostasis. If patients with lower abdominal or pelvic modalities are abnormal. This selective approach to arteriog-
injuries are hemodynamically normal, further imaging is raphy and operation for posterior knee dislocation has been
useful and can include plain radiographs of the abdomen and shown to be safe and effective and has reduced the rate
pelvis followed by CTA. In addition to providing detail regard- of negative or nontherapeutic exploration (Figs. 15-2 and
ing intraabdominal and retroperitoneal structures and pelvic Fig. 15-3).27
fracture, CTA may demonstrate contrast extravasation from
or occlusion of an iliac or proximal femoral vessel. In these Tibial Level Injuries
instances, CTA provides a quick and detailed assessment of The redundant nature of perfusion to the ankle and foot
injury allowing for better operative planning including the through three tibial arteries (anterior, posterior, and peroneal)
sequence of steps and the selective use of endovascular means that vascular trauma at this level is better tolerated than
techniques. that to more proximal levels of the lower extremity. In order
In contrast to penetrating trauma, iliac injury from blunt for limb-threatening ischemia to result from trauma at this
mechanisms often presents with more gradual, insidious level, all three tibial vessels must be disrupted which is uncom-
blood loss. If the patient has an unstable pelvic fracture, early mon. In the civilian setting, patients with penetrating injuries
application of a pelvic sheet or binder is indicated and should to the leg (i.e., below the knee) have been shown to be less
precede additional diagnostic workup. Early application of a likely to present with signs of ischemia than those with blunt
binder around the pelvis is especially useful in controlling
venous bleeding associated with complex pelvic fractures and
works by stabilizing the fracture and inducing tamponade. In
some instances of pelvic fracture with hemodynamic instabil-
ity, arteriography with the option of embolization of bleeding
is helpful. This is especially true if contrast extravasation is
observed from a branch or branches of the internal iliac arter-
ies on the initial CTA. Increasingly, embolization of bleeding
vessels can be pursued in an endovascular OR that is able to
accommodate catheter-based procedures as well as traditional
open operations.
Femoral and Popliteal Injuries
Patients with femoral or popliteal vascular trauma may present
with hard or soft signs of injury. However, experience shows
that most injuries in this location are accompanied by hemor-
rhage and/or ischemia at some point following the event.15 In
some cases, limb-threatening complications may result from
overlooking or missing the hard signs of vascular injury
because the active bleeding will have stopped or the degree of
ischemia will be incomplete.25 Although most cases of femoral
or popliteal trauma with hard signs require prompt operative
intervention, contrast arteriography or CTA may be useful in
more complex scenarios. In cases of mangled lower extremity
with vascular and orthopedic components, the location of
fracture(s) and vascular injury may be best determined with
arteriography or CTA. Management of the extremity with
multiple penetrating wounds at different levels of the limb
may also be aided with arteriography and/or CTA before oper- FIGURE 15-2 Computed tomography yielding diagnostic informa-
ation. In these cases although hard signs of bleeding and/or tion regarding vascular status in light of significant potential
ischemia may be present, the level of the injury and therefore artifacts.

FIGURE 15-3.  Rapid external fixation without compromising vascu-
lar exposure. External fixation was applied before operative exposure
for vascular repair.
trauma (33% vs. 68%, respectively). This observation may be
partly due to the redundant nature of perfusion and the fact
that penetrating wounds are less likely to affect all of the tibial
arteries. In contrast, blunt trauma to the leg often results in
complex tibia and fibula fractures (i.e., Gustillo fractures)
which are more prone to injure all of the tibial arteries and
result in ischemia.27 Studies have shown that when tibial
vessels are injured by blunt mechanisms, they injuries are
almost always associated with a fracture (97%). Blunt mecha-
nisms leading to tibial vascular trauma may also result in open
fractures with soft-tissue injuries (59% of cases) and periph-
eral nerve injuries (53% of cases). Less commonly, penetrating
trauma leading to tibial vascular injury is associated with frac-
ture (31% of cases), soft-tissue injury (6% of cases), and nerve
dysfunction (20% of cases).27 Like the diagnosis of popliteal
artery injury, imaging of the tibial vessels should be performed
selectively. In most cases, contrast arteriography and/or explo-
ration of the tibial arteries is reserved for patients with persis-
tent signs of ischemia such as a diminished IEI (<0.90).
Preoperative Preparation
Computed tomography is an important adjunct in preopera-
tive preparation in the hemodynamically stable blunt trauma
patient. This imaging modality can also be a useful adjunct in
select patients with penetrating trauma who have normal
hemodynamic measures and equivocal physical examination
findings. Extravasation of contrast from a vascular structure
is indicative of vessel injury. Even in the absence of active
extravasation, pelvic hematoma can be a sign of venous injury
or bleeding from the internal iliac artery or from smaller
branches. Lack of contrast within the vascular lumen can be
indicative of thrombosis or dissection causing a reduction in
flow. In cases of diagnosed or suspected vascular injury on CT,
angiographic evaluation may be useful and may provide the
possibility of catheter-based intervention. The utility of mul-
tidetector computed tomographic angiography (MDCTA)
may be limited in some patterns of penetrating trauma, espe-
cially those associated with retained metallic fragments from
firearm or other explosive mechanisms. In these instances, the
15  /  Lower Extremity Vascular Trauma 171
FIGURE 15-4  Zone of injury is explored, and the injured vessel is
débrided to healthy vessel.
metallic fragments may cause artifacts, which make interpre-
tation of the adjacent vessels difficult. However, even in the
presence of metallic artifact, MDCTA often provides impor-
tant diagnostic information (Fig. 15-4). Inaba et al provided
an important study of MDCTA and showed its value in man-
aging severe lower extremity injury. In their study, only 1 of
63 scans was indeterminate due to retained metallic artifact;
and the rest provided elements of important diagnostic infor-
mation helping guide management. Furthermore, in their
clinical series, three injuries distal to the knee were evaluated
by conventional arteriography after MDCTA, and in all cases
the arteriogram confirmed MDCTA providing no additional
information. Moreover, in White et al’s analysis of MDCTA in
the evaluation of vascular trauma, additional benefits were
delineated. In this study, multiple extremities (i.e., simultane-
ous) were evaluated in 15 of 20 CT studies. Most commonly,
this meant both lower extremities were evaluated with one
study, but an upper and a lower extremity could be evaluated
simultaneously as well. This study also demonstrated that
MDCTA was diagnostic in the presence of retained metallic
fragments. Finally, the study by White and colleagues showed
that MDCTA also provided useful diagnostic information in
8 of 10 patients with external fixator devices or intramedullary
nails in place. Together, these experiences confirmed that
MDCTA is a useful diagnostic option to detect vascular injury
when one has a high index of suspicion, even in the absence
of hard signs or a normal IEI examination.21,28
Junctional Distal Iliac and Proximal  
Femoral Injuries
As stated previously, control of hemorrhage from junctional
injuries can be difficult and must first be managed with direct
compression. Operative exposure and/or control of junctional
vascular injuries typically requires either an inguinal or a
transplant incision (Fig. 15-5) to gain access to the external
iliac artery and vein. Once exposed, the common or external
iliac or common femoral arteries can be controlled using vas-
cular clamps. Additional techniques and devices to rapidly
apply pressure to junctional vascular injuries in the pre-
and out-of-hospital settings have been developed including
the Combat Ready Clamp (CRoC; Combat Medical Systems,
172 SECTION 3  /  DEFINITIVE MANAGEMENT
FIGURE 15-5  Bilateral tourniquets applied allowing transport for
definitive surgical repair. The application of tourniquets prevents
death from hemorrhage.
Fayetteville, NC) and the Junctional Emergency Treatment
Tool (JETT; North American Rescue, Greer, SC). These devices
are designed to be placed on the patient by initial responders
in the tactical environment (e.g., Tactical Combat Casualty
Care) and include mechanical properties that allow compres-
sion of the distal external iliac and proximal femoral vessels.
The utility of the CRoC, JETT, and other emerging adjuncts
to control junctional vascular injury has not been fully evalu-
ated. However, promising reports on their efficacy have been
registered from the terminal stages of the war in Afghanistan
and anecdotal cases of civilian trauma. Despite successes asso-
ciated with the development of a small number of junctional
hemorrhage control devices, further research is needed to
develop approaches or tools to control noncompressible torso
and junctional hemorrhage at the point of injury and in the
acute, out-of-hospital phase of care.
Femoral and Popliteal Injuries
In the case of extremity trauma, hemorrhage control strategies
including tourniquets and topical hemostatic agents have
been successfully codified in the Committee on Tactical
Combat Casualty Care’s (TCCC’s) PreHospital Trauma Life
Support (PHTLS) manual.29,30 Considerable detail on the con-
tributions of the TCCC and the PHTLS manual is provided
in the Chapter 15 of this textbook. The TCCC guidelines
emphasize three objectives: Treat the patient, prevent addi-
tional casualties, and complete the mission. Advances in the
prehospital care of those with femoral and popliteal vascular
trauma put forth by the TCCC include prompt hemorrhage
control, establishment of intravenous or intraosseus access,
and use of fluid resuscitation in only those patients who are
in shock. Training and adherence to these and other PHTLS
guidelines has been shown by Kotwal and colleagues to reduce
preventable death in wounded service personnel.2
If extremity hemorrhage cannot be controlled with direct
pressure, prompt application of a tourniquet should be per-
formed. Tightening of the tourniquet should continue until
arterial bleeding from the limb has stopped or until distal
pulses are no longer palpable (Fig. 15-6). If a single tourniquet
is not successful in controlling extremity hemorrhage, a
FIGURE 15-6  Posterior knee dislocation.
second tourniquet should be applied to increase the effective
tourniquet width. Kragh and others from the United States
Army Institute of Surgical Research reported that the applica-
tion and use of tourniquets to control extremity bleeding
before the onset of shock resulted in lower mortality than
application of tourniquets after the onset of hemodynamic
instability.2-4 The importance of the proper application of the
tourniquet cannot be overemphasized as incorrect placement
is associated with mortality from hemorrhage. In addition to
their effectiveness, properly applied tourniquets are safe. In a
clinical series of 428 tourniquets applied on 309 severely
injury limbs, the incidence of nerve palsy was 1.7%. There was
no association with vascular thrombosis, myonecrosis, rigor,
pain, fasciotomy, or renal failure.3 It is important to under-
stand the success of tourniquets in the wars in Afghanistan
and Iraq in the context of short medical evacuation and there-
fore relatively short tourniquet times. Reports from those wars
and clinical experience of the editors suggest that the vast
majority of tourniquets applied during the wars in Afghani-
stan and Iraq were in place for 2 hours or less. Clearly tour-
niquet application and the potential adverse effects of complete
limb ischemia for longer periods of time in future military or
civilian scenarios will need to be reappraised.
Tibial Level Injuries
Tibial vascular injury may be the result of penetrating or blunt
trauma and is most commonly associated with fracture of the
tibia or fibula.27 The order or priority of injury management
in these cases is dictated by the presence or absence of hemor-
rhage and/or complete ischemia. In cases in which control of
bleeding is difficult, exploration of the vascular injury with
ligation of the vessel or placement of a temporary vascular
shunt may be necessary before fracture reduction and stabili-
zation. The same is true in some cases in which there is com-
plete ischemia (i.e., no audible Doppler signal) of the leg
below the injury. However, in most instances, fracture reduc-
tion or traction and stabilization can be performed promptly
and results in restoration of perfusion to the leg and foot. If
evidence of arterial ischemia persists (i.e., IEI less than 0.9)
after maneuvers to reduce and stabilize the fracture, further
diagnostic evaluation such as CTA or arteriography may be
required. Alternatively—and especially in the setting of open,

FIGURE 15-7 Transplant incision allowing rapid exposure of the iliac
artery and vein. The artery is being mobilized using a vessel loop to
explore the iliac vein for bleeding. (Courtesy Dr. Christopher T. Barry.)
penetrating wounds—the tibial vessel(s) can be explored and
evaluated, directly obviating the need for additional imaging
(Fig. 15-7).
Helpful Considerations
to Avoid Pitfalls
• Evaluation and diagnosis of the injured lower extremity
should be preceded by hemorrhage control, initiation
of resuscitation, and evaluation of life-threatening
injuries.
• Junctional vascular injury carries a high mortality and
must be considered in the setting of lower abdominal,
pelvic, peroneal, and buttock wounds.
• Control of hemorrhage from proximal and junctional
lower extremity trauma may be difficult to obtain using
direct manual pressure and tourniquets.
• Physical examination of the injured and noninjured
lower extremity should be performed using continuous-
wave Doppler to improve sensitivity.
• CT angiography is a useful diagnostic adjunct, especially
in patients with soft signs of lower extremity vascular
trauma and who require CT imaging of the torso or
head.
• The anterior compartment of the leg is the most com-
monly neglected compartment in the performance of
lower extremity fasciotomy. Care must be taken to ensure
that this compartment is identified separately from the
lateral compartment through the lateral leg incision.
Opening of the anterior compartment exposes the
muscles and anterior neuromuscular bundle, as well as
the intermuscular septum, which separates the anterior
and the lateral compartments. Both sides of this septum
should be visualized assuring that both the anterior and
the lateral compartments have been opened widely.
15  /  Lower Extremity Vascular Trauma 173
Operative Strategy and Technique
Preparation begins with expeditious transport of the patient
to the OR, because longer ischemic time is associated with
higher amputation rates and poorer neuromuscular recovery.
The surgical scrub and draping of the patient should be from
the umbilicus to the toes of both lower extremities. Preparing
the operative field to include the umbilicus and lower abdomen
allows for retroperitoneal exposure and control of the iliac
vessels if needed. Preparation of the contralateral lower
extremity allows one to use saphenous vein from the nonin-
jured extremity as conduit for vascular reconstruction if
needed. Also, access to the contralateral femoral artery may be
useful to perform percutaneous, transluminal arteriography
of the injured lower extremity either as a pre- or completion
step using an “up and over” approach. In rare cases, having
access to the contralateral femoral artery can be useful as a
source of inflow (i.e., cross femoral bypass) for complex
femoral or distal iliac artery injuries.
Regardless of anatomic level, lower extremity vascular
reconstruction begins with exposure of the injured segment.
Depending on the experience of the surgeon and the anatomic
location of the injury, this may be preceded by obtaining
remote proximal arterial control. Frequently junctional or
proximal femoral vascular injuries require control at an unin-
jured segment such as the iliac artery through a retroperito-
neal exposure. Injuries in the popliteal fossa and those at the
tibial trifurcation may also benefit from inflow control at a
proximal, uninjured segment. In contrast, superficial femoral
injuries in the thigh and those below the tibial trifurcation can
often be controlled by extending any penetrating wounds and
exploring the injured area directly.
Once the injured segment of vessel(s) has been exposed
and controlled, assessment should be made as to the extent of
injury and adequacy of distal perfusion. The later aspect of
this assessment is greatly aided by use of the continuous-wave
Doppler machine in the OR. The spectrum of vascular trauma
ranges from vessel contusion with degrees of thrombosis to
transection with a missing segment. In considering manage-
ment strategies, one must remember that ligation is a viable
option in many scenarios. In other words management of
lower extremity vascular trauma does not always require vas-
cular reconstruction and restoration of flow through the
injured segment. For example, injury of a tibial artery or a
branch of the superficial femoral or profunda femorus arteries
can often be ligated without compromising viability of the
extremity. In these instances, redundant or collateral circula-
tion often exists, which will keep the limb viable, even with a
degree of ischemia, without repair of the injured vessel. Viabil-
ity in these scenarios is most reliably predicted by assessment
of capillary refill and with the presence of an arterial Doppler
signal distal to the injury. Vessel ligation, with or without
primary amputation, may also be a prudent damage control
option in patients with a severely mangled extremity or those
with a constellation of other life-threatening injuries or physi-
ology. In these damage control scenarios, viability of the limb
may not be of as much concern because amputation is accepted
as a necessity to save the individual’s life.
If reconstruction of lower extremity vascular injury is
planned, standard operative techniques should be used regard-
less of anatomic level. The nature of vascular trauma means
that the use of systemic heparin as an anticoagulant must
174 SECTION 3  /  DEFINITIVE MANAGEMENT
FIGURE 15-8  Angiogram of popliteal artery after posterior knee dis-
location (prior figure).
occur on a selective and sometimes partial basis. In instances
of isolated lower extremity vascular trauma with limited soft-
tissue damage, use of full-dose heparin before and during the
vascular reconstruction is often possible. In contrast, patients
with lower extremity vascular trauma who also have torso or
head injuries or larger, complex soft-tissue wounds are not
able to receive systemic heparin. As such, while preferable in
all cases, the use of anticoagulation is a judgment call made
by the operative surgeon in close communication with the
anesthesia, neurosurgical, and other specialty providers. When
considering the use of heparin, one should recognize and
make use of the benefit of limited amounts of local and
regional heparin that can be used on and infused proximal
and distal to the segment undergoing repair.
One must also open and inspect the vessel and débride the
injured segment until normal vessel wall is present (Fig. 15-8).
Intraluminal platelet aggregate and thrombus must be
removed directly using forceps or with a Fogarty thromboem-
bolectomy catheter and diluted amounts of heparin flush (i.e.,
heparinized saline). As mentioned, this same dilute heparin
should be gently instilled proximal and distal to the controlled
vascular segment to reduce the incidence of thrombus forma-
tion during assessment and repair. Lower extremity vascular
reconstruction generally consists of primary repair, patch
angioplasty, or placement of an in-situ interposition graft.
Bypass with ligation of the intervening injured segment is
another option that may be used with popliteal and tibial level
arterial injuries. Regardless of the method, fine monofilament
suture and surgical loupe magnification are central to most
attempts at vascular reconstruction.
Lateral arteriorrhaphy (or venorrhaphy) is a method of
primary repair that can be pursued if the vessel diameter will
not be narrowed with this approach. In most instances of
extremity trauma, this type of lateral wall repair is not possible
because the vessels are small by nature. If 50% or more of the
vessel wall is uninjured, patch angioplasty using autologous
vein or other synthetic material may be an option to allow
repair and to prevent narrowing of the lumen. End-to-end
anastomosis is another form of primary repair that can be
used if the vessel is transected sharply. In order for primary,
end-to-end repair to be possible, the vessel must approximate
without tension (i.e., tension-free) after débridement of the
edges has taken place. Because extremity vessels are elastic and
frequently spasm and retract in the setting of trauma, it is the
exception that the edges will come together in a satisfactory
manner. In these cases and in those where a segment of vessel
has been transected with a missing segment, performance of
an interposition graft is required. It is the authors’ and editors’
experience that most cases of significant extremity vascular
injury and especially injury from penetrating gunshot or
explosive mechanisms requires vessel resection and use of an
interposition graft.
Reversed saphenous vein is generally preferred as the
conduit in instances where an interposition graft is required.
Autologous vein is especially recommended in contaminated
cases such as those with an open or penetrating mechanism.
Synthetic conduit such as expanded polytetrafluoroethylene
(ePTFE) or polyester (Dacron) may also be used for larger
vessel (i.e., proximal) extremity vascular injury and may be
preferred because of size match with the injured vessel. Expe-
rience from the wars in Afghanistan and Iraq has demon-
strated the effectiveness of saphenous vein as the conduit of
choice for lower extremity vascular trauma. However, this
same experience has highlighted challenges associated with
the dismounted complex blast injury pattern that often results
in one or more severely mangled lower extremities. In these
cases, most if not all of the saphenous vein is injured or absent
and therefore is not able to be used as conduit. In these sce-
narios, creative use of temporary vascular shunts or synthetic
conduits has been shown to be effective in the short term and
midterm. In review of combat related registries, ePTFE grafts
were used in 14 of 95 patients with complex lower extremity
blast injury undergoing extremity vascular repair. Seventy-
nine percent of these remained patent long enough to allow
the patient to be stabilized and to be evacuated to a level 5
facility in the United States. In many instances, the patient
then underwent a more deliberate evaluation, reoperation,
and resection of the synthetic conduit in favor of remaining
autologous vein. Importantly, in this experience there were no
short- or midterm prosthetic graft disruptions, amputations,
or deaths due to graft failure confirming the utility of this
damage control approach (i.e., prosthetic first followed by
resection and use of vein later) in select injury patterns.31
Extraanatomic bypass using synthetic conduit routed remotely
from the zone of injury should also be considered in some
injury patterns in which in-situ vein interposition graft place-
ment is not possible.32
Considerations for Extremity
Venous Injury
The management of extremity vein injury proceeds along
similar lines as those for arterial injury with the options being
repair and restoration of venous outflow versus ligation.

Ligation of extremity venous injury is better tolerated and
performed much more commonly than arterial ligation,
although repair of larger, proximal venous injuries should be
considered in some scenarios. Specifically, repair of popliteal,
superficial, and common femoral vein injuries should be con-
sidered to reduce acute venous hypertension and longer-term
morbidity if the injuries are isolated and amenable to repair
and if the patient is in good physiologic condition. Experience
from the wars in Afghanistan and Iraq has shown the utility
and effectiveness of this selective repair strategy (i.e., repairs
some but not all) for more proximal vein injuries. The group
from Walter Reed demonstrated a near-85%, 2-year patency
of venous repair and a trend toward reduced symptoms of
chronic phlegmasia in those having been afforded venous
repair. Importantly, that experienced showed no increased
incidence of venous thrombosis or pulmonary thrombembo-
lism in the cohort of patients undergoing extremity vein
repair.33
Extremity vein injury in the multiply injured patient who
is in poor physiologic condition should be ligated. Similarly,
complex extremity vein injuries that require long segment
interposition grafting or use of synthetic conduits should be
managed with ligation in most instances. A temporary vascu-
lar shunt may provide an interval option for some larger, more
proximal vein injuries. In this setting, shunts allow for contin-
ued venous outflow (i.e., decompression) while the patient is
resuscitated, and the surgeon has the opportunity to consider
the definitive management strategy, be it reconstruction or
ligation. In order for venous shunts to be effective for more
than a few hours, experience suggests that the patient will need
to be dosed with systemic heparin to avoid shunt thrombosis.
Maintaining venous patency and outflow with or without the
temporary use of a vascular shunt is especially important in
certain watershed or “gatekeeper” veins such as the popliteal
vein; in the confluence of the deep, superficial, and common
femoral veins; and in the iliac vein. Parry et al used temporary
vascular shunts in the management of 18 extremity vein inju-
ries 16 of which went on to venous repair after shunt removal.
As part of their advantage, placement of temporary vascular
shunts is generally quick and allows for manipulation and
stabilization of concomitant orthopedic fractures before the
shunt is removed and consideration given of vascular repair.34
Lateral venorrhaphy is the simplest method to repair venous
lacerations while end-to-end anastomosis and patch veno-
plasty are useful for repair of veins without segmental loss. For
injuries that destroy large portions of the vein, an interposi-
tion graft using autologous vein or prosthetic conduit is the
preferred approach. As noted previously, modern experience
from Walter Reed confirms observations first made in the
Vietnam War that repair of extremity venous injuries does not
increase the incidence of thrombophlebitis or pulmonary
thromboembolism.35
Those who advocate for routine ligation of extremity vein
injury take the point of view that the immediate side effects
are few and manageable and that the long-term complications
are mitigated by the development of venous collaterals. Pro-
ponents of ligation also show that symptoms of acute venous
hypertension can be alleviated by extremity elevation and by
use of compression stockings. Timerblake and Kerstein
reported that 64% of patients with isolated femoral venous
injury and 59% of those with concomitant arterial injury
underwent ligation with only one third of the patients devel-
15  /  Lower Extremity Vascular Trauma 175
oping transient edema and with none progressing to perma-
nent sequelae.36 Kurtoglu et al recommended that patients
with extensive extremity vein laceration should undergo liga-
tion coupled with judicious use of leg fasciotomy, with eleva-
tion of the limb, with compression, and with monitoring for
progression of deep venous thrombosis. This same group
reported that despite concomitant arterial injury requiring
revascularization, extremity vein ligation resulted in mild
venous morbidity (CEAP Classification C2-C3) in 60% of
their series.37
In contrast, a number of studies have touted the advantages
of extremity vein repair, suggesting that this approach may
play a role in recovery from a major trauma. Parry et al exam-
ined the short-term patency of several methods of extremity
vein repair in a civilian trauma setting and found a patency
rate of nearly 75% regardless of the type of reconstruction
(primary repair, vein patch angioplasty, interposition graft).34
This group also reported that a large number of venous repairs
that had thrombosed in the early time period went on to
recanalize over time. In a longer follow-up study, Kuralay et al
reported that patency was predicted by the anatomic position
of the venous injury rather than by the type of repair.38 This
group took advantage of excellent follow-up of military per-
sonnel in the Turkish Health System to compare short- and
long-term results of venous repair in the lower extremity. At
an average of 6 years following injury and vein repair, this
group reported patency rates of the common femoral, the
femoral, and the popliteal veins to be 100%, 78%, and 60%,
respectively. Notably all infrapopliteal veins in this series were
found to be thrombosed shortly after the time of repair. This
group suggested that higher venous flow in the larger, more
proximal veins was largely responsible for the improved
patency. It is also worth noting that there may have been a
technical advantage to repair of the larger veins compared to
the smaller more distal veins, which often present significant
challenges because of their diminutive sizes. As mentioned
previously, in the largest review of military venous repair since
the 1970s, Quan et al from Walter Reed reported a short-term
patency of 85% with no increased rate of venous thrombosis
or thromboembolism in those having had repair.39
Junctional Distal Iliac and Proximal  
Femoral Injuries
Exposure of the iliac vessels can be accomplished via an ante-
rior, inframesocolic, transperitoneal approach by dissection of
the peritoneum of the paracolic gutter and by medial rotation
of the ascending (right iliac) or descending (left iliac) colon
(Fig. 15-9). The external iliac arteries are relatively protected
by the walls of the pelvis as they rise to join the common
femoral arteries underneath the inguinal ligaments. The main
side branch of the external iliac artery is the inferior epigastric,
although the distal external iliac artery is also crossed by the
lateral circumflex iliac vein at the inguinal ligament. As with
other vascular injuries, direct pressure should be utilized to
control any obvious sources of bleeding. Proximal control is
gained by applying clamps to the common iliac artery. It is
worth noting that hurried, “blind” application of vascular
clamps to vessels that are not dissected or exposed is often
fraught with problems, including injury to adjacent vascular
structures. This scenario is particularly problematic in the iliac
position because of the direct apposition of the iliac veins
underneath and alongside the iliac arteries. As such, one must
176 SECTION 3  /  DEFINITIVE MANAGEMENT

be careful to place the proximal iliac clamp only on the artery injuries. Careful dissection is necessary to isolate and control
and not to inadvertently injure the adjacent vein because of the internal iliac artery to stem retrograde or cross-pelvic
chaos surrounding the patient’s presentation. If necessary, bleeding. During dissection, one must also take care to iden-
proximal control may be gained by initial cross-clamping of tify and avoid injury to the ipsilateral ureter which crosses over
the distal aorta. Division of the inguinal ligament may also be the anterior surface of the iliac artery at the pelvic rim. Careful
necessary for distal control of junctional zone vascular dissection starting at the most proximal and distal points of
exposure and moving toward the center of the field can help
one isolate the location of vascular disruption and also the
Phrenic artery internal iliac artery.
Celiac artery In the case of iliac and/or junctional femoral vascular
injury from penetrating trauma, exposure and control can
IVC SMA
also be achieved via a retroperitoneal incision (Fig. 15-10).
The curvilinear incision in this scenario starts above the pubic
bone, extends laterally and cranially, and passes along the edge
Left of the rectus abdominus muscle. The incision is deepened
renal vein using the lateral edge of the rectus as a guide proceeding in
Testicular the lateral extraperitoneal plane, reflecting the peritoneum
(ovarian) vein
and abdominal contents medial. This incision can be done
fairly quickly to gain access to the iliac vessels and to apply
proximal control. However, this exposure is extraperitoneal
Testicular
(ovarian) artery
and will not allow exploration of the abdominal cavity. The
Testicular authors use this exposure frequently because it can be per-
(ovarian) vein IMA
formed rapidly and can allow good visualization of lower
Ureter extremity junctional zone injuries.
Ligation of one internal iliac artery is generally well toler-
ated and does not result in the severity of ischemic conse-
quences as seen when ligating the common or external iliac
artery. Ligation of the common or external iliac artery should
be considered in only the most extreme situations as a life-
saving maneuver. Ligation at this proximal inflow point to the
extremity is poorly tolerated and results in a high likelihood
of proximal limb loss. Interval arterial repair is also poorly
tolerated, possibly due to the severity of reperfusion injury.
The use of a temporary vascular shunt may be beneficial and
should be considered to restore or to maintain perfusion
FIGURE 15-9  Surgical anatomy of junctional zone. IMA, Inferior mes- through the iliac or iliofemoral segment in complex scenarios
enteric artery; SMA, superior mesenteric artery. in which the patient has other life-threatening injuries or

Aorta

Common iliac artery

External iliac artery

Reflected
peritoneal cavity

FIGURE 15-10  Surgical retroperitoneal exposure of iliac

vessels.
 15  /  Lower Extremity Vascular Trauma 177

Right
Ext. iliac a. common iliac a.
Deep iliac Int. iliac a.
Superf. iliac Superior
circumflex a. gluteal a.
Superf. Inf. gluteal a.
epigastric a. Common
Ascend. branch lat. femoral a.
circumflex a. Obturator a.
Transverse branch lat. Medial circumflex
circumflex femoral a. femoral a.
Lat. circumflex
femoral a.
Superf.
Descend. branch lat. femoral a.
circumflex femoral a.
FIGURE 15-11 Temporary intravascular shunt as applied in the Perforating branches
superficial femoral artery. deep femoral a. Deep femoral a.

Descend.
genicular a.

Lat. sup. genicular a.

FIGURE 15-13  Surgical anatomy of femoral vessels.

FIGURE 15-12 Temporary intravascular shunt with midline suture
tied at the time of application. On reexploration, migration is obvi-
ously seen.
adverse physiology. If possible, maintaining flow through a
vascular shunt would be preferable to damage control ligation
in such a scenario. A large shunt such as a 14 Fr Argyle or even
a 14 or 16 Fr pediatric chest tube may be inserted into the ends
of the injured iliac vessel after they have been flushed in an
antegrade and retrograde manner to restore extremity perfu-
sion. The shunt may be secured to the artery using heavy silk
sutures (Fig. 15-11), and a third suture can be tied in the
midportion of the shunt to aid in positioning and removal.
The midline suture may also provide a vantage point to discern
whether or not the shunt has migrated distally (Fig. 15-12).
This same sequence of steps may be used to insert a smaller
shunt in a more distal extremity vascular injury (e.g., superfi-
cial femoral or popliteal) to limit extremity ischemic time
until formal vascular repair can be considered and performed.
Because they limit the burden of extremity ischemia, tempo-
rary vascular shunts have been shown to be associated with
lower mortality and with lower amputation rates compared to
arterial ligation.40
When no other options are available and it is necessary to
save the patient’s life, the common or external iliac artery may
be divided and oversewn with a double row of sutures above
the level of injury. This damage control maneuver should be
done in combination with a two-incision, four-compartment
fasciotomy of the leg to monitor viability of the extremity
musculature and to reduce the risk of compartment syn-
drome. If or when a patient’s condition stabilizes, consider-
ation should be given to an operation that would provide
inflow to the extremity such a cross-femoral (femoral–to-
femoral) bypass with 8-mm ringed ePTFE. If the patient will
not tolerate further operative procedures, resuscitation should
proceed in the surgical intensive care unit; and consideration
should be given to a return to the OR for extraanatomic
bypass or amputation at the earliest possible time.
Femoral and Popliteal Injuries
The common femoral artery and vein are exposed via a lon-
gitudinal incision beginning at the inguinal ligament. The
proximal position of the incision to expose the common
femoral artery can be estimated by locating and visualizing the
midpoint of the inguinal ligament. The incision is extended
caudal 8 to 10 cm but may be extended as necessary for proxi-
mal or distal exposure, control, and repair of injuries (Fig.
15-13). Areas of hematoma or wounds should be avoided
initially until after proximal and distal control is achieved. In
the setting of vascular injury with occlusion or disruption of
the superficial femoral artery, the perfusion from the profunda
femoral artery often is not sufficient to prevent ischemia of
the lower leg. As noted previously, the continuous-wave
178 SECTION 3  /  DEFINITIVE MANAGEMENT

Doppler should be used in these scenarios to assess for the Femoral a.

Descend. branch
presence of an arterial signal in the foot before or at the time lat. circumflex
of operative exploration. Control of the profunda femoris Descend.
femoral a.
genicular a.
artery is gained in the same incision and exposure. The origin
of the profunda is most commonly on the posterior lateral Popliteal a. Articular branches
aspect of the common femoral artery. Approximately one descend. genicular a.
third of patients have a dual profunda origin with the second Superior medial
orifice arising from the posterior common femoral artery. Of Superior lat. genicular a.
note, the lateral circumflex femoral vein crosses the proximal genicular a.
portion of profunda artery and should be identified, ligated,
and divided to facilitate proper exposure of the profunda and
Inf. lat. genicular a.
avoid inadvertent venous injury. Injuries to the profunda
femoral artery should be repaired if this can be accomplished
relatively expeditiously in an otherwise-stable patient. Options Ant. tibial Inf. medial
include direct repair, placement of an interposition graft or recurrent a. genicular a.
proximal ligation and distal reimplantation to the superficial
femoral artery. If this is not possible, ligation should be per- Ant. tibial a. Post. tibial a.
formed. In the young patient, acute ligation of the profunda
femoral artery is generally well-tolerated if the superficial
femoral artery is uninjured. In a report by Woodward et al on FIGURE 15-14  Surgical anatomy of popliteal vessels including bony
methods of repair of femoropopliteal injury during Operation landmarks.
Iraqi Freedom (OIF), no patients undergoing profunda
femoral artery ligation progressed to require amputation.6
The mechanism of injury will often dictate the type
of vascular reconstruction. Stab wounds or laceration
injuries are often able to be repaired by using lateral suture
or end–to-end primary methods. Gunshot wounds or pene- Medial approach
trating injuries from explosive mechanisms often require arte-
rial débridement to uninjured aspects of the vessel and Vastus medialis m.
placement of an interposition graft. As noted previously,
the favored conduit in these scenarios is autologous saphe- Popliteal a.
nous vein. However, use of a synthetic vascular graft is Popliteal v.
Sartorius m. Popliteal a.
acceptable in certain scenarios in which there is no saphenous Popliteal v.
vein or in which the available saphenous vein is being
saved for a later, more-definitive reconstruction (i.e., interval Vastus medialis m.
reconstruction).31,41
In order to expose the popliteal space, the knee is flexed or Medial head
gastrocnemius
bent slightly (i.e., frog leg position); and a soft roll or bump A m.
is placed behind the leg, below the knee to elevate or suspend
Cut ends of
the thigh. This maneuver makes it such that the medial mus- medial head Tibial n.
culature of the thigh pulls freely away from the femur and gastrocnemius
allows gravity to open up the above-knee popliteal space. Con- m.
versely, to expose the below-knee popliteal space, the soft roll Popliteal vv.
or bump is placed above the knee such that the muscles of the B
gastrocnemius and soleus muscles pull freely away from the FIGURE 15-15  Surgical exposure of popliteal vessel via medial
tibia. While these maneuvers may seem rudimentary, they are incision.
absolutely essential to be successful in this challenging ana-
tomic exposure. Failure to flex the knee and move the elevat-
ing bump or roll of towels in this manner will result in the below-knee popliteal space. Care should be taken not to divide
surgeon attempting to expose an inaccessible popliteal space the saphenous vein in this location as it generally lies just
that is compressed closed on the OR table. under the skin in this medial incision. Division of the proximal-
Once the lower extremity has been positioned in such a most portion of the medial head of the gastrocnemius and its
manner to expose the above-knee popliteal space, an incision attachments to the tibia will facilitate opening of the below-
is placed on the anterior border of the sartorius muscle (Fig. knee popliteal space. After these initial maneuvers above and
15-14). The muscle is retracted posterior or down to expose below the knee have been accomplished, one should spend
the popliteal space, which contains the neurovascular bundle. time positioning and repositioning deep, narrow, handheld
The popliteal vein is generally medial to and covering the retractors and performing further dissection of the popliteal
artery and therefore encountered first in the exposure. Ten- vessels. The uses of Weitlaner and/or Henly popliteal retractor
donous attachments of the adductor magnus muscle can be instruments will also be necessary to spread open the popliteal
divided if necessary for improved proximal extent of exposure space as widely as possible. The Henly retractor has a set of
(Fig. 15-15). A medial incision 2 to 3 fingerbreadths posterior blades with adjustable depths that often facilitate opening of
to the medial edge of the tibia will initiate exposure of the the above- and below-knee popliteal spaces.

If after intentional efforts have been made to dissect and
retract the popliteal space and vessels cannot be seen, the
tendons of the semimembranosus, semitendinosus, and graci-
lis muscles may be divided to improve exposure. While it is
acceptable to divide these structures, doing so carries some
morbidity; and it may not be necessary in some cases. There-
fore the authors generally start this exposure without dividing
these tendonous attachments and make an intentional effort
to control and expose the popliteal space with more moderate
steps. If the nature of the injury or body habitus of the patient
are such that more extensive dissection is required, the tendons
of these muscles are divided.
Tibial Level Injuries
The tibial vessels originate at the end of popliteal artery below
the tibial plateau of the knee. The majority of limbs (91%)
have a redundant branching pattern that has the anterior tibial
artery as the first branch and the tibial-peroneal trunk giving
rise to the posterior tibial and peroneal arteries. Other branch-
ing patterns are also seen. For example, approximately 3% of
limbs do not have a true tibial-peroneal trunk and instead
have a true trifurcation of the anterior tibial, posterior tibial,
and peroneal arteries. Perhaps of more importance in vascular
trauma is the anatomic variant with altered perfusion to the
foot. Hypoplasia of the posterior tibial artery or anterior tibial
artery has been reported in about 1% of limbs. These cases
may be identified only by use of continuous-wave Doppler
ultrasound and in such rare cases it is paramount to recognize
that the peroneal artery may be the only perfusion to the
foot.42
The posterior tibial and peroneal vessels, which lie in the
deep posterior compartment of the leg, are best approached
through the medial incision previously described. This inci-
sion is made 1 to 2 fingerbreadths below the medial edge of
the tibia, again with care taken not to injure the saphenous
vein. The incision may be a continuation of the original
below-knee exposure or made separately depending on the
location of injury. The skin, subcutaneous tissue, and super-
ficial fascia are all incised to open the posterior superficial
compartment of the leg. The attachments of the soleus muscle
to the medial edge of the tibia must be incised longitudinally
along the length of the tibia to enter the posterior deep com-
partment of the leg which contains the posterior tibial and
peroneal arteries. The posterior tibial artery is medial to the
peroneal and is therefore the first to be encounter through the
medial approach and dissection.
The anterior tibial artery and vein are in the anterior com-
partment of the leg and are exposed and controlled via a
longitudinal, lateral leg incision. The incision and division of
fascia open the anterior and lateral compartments, which are
separated by an intermuscular septum. The anterior tibial
artery lies deep in the anterior compartment underneath the
anterior tibialis and extensor muscles and on the surface of
the interosseous membrane with the deep peroneal nerve.
Typically, to locate this neuromuscular bundle, one bluntly
develops a plane between the anterior tibialis and the extensor
muscles. Because of the close proximity and the narrow space
between the tibia and fibula, exposure of the anterior tibial
vessels is very difficult as one moves more distal on the leg.
As stated, the redundant nature of circulation to the foot
makes it likely that control with ligation and Doppler assess-
ment will be the maneuver of choice for isolated tibial vessel
15  /  Lower Extremity Vascular Trauma 179
trauma. In contrast, injury to the distal-most popliteal artery
or to the tibial peroneal trunk may result in more complete
leg ischemia. When managing tibial vascular injuries, one
must control bleeding, reduce any fractures, warm and resus-
citate the patient, and examine the foot with continuous-wave
Doppler. In most cases after these maneuvers an arterial signal
will be present in the foot indicating viability and obviating
the need for additional maneuvers. If there is no Doppler
signal after these steps, one must consider that there may be
injury to more than one tibial vessel or to the tibial peroneal
trunk. The options in this scenario are (1) to attempt to restore
flow with a small caliber, temporary vascular shunt, (2) to
perform vascular reconstruction with a below-knee popliteal–
to-tibial bypass or interposition graft using saphenous
vein, or (3) to accept ligation and to continue expectant
management.
An analysis of combat-related tibial injuries by Burkhardt
et al demonstrated the effectiveness of a selective revascular-
ization approach to tibial arterial injuries (i.e., repair some
but not all). Burkhardt and colleagues confirmed that a
portion of patients with tibial vessel injury can be managed
with ligation and expectant observation without increased
rates of amputation. In this experience, the amputation rate
in the patients managed with no reconstruction (22%) was
no different than that in patients who underwent tibial level
arterial reconstruction (19%). Presenting factors that were
associated with the need for subsequent tibial level vascular
reconstruction were occlusion of more than one tibial artery,
lack of Doppler signal in the foot, and a less-severe Injury
Severity Score (ISS) of <16. In patients with two-vessel occlu-
sion, treatment modality did not affect outcomes, but those
with only the peroneal artery patent were more likely to
undergo bypass as opposed to those with either the anterior
or posterior tibial artery patent. The observation that the
most severely injured patients (ISS >16) were less likely to
undergo tibial level reconstruction confirmed effective use of
the damage control approach of ligation and expectant man-
agement.7,43 In this context, one should be mindful that in
some cases primary amputation should be performed when
ischemic damage has been present for more than 6 hours or
when the severity of the mangled extremity is such that there
is severe orthopedic injury to the foot and/or ankle with asso-
ciated injuries, which would preclude a safe attempt at limb
salvage.27
Postoperative Care
Postoperative care of the junctional zone and lower extremity
vascular trauma patient requires excellent communication
between the various surgical teams, the intensive care team,
and the nursing staff. Standard intensive care monitoring of
critically ill trauma patients is initiated for the first 24 hours
postoperatively. Pulse and Doppler signal exams are per-
formed hourly in conjunction with vital signs. The location
and quality of the pulse (weakly palpable or strongly palpable)
or the Doppler signal (monophasic, biphasic, triphasic) is
documented in the postoperative note by the attending surgery
team. Change in the vascular examination or signs of bleeding
warrant either open surgical exploration or angiography
depending on the hemodynamic stability of the patient.
Mechanical thromboprophylaxis in the form of pneumatic
compression devices is initiated along with subcutaneous
180 SECTION 3  /  DEFINITIVE MANAGEMENT
prophylactic dosing of low molecular weight heparin if the
risk of bleeding is sufficiently low. If there has been an extrem-
ity venous injury treated with ligation, the leg should be ele-
vated and wrapped from the toes to the groin with a
compression wrap cutting openings to monitor the arterial
pulse or the Doppler signal. The entire extremity must be
monitored for viability and compartment syndrome in the
first 24 to 72 hours, even if a leg fasciotomy has been per-
formed, as a small risk of compartment syndrome in the thigh
still exists.
Complications
Thrombosis or occlusion is the most notable complication
following repair of an extremity vascular injury. Primary
repair of small vessel injuries is less likely to result in this
complication than the use of longer prosthetic grafts although
many other factors play into this possibility. Frequent postop-
erative pulse examination with early recognition and manage-
ment of this complication is necessary to reduce morbidity.
When prosthetic vascular grafts are used, special attention for
signs of graft infection is needed. While graft infection in the
immediate postoperative period and in the short term are not
highly reported, ominous signs include fever, leukocytosis,
and continued bleeding. When graft infection is suspected, the
process of removal and revascularization through clean surgi-
cal fields is the operation of choice (Fig. 15-16).
For later manifestation of venous injury, imaging modali-
ties are the keys to discovery. Traumatic arteriovenous fistulae
may manifest with tenderness, edema, varicosities, palpable
FIGURE 15-16 Computed tomography showing extraanatomic
bypass through clean surgical fields after excision of infected bypass
graft.
thrill, or audible bruit long after the initial injury. In some
instances, it is feasible to use duplex ultrasonography to diag-
nose associated venous injuries. Ultrasound is an excellent
modality because of its ease of use, noninvasive nature, and
immediate results. However, for situations with extensive soft-
tissue or orthopedic injuries, ultrasound may not be feasible.
In these cases, computed venography is a viable alternative.
Junctional Distal Iliac and Proximal  
Femoral Injuries
Prompt management and repair of common femoral artery
trauma has encouraging results. Nationwide, mortality from
common femoral artery injury in patients with isolated lower
extremity trauma is low (7.5%). Those that died were hypo-
tensive on arrival and had Glasgow Coma Scale (GSC) scores
of 3, even in the absence of associated head injuries.9 Postop-
erative complications are common (23%) and include wound
infections (15%), venous thrombosis (3%), postoperative
hemorrhage (2.5%), acute respiratory distress syndrome
(ARDS) (2%), and arterial thrombosis (0.5%). Factors associ-
ated with an increased risk for postoperative complications
included ISS greater than 25, deranged physiology in the OR
(acidosis, hypothermia, hypotension, coagulopathy) and the
presence of other injuries.8
Leg fasciotomy following femoral vessel injury is consis-
tently reported to be around 25%.44,45 The need for calf fasci-
otomy is increased in concomitant venous and arterial injury
as compared to arterial injury alone (33% and 13%, respec-
tively).8 Other factors associated with fasciotomy include
increased resuscitation with packed red blood cells (PRBCs)
(8.2 units versus 1.8), plasma (3.7 versus 0.8), platelets (0.5
versus 0.1), dislocation, and open fracture.7
Overall, amputation rate is substantial (from 15% to
35%) with femoral artery injury.46 Primary amputation is
reserved for the situation where limb salvage is impossible,
such as in the mangled extremity, in extensive gangrene, and
in muscle necrosis. Blunt-injury and high-velocity firearm
injuries are associated with higher delayed amputation rates
compared to other mechanisms of injury. Likely, this is due
to the increased force in these types of injuries, which causes
associated nerve and soft-tissue damage. In terms of vascular
revascularization procedure performed, the only association
with increased amputation rates was reexploration and failed
revascularization.46
Femoral and Popliteal Injuries
Popliteal artery injury is associated with lower mortality than
injuries to the common femoral artery and superficial femoral
artery, but is also associated with a higher incidence of ampu-
tation.9 As seen from the military experience, ligation is poorly
tolerated and has a high rate of limb-loss.8,9 However, using
modern vascular surgical technique and minimizing warm
ischemic time, increased limb salvage can be achieved with
repair.
Tibial Level Injuries
In penetrating trauma, prompt revascularization for ischemic
limbs in tibial artery injury affords excellent results. Revascu-
larization to a single target is sufficient to provide flow to the
lower leg. Ligation and/or observation in single-vessel injuries
is well tolerated as long as collateral circulation is confirmed
before the ligation, preferably by arteriography. Some double

Saphenous nerve
Great saphenous v.
Medial incision
Tibial n.
Posterior tibial a.
and v.
FIGURE 15-17  Surgical exposure for 2-incision,
4-compartment lower extremity fasciotomy.
artery injuries are well tolerated. However, if the peroneal was
the sole remaining artery, revascularization of the anterior or
posterior tibial artery is necessary for limb salvage. In blunt
trauma, there is a high incidence of limb loss that increases
when there is ischemia on presentation.27
Delayed fasciotomy and the need for fasciotomy revision
(extension of the incision or opening of a missed compart-
ment) are associated with increased morbidity and mortality.
As such, the authors generally perform prophylactic four-
compartment fasciotomy of the leg utilizing a two-incision
approach for those at risk for compartment syndrome: namely,
those patients with prolonged ischemia (>4 hours) before
revascularization and severe infrageniculate leg injury (i.e.,
mangled extremity). The authors also have a low threshold to
perform leg fasciotomy in patients who have had ligation of a
large extremity venous injury, those who have had hemor-
rhagic shock requiring significant resuscitation, and those
with combined arterial and venous injuries.18 If uncertainty
exists about whether or not fasciotomy is indicated at the time
of the initial vascular repair, our preference is to proceed with
fasciotomy due to the increased morbidity and mortality from
delayed fasciotomy.47
Using the two-incision approach, all four compartments
can be quickly and safely decompressed. A longitudinal skin
incision lateral to the tibia is used to visualize the anterior and
lateral compartments. Parallel incisions in the fascia are used
to decompress these compartments. The second skin incision
is medial and immediately posterior to the tibia. This incision
is used to access both posterior compartments (Fig. 15-17).
Care must be taken to avoid the superficial peroneal nerve and
the saphenous vein. Also, when decompressing the anterior
and lateral compartments, the intermuscular septum should
be identified to ensure that both compartments have indeed
been opened and that one is not misguided by the appearance
of the similar muscle groups.
15  /  Lower Extremity Vascular Trauma 181
Anterior tibial a.
and v.
Tibia
Lateral incision
Peroneal n.
Fibula
Fibular a.
and v.
Small
saphenous v.
Conclusion
Extremity vascular trauma is common in both the civilian and
the military settings. Recent experience in the wars in Afghani-
stan and Iraq has confirmed the imperative of initial hemor-
rhage control including the use of tourniquets and direct or
manual pressure with or without hemostatic agents if possible.
Once hemorrhage control has been achieved, management
options include (1) continued tourniquet application or liga-
tion of the vascular injury, (2) restoration of perfusion (arte-
rial and/or venous) with a temporary vascular shunt, and (3)
vascular reconstruction either initially or following use of a
vascular shunt. The choice of management depends on the
anatomic location of the extremity vascular injury; whether it
is arterial, venous, or both; the extent of the mangled extrem-
ity; and the physiologic status of the patient (i.e., associated
injuries or adverse physiology). While simple vascular recon-
struction may be possible for uncomplicated, isolated vascular
injuries cared for by experienced surgeons, more complex
injury patterns occurring in the setting of the mangled extrem-
ity benefit greatly from damage control adjuncts and from a
multidisciplinary approach.
REFERENCES
1. Eastridge BJ, Hardin M, Cantrell J, et al: Died of wounds on the battle-
field: causation and implications for improving combat casualty care.
J Trauma 71(1 Suppl):S4–S8, 2011.
2. Kotwal RS, Montgomery HR, Kotwal BM, et al: Eliminating preventable
death on the battlefield. Arch Surg 146(12):1350–1358, 2011.
3. Kragh JF, Jr, Walters TJ, Baer DG, et al: Practical use of emergency tour-
niquets to stop bleeding in major limb trauma. J Trauma 64(2 Suppl):S38–
S49, Discussion S49–50, 2008.
4. Kragh JF, Jr, Walters TJ, Baer DG, et al: Survival with emergency tourni-
quet use to stop bleeding in major limb trauma. Ann Surg 249(1):1–7,
2009.
5. Fox CJ, Gillespie DL, O’Donnell SD, et al: Contemporary management of
wartime vascular trauma. J Vasc Surg 41(4):638–644, 2005.
182 SECTION 3  /  DEFINITIVE MANAGEMENT
6. Woodward EB, Clouse WD, Eliason JL, et al: Penetrating femoropopliteal
injury during modern warfare: experience of the Balad Vascular Registry.
J Vasc Surg 47(6):1259–1264, Discussion 1264–1265, 2008.
7. Burkhardt GE, Cox M, Clouse WD, et al: Outcomes of selective tibial
artery repair following combat-related extremity injury. J Vasc Surg
52(1):91–96, 2010.
8. Debakey ME, Simeone FA: Battle injuries of the arteries in World War II:
an analysis of 2,471 cases. Ann Surg 123(4):534–579, 1946.
9. Hughes CW: Arterial repair during the Korean war. Ann Surg 147(4):555–
561, 1958.
10. Makins GH: On gunshot injuries to the blood vessels, New York, 1919,
William Wood and Company.
11. Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam:
1,000 cases. J Trauma 10(5):359–369, 1970.
12. Ziperman HH: Acute arterial injuries in the Korean war; a statistical
study. Ann Surg 139(1):1–8, 1954.
13. Mattox KL, Feliciano DV, Burch J, et al: Five thousand seven hundred
sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution
1958 to 1987. Ann Surg 209(6):698–705, Discussion 706–707, 1989.
14. Branco BC, Inaba K, Barmparas G, et al: Incidence and predictors for the
need for fasciotomy after extremity trauma: a 10-year review in a mature
level I trauma centre. Injury 42(10):1157–1163, 2010.
15. Asensio JA, Kuncir EJ, Garcia-Nunez LM, et al: Femoral vessel injuries:
analysis of factors predictive of outcomes. J Am Coll Surg 203(4):512–
520, 2006.
16. Kauvar DS, Sarfati MR, Kraiss LW: National trauma databank analysis of
mortality and limb loss in isolated lower extremity vascular trauma. J Vasc
Surg 53(6):1598–1603, 2011.
17. Mullenix PS, Steele SR, Andersen CA, et al: Limb salvage and outcomes
among patients with traumatic popliteal vascular injury: an analysis of
the National Trauma Data Bank. J Vasc Surg 44(1):94–100, 2006.
18. Franz RW, Shah KJ, Halaharvi D, et al: A 5-year review of management
of lower extremity arterial injuries at an urban level I trauma center.
J Vasc Surg 53(6):1604–1610, 2011.
19. Surgeons ACo: Advanced trauma life support for doctors, ATLS: student
course manual, 2008, American College of Surgeons.
20. Gillespie DL, Woodson J, Kaufman J, et al: Role of arteriography for blunt
or penetrating injuries in proximity to major vascular structures: an
evolution in management. Ann Vasc Surg 7(2):145–149, 1993.
21. Inaba K, Potzman J, Munera F, et al: Multi-slice CT angiography for arte-
rial evaluation in the injured lower extremity. J Trauma 60(3):502–506,
Discussion 506–507, 2006.
22. Johansen K, Lynch K, Paun M, et al: Non-invasive vascular tests reliably
exclude occult arterial trauma in injured extremities. J Trauma 31(4):515–
519, Discussion 519–522, 1991.
23. Lynch K, Johansen K: Can Doppler pressure measurement replace “exclu-
sion” arteriography in the diagnosis of occult extremity arterial trauma?
Ann Surg 214(6):737–741, 1991.
24. Degiannis E, Velmahos GC, Levy RD, et al: Penetrating injuries of the iliac
arteries: a South African experience. Surgery 119(2):146–150, 1996.
25. Frykberg ER: Popliteal vascular injuries. Surg Clin North Am 82(1):67–
89, 2002.
26. Applebaum R, Yellin AE, Weaver FA, et al: Role of routine arteriography
in blunt lower-extremity trauma. Am J Surg 160(2):221–224, Discussion
224–225, 1990.
27. Padberg FT, Jr, Rubelowsky JJ, Hernandez-Maldonado JJ, et al: Infrapop-
liteal arterial injury: prompt revascularization affords optimal limb
salvage. J Vasc Surg 16(6):877–885, Discussion 885–886, 1992.
28. White PW, Gillespie DL, Feurstein I, et al: Sixty-four slice multidetector
computed tomographic angiography in the evaluation of vascular
trauma. J Trauma 68(1):96–102, 2010.
29. Butler FK, Jr, Hagmann J, Butler EG: Tactical combat casualty care in
special operations. Mil Med 161(Suppl):3–16, 1996.
30. Jeffrey P, Salomone MD, McSwain NE: PHTLS: prehospital trauma life
support, 2006, Elsevier Mosby.
31. Vertrees A, Fox CJ, Quan RW, et al: The use of prosthetic grafts in complex
military vascular trauma: a limb salvage strategy for patients with severely
limited autologous conduit. J Trauma 66(4):980–983, 2009.
32. Daugherty ME, Sachatello CR, Ernst CB: Improved treatment of popliteal
arterial injuries using anticoagulation and extraanatomic reconstruction.
Arch Surg 113(11):1317–1321, 1978.
33. Quan RW, Gillespie DL, Stuart RP, et al: The effect of vein repair on the
risk of venous thromboembolic events: a review of more than 100 trau-
matic military venous injuries. J Vasc Surg 47(3):571–577, 2008.
34. Parry NG, Feliciano DV, Burke RM, et al: Management and short-term
patency of lower extremity venous injuries with various repairs. Am J
Surg 186(6):631–635, 2003.
35. Rich NM, Hobson RW, Collins GJ, Jr, et al: The effect of acute popliteal
venous interruption. Ann Surg 183(4):365–368, 1976.
36. Timberlake GA, Kerstein MD: Venous injury: to repair or ligate, the
dilemma revisited. Am Surg 61(2):139–145, 1995.
37. Kurtoglu M, Yanar H, Taviloglu K, et al: Serious lower extremity venous
injury management with ligation: prospective overview of 63 patients.
Am Surg 73(10):1039–1043, 2007.
38. Kuralay E, Demirkilic U, Ozal E, et al: A quantitative approach to lower
extremity vein repair. J Vasc Surg 36(6):1213–1218, 2002.
39. Quan RW, Adams ED, Cox MW, et al: The management of trauma venous
injury: civilian and wartime experiences. Perspect Vasc Surg Endovasc
Ther 18(2):149–156, 2006.
40. Ball CG, Feliciano DV: Damage control techniques for common and
external iliac artery injuries: have temporary intravascular shunts replaced
the need for ligation? J Trauma 68(5):1117–1120, 2010.
41. Feliciano DV, Mattox KL, Graham JM, et al: Five-year experience with
PTFE grafts in vascular wounds. J Trauma 25(1):71–82, 1985.
42. Day CP, Orme R: Popliteal artery branching patterns—an angiographic
study. Clin Radiol 61(8):696–699, 2006.
43. Whitman GR, McCroskey BL, Moore EE, et al: Traumatic popliteal and
trifurcation vascular injuries: determinants of functional limb salvage.
Am J Surg 154(6):681–684, 1987.
44. Cargile JS, 3rd, Hunt JL, Purdue GF: Acute trauma of the femoral artery
and vein. J Trauma 32(3):364–370, Discussion 370–371, 1992.
45. Feliciano DV, Herskowitz K, O’Gorman RB, et al: Management of vascu-
lar injuries in the lower extremities. J Trauma 28(3):319–328, 1988.
46. Hafez HM, Woolgar J, Robbs JV: Lower extremity arterial injury: results
of 550 cases and review of risk factors associated with limb loss. J Vasc
Surg 33(6):1212–1219, 2001.
47. Ritenour AE, Dorlac WC, Fang R, et al: Complications after fasciotomy
revision and delayed compartment release in combat patients. J Trauma
64(2 Suppl):S153–S161, Discussion S161–S162, 2008.
 SECTION 4

Hot Topics in
Vascular Injury and
Management
Damage Control: Prehospital
Care of the Patient With
Vascular Injury*
LORNE H. BLACKBOURNE AND FRANK K. BUTLER
Introduction
Control of hemorrhage resulting from vascular disruption has
been the historical cornerstone of trauma care.1 Throughout
the world, traumatic injury is the leading cause of mortality
and morbidity for patients aged 1 to 59.2,3 In the United States,
trauma is the leading cause of death in individuals aged 1 to
40, accounting for over 150,000 deaths per year.4,5 The goals
of trauma management are to ensure survival and to optimize
the patient’s potential for achieving and maintaining the best
possible functional recovery.
A comprehensive overview of the prehospital care of the
trauma patient has been provided for both the civilian6 and
military7 settings. This chapter will focus more directly on two
aspects of prehospital care—stopping the bleeding that results
from vascular trauma and preventing and treating hemor-
rhagic shock.
Preventable Death
Avoidance of preventable death is the most important outcome
measure in battlefield trauma care. Every preventable death is
a call to action. Every effort is also made to ensure that limbs
are saved whenever possible and that other avoidable adverse
outcomes from the trauma are minimized.
Understanding the incidence of death from potentially sur-
vivable injuries in combat requires examination of autopsy
records from the Office of the Armed Forces Medical Exam-
iner (AFME).8,9 Published reports of the incidence of death
in casualties with potentially survivable injuries from the
conflicts in Iraq and Afghanistan range from 15% to 28%.8,9
Hemorrhage is still the leading cause of death in combat
casualties.8-10 The key to reducing preventable fatalities is to
achieve rapid and definitive control of vascular disruption and
subsequent hemorrhage.
It is useful to think of hemorrhage in the prehospital setting
as being one of the following two types: compressible (either
extremity hemorrhage or external hemorrhage not suitable
for a tourniquet) or noncompressible (internal). The extremi-
ties are the most commonly injured anatomic region in the
combat wounded, representing over 50% of all anatomic
combat wounds.11 In polytrauma casualties (most commonly
from fragments from explosive devices), 82% of combat
wounded have an injury to at least one limb.11 Martin’s paper
*Note: The views, opinions, and assertions expressed in this chapter are those
of the authors alone and do not necessarily reflect the views of the Depart-
ment of the Army or the Department of Defense.
16 
from Iraq, describing 151 in-hospital deaths, noted that the
predominant causes of death were head injury (45%) and
hemorrhage (32%). Improvements in diagnosing ongoing
blood loss and resuscitation from shock (including efforts
directed at maintaining coagulation status as close to normal
as possible) offer the potential for improved survival in both
categories (Fig. 16-1).12
General Aspects of Care
Tactical Combat Casualty Care (TCCC) is a set of prehospital
trauma care guidelines customized for use on the battle-
field.13,14 TCCC recognizes the need to combine good medi-
cine with good small-unit tactics while treating trauma on the
battlefield. It focuses intensely on minimizing blood loss in
injured warriors, and it has rapidly gained traction as an effec-
tive means of reducing combat death. In one study of a U.S.
Army unit where TCCC training was instituted—before the
start of the conflicts in Iraq and Afghanistan—the overall
incidence of preventable deaths in 419 battle injury casualties
was 3%, with no deaths due to lack of required prehospital
interventions.15 TCCC has been recommended for all deploy-
ing U.S. combatants and physicians,16-18 is part of all U.S.
military service combat medical training,19-21 is an integral
component of the Army’s Combat Lifesaver course,22 and is
mandatory for deploying Special Operations forces.23 TCCC
has just been adopted as the standard of care by the ABCA
(America, Britain, Canada, Australia, and New Zealand)
Armies’ Program.24
Prehospital Trauma Life Support (PHTLS) is the civilian
counterpart to TCCC.6 It is designed primarily for use by
nonphysicians in the prehospital setting and concentrates
more on the management of blunt trauma than TCCC and,
as such, reflects the nature of the epidemiology of civilian
injury patterns. Implementation of a comprehensive PHTLS
program has been shown to reduce mortality in trauma
systems.25 The last 15 years has seen an increasingly close
working relationship develop between the civilian and the
military prehospital trauma care sectors, with an ongoing
exchange of information and management concepts and
copublication of both sets of management strategies in the
seventh edition of the PHTLS manual.6,7
Control of Extremity Hemorrhage:
Tourniquets
Although tourniquets had been available for use in trauma
patients for almost 500 years by the time of the Vietnam War,26
185
 16  /  Damage Control: Prehospital Care of the Patient With Vascular Injury 185.e1

ABSTRACT
The recent decade of war experienced by the United States
and its coalition partners has produced sweeping changes
in the prehospital management of combat casualties. Col-
lectively called Tactical Combat Casualty Care (TCCC),
these new wartime prehospital trauma care strategies have
centered on identification of the common causes of pre-
ventable battlefield mortality and the deployment of tai-
lored management strategies directed at avoiding these
deaths.
Blood vessel trauma and disruption with subsequent
hemorrhage remains the most common cause of prevent-
able death in the combat wounded, so TCCC has a strong
emphasis on the management of vascular injuries. Tourni-
quets are used aggressively on the battlefield to control
extremity hemorrhage; hemostatic dressings, such as Com-
bat Gauze, are used for compressible hemorrhage that
occurs in anatomic locations not amenable to tourniquet
use; new interventions for junctional hemorrhage control
are being introduced; and tranexamic acid, an antifibrino-
lytic agent, is now being used to help improve survival in
casualties with noncompressible hemorrhage. There is also
an increased focus on the prevention and management of
trauma-associated coagulopathy, on hypothermia preven-
tion, and on the use of hypotensive resuscitation instead
of large-volume crystalloid fluid resuscitation. Prehospital
damage control resuscitation with 1 : 1 plasma and packed
red blood cell (PRBC) transfusion is used as soon as blood
products are logistically feasible. Finally, evacuation strate-
gies that call for more highly-skilled medical providers dur-
ing transport and minimized transport time to definitive
care have gained wide acceptance.
The combination of these prehospital measures (with
improved definitive care, advances in strategic evacuation,
and improvements in personal protective equipment) have
produced unprecedented casualty survival rates in the
conflicts in Iraq and Afghanistan. Many of these strategies
are also gaining increased acceptance in civilian trauma
systems.

Key Words:  Combat Gauze,

freeze-dried plasma,
hemostatic agents,
Hextend,
hypotensive resuscitation,
junctional hemorrhage,
prehospital care,
Tactical Combat Casualty Care (TCCC),
tourniquets,
tranexamic acid (TXA)
186 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
Head
30%
Trunk Upper
15% extremity
30%
Lower
extremity
25%
FIGURE 16-1  Distribution of combat injuries: head, 30%; trunk,
15%; lower extremities, 25%; upper extremities, 30%. (From Owens
B, et al: Combat Wounds in Operation Iraqi Freedom and Operation
Enduring Freedom. J Trauma 64:295–299, 2008.)
it is notable that exsanguination from extremity wounds was
the leading cause of preventable death in the Vietnam conflict.
In this respect, Maughon’s 1970 study on causes of death in
U.S. combatants documented a 7.4% incidence of preventable
death.27
Noting the implications of Maughon’s study and further
writings from Ron Bellamy, the originators of TCCC estab-
lished this course in 1996—some 5 years before the onset of
Operation Enduring Freedom (OEF) in Afghanistan—and
made an appeal for aggressive use of tourniquets to control
life-threatening extremity hemorrhage.14 This call was con-
trary to what was taught in civilian trauma courses and
centers, but further evidence was provided by Mabry’s analysis
of extremity hemorrhage among U.S. Special Operations
casualties sustained in Mogadishu.28 Further data of the sig-
nificance of extremity hemorrhage as a cause of preventable
death continued to accrue from the Iraq and Afghanistan
wars.8,9,29 Kelly’s paper from 2008, which reviewed fatalities
occurring up to December 2006, documented a 7.8% death
B C
FIGURE 16-2  A, Combat Application Tourniquet (CAT). B, Special
Operations Forces Tactical Tourniquet (SOFTT). C, Emergency and
Military Tourniquet (EMT).
rate from extremity hemorrhage with 77 deaths resulting from
failure to use a tourniquet. To restate, even in 2006, the death
rate from extremity hemorrhage in U.S. forces in Iraq and
Afghanistan was essentially the same as that observed in
Vietnam.
Contrast this experience with the aforementioned Kotwal
study that documented the Ranger experience with TCCC.15
The Rangers are one of only three groups in the U.S. military
to have implemented TCCC protocols and training through-
out their combatant force and to have done so before 2001,
and they were the only group to publish their experience.
Every Ranger went to war in Iraq and Afghanistan equipped
with a tourniquet and trained in its use. Preventable deaths
from failure to obtain prehospital control of extremity hemor-
rhage throughout the recent decade of conflict have been zero.
Two publications were instrumental in bringing about the
widespread adoption of tourniquets to control extremity
hemorrhage from vascular trauma by the U.S. military. Firstly,
Holcomb’s 2007 analysis of a small cohort of Special Opera-
tions fatalities from OEF revealed that, several years into the
war, extremity hemorrhage was still a leading cause of pre-
ventable death.30 Secondly, a report from the U.S. Army Insti-
tute of Surgical Research describing the laboratory evaluation
of commercially available tourniquets made specific recom-
mendations about which tourniquet would best suit troops
for use on the battlefield.31 The three tourniquets that were
found to meet this requirement were the Combat Application
Tourniquet (CAT), the Special Operations Forces Tactical
Tourniquet (SOFTT), and the Emergency Medical Tourniquet
(EMT) (Fig. 16-2, A-C). The EMT is a pneumatic tourniquet
and is susceptible to ballistic damage (bullets or shrapnel
strikes) that may render the tourniquet nonfunctional. The
CAT was fielded by both Special Operations forces23 and sub-
sequently by the Army in 2005, although the SOFTT is pre-
ferred by some individual units. The CAT® and SOFTT are
both windlass-type devices that are lightweight and relatively
inexpensive. These tourniquets can be readily applied to one’s
 16  /  Damage Control: Prehospital Care of the Patient With Vascular Injury 187
own or another’s extremity and are rugged, reliable, and small
enough to be easily carried. The CAT has been designated as
an item of individual issue to ground combatants in all ser-
vices and has proven effective and reliable in the current
conflicts.32 (See Fig. 16-2, A-C). Evaluation and testing of
updated models continues in the quest to refine tourniquet
design.7,33
The relevance of vascular trauma throughout the TCCC
Guidelines is readily apparent. Specifically, these guidelines,
last updated in October 2014, call for tourniquet use in the
Care Under Fire Phase of Care (that phase of battlefield
trauma care carried out in the presence of effective incoming
fire) as follows7:
7. Stop life-threatening external hemorrhage if tactically
feasible:
• Direct casualty to control hemorrhage by self-aid if
able.
• Use a CoTCCC-recommended limb tourniquet for
hemorrhage that is anatomically amenable to tourni-
quet use.
• Apply the limb tourniquet over the uniform clearly
proximal to the bleeding site(s). If the site of the life-
threatening bleeding is not readily apparent, place the
tourniquet “high and tight” (as proximal as possible)
on the injured limb and move the casualty to cover.
When effective incoming fire is not an immediate threat to
life, that phase of care is referred to as Tactical Field Care
(TFC) and tourniquet guidelines are as follows:
Bleeding
a. Assess for unrecognized hemorrhage and control all
sources of bleeding. If not already done, use a
CoTCCC-recommended limb tourniquet to control
life-threatening external hemorrhage that is anatom-
ically amenable to tourniquet use or for any trau-
matic amputation. Apply directly to the skin 2-3
inches above the wound. If bleeding is not controlled
with the first tourniquet, apply a second tourniquet
side-by-side with the first.
b. For compressible hemorrhage not amenable to limb
tourniquet use or as an adjunct to tourniquet
removal, use Combat Gauze as the CoTCCC hemo-
static dressing of choice. Celox Gauze and Chi-
toGauze may also be used if Combat Gauze is not
available. Hemostatic dressings should be applied
with at least 3 minutes of direct pressure. If the bleed-
ing site is amenable to use of a junctional tourniquet,
immediately apply a CoTCCC-recommended junc-
tional tourniquet. Do not delay in the application of
the junctional tourniquet once it is ready for use.
Apply hemostatic dressings with direct pressure if a
junctional tourniquet is not available or while the
junctional tourniquet is being readied for use.
c. Reassess prior tourniquet application. Expose the
wound and determine if a tourniquet is needed. If it
is, replace any limb tourniquet placed over the
uniform with one applied directly to the skin 2-3
inches above wound. Ensure that bleeding is stopped.
When possible, a distal pulse should be checked. If
bleeding persists or a distal pulse is still present, con-
sider additional tightening of the tourniquet or the
use of a second tourniquet side-by-side with the first
to eliminate both bleeding and the distal pulse.
d. Limb tourniquets and junctional tourniquets should
be converted to hemostatic or pressure dressings as
soon as possible if three criteria are met: the casualty
is not in shock; it is possible to monitor the wound
closely for bleeding; and the tourniquet is not being
used to control bleeding from an amputated extrem-
ity. Every effort should be made to convert tourni-
quets in less than 2 hours if bleeding can be controlled
with other means. Do not remove a tourniquet that
has been in place more than 6 hours unless close
monitoring and lab capability are available.
e. Expose and clearly mark all tourniquet sites with the
time of tourniquet application. Use an indelible
marker.
Additional recommendations regarding tourniquet use to
control vascular injury with bleeding have been adopted by
both the Army and TCCC and are shown in Box 16-1.7
When tourniquets are used in the prehospital setting, they
have been documented to be remarkably effective at decreas-
ing preventable deaths due to extremity hemorrhage.34 In
order to be most effective, the tourniquet must be applied to
the bleeding limb before the casualty has lost enough blood
to suffer hypovolemic (Class III) shock. Complications are few
if the correct TCCC guidelines are followed. There were no
otherwise-preventable incidences of limb loss occurring as a
result of tourniquet ischemia in Kragh’s case series of 232
patients with tourniquets on 309 extremities.32
Since 2005, TCCC and the use of tourniquets have gained
increasing acceptance within the U.S. military. Over the first 5
years of the wars in Afghanistan and Iraq, 7 out of every 100
combat fatalities were due to hemorrhage from extremity
wounds. (9) There was no reduction in preventable deaths
from this type of injury since the Vietnam war, despite 40
years of elapsed time. The Eastridge report notes that by the
end of the war—after TCCC had been implemented in much
of the military—deaths from extremity hemorrhage had
dropped to 2.6%. (10) The use of prehospital tourniquets
remains one of the major lessons learned from the recent
conflicts in Iraq and Afghanistan.13,21,35,36
Control of External Nonextremity
Hemorrhage
Hemostatic Agents
Some anatomic areas such as the neck, the groin, and the axilla
contain large vascular structures that are not amenable to
tourniquet placement. Bleeding from these areas is often
termed junctional hemorrhage as it arises from vascular struc-
tures in the transition area between the torso and the extremi-
ties. A broader description of junctional hemorrhage is
provided in the following section; but for the combat casualty,
once care has entered the tactical field phase, better security
and more time mean that additional hemorrhage control
options become available. For junctional hemorrhage, these
options often include a form of topical hemostatic agents and
dressings.
The HemCon dressing and the granular agent QuikClot
were the initial hemostatic agents to be utilized by TCCC
protocols, on the basis of their efficacy of controlling severe
bleeding in animal models.7,37,38 These agents were found to
work effectively, although some casualties were reported to
188 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
Box 16-1 Tourniquet Tips
POINTS TO REMEMBER
• Damage to the arm or leg is rare if the tourniquet is left on
less than 2 hours.
• Tourniquets are often left in place for several hours during
surgical procedures.
• In the face of massive extremity hemorrhage, it is better to
accept the small risk of damage to the limb than to allow a
casualty to bleed to death.
SIX MAJOR TOURNIQUET MISTAKES
1. Not using a tourniquet when it should be used.
2. Using a tourniquet when it should not be used.
3. Putting the tourniquet on too proximally.
4. Not tightening the tourniquet well enough.
5. Not taking the tourniquet off when possible.
6. Periodically loosening the tourniquet to allow intermittent
blood flow.
DEATH FROM EXSANGUINATION
How long does it take to bleed to death from a complete
femoral artery and vein disruption?
Most humans with such an injury will exsanguinate in
about 10 minutes, but some will bleed to death in as little as
3 minutes.
TOURNIQUET APPLICATION
1. Apply without delay for life-threatening bleeding in the Care
Under Fire phase.
Both the casualty and the corpsman/medic are in serious
danger while a tourniquet is being applied in this phase.
The decision regarding the relative risk of further injury versus
that of bleeding to death must be made by the person
rendering care.
The life-saving benefit of a tourniquet is far more pronounced
when the tourniquet is applied BEFORE the casualty has
gone into shock from his wound.
2. Non–life-threatening bleeding should be ignored until the
Tactical Field Care phase.
suffer cutaneous burns with QuikClot use.39,40,41 These hemo-
static agents were also found to perform well when used in
civilian trauma settings.39
Newer hemostatic agents have since become available and
have been tested at both the U.S. Army Institute for Surgical
Research (USAISR) and the Naval Medical Research Center
(NMRC).42 Both laboratories found that the new agents
Combat Gauze and Woundstat were consistently more effec-
tive than HemCon and QuikClot. In one ISR study, which
used a 6-mm femoral arteriotomy model, only 2 of the 6
animals treated with placebo gauze survived, whereas 8 of the
10 Combat Gauze animals survived. No significant exother-
mic reaction was noted with either Combat Gauze or Wound-
stat. Celox was also found to perform better than HemCon
and QuikClot (Fig. 16-3). Survival time analysis and a
summary of the characteristics of the various hemostatic
agents are shown in Figure 16-3 and Table 16-1.
Based on the ISR and NMRC testing results, the TCCC
guidelines were changed; and Combat Gauze (Fig. 16-4) is
presently recommended as the first line treatment for life-
threatening hemorrhage that is not amenable to tourniquet
placement. Note that although WoundStat was also effective,
subsequent studies at USAISR demonstrated that WoundStat
use resulted in occlusive thrombi in injured vessels and
3. Apply proximal to the site of hemorrhage over the uniform
during Care under Fire.
4. Tighten tourniquet until the bleeding stops.
5. During Tactical Field Care, expose the wound and reapply
the tourniquet directly on the skin 2-3 inches above the
bleeding site.
6. Check for a distal pulse.
7. Tighten the tourniquet or apply a second tourniquet
side-by-side and just proximal to the first as needed to
eliminate the distal pulse.
8. Note the time of tourniquet application.
REMOVING THE TOURNIQUET
Tourniquets still in place two hours after application should
always be checked at that point to see if hemorrhage control can
be accomplished by other methods. This will help to decrease the
risk of possible extremity damage due to tourniquet ischemia.
• Remove as soon as direct pressure or hemostatic dressings
become feasible and effective, unless the casualty is in shock
or unless the tourniquet has been on for more than 6 hours.
• Only a combat medic, a physician’s assistant, or a physician
should remove tourniquets.
• Do not remove the tourniquet if the distal extremity is gone.
• Do not attempt to remove the tourniquet if the casualty will
arrive at a hospital in 2 hours or less after application.
Technique for Removal
1. Apply Combat Gauze as per instructions.
2. Loosen the tourniquet.
3. Apply direct pressure for 3 minutes.
4. Check for bleeding.
5. If there is no bleeding, apply pressure dressing over the
Combat Gauze.
6. Leave the tourniquet in place, but loose.
7. Monitor for bleeding from underneath the pressure dressings.
8. If bleeding does not remain controlled using nontourniquet
methods, retighten the tourniquet until bleeding is controlled
and the distal pulse is extinguished; expedite evacuation.
Survival Time Analysis
100 WS* (100%)
CG* (80%)
75
% Survival
Celox* (60%)
50
*P < 0.05 vs. HC
P < 0.0001
25 (Log rank test)
ACS+ (16%)
HC (10%)
0
0 50 100 150 200
Time (min)
FIGURE 16-3  Survival time analysis. ACS, Advanced Clotting Sponge
Plus; CG, Combat Gauze; HC, HemCon; WS, WoundStat. (Courtesy Dr.
Bijan Kheirabadi.)
resulted in evidence of toxicity to the endothelial cells.43
Concern about thromboembolic complications resulted in a
decision not to recommend this agent in TCCC.
Combat Gauze also has the advantage of being a gauze-
type agent rather than a granular one. Based on their field
experience, combat medics, corpsmen, and pararescuemen on
the Committee on Tactical Combat Casualty Care expressed a
preference for gauze over a granular agent. They noted that
 16  /  Damage Control: Prehospital Care of the Patient With Vascular Injury 189

Table 16-1 Hemostatic Agent Comparison

QC ACS+ HemCon Celox WoundStat Combat Gauze
Hemostatic efficacy + + +++ ++++ ++++
Side effect None None Unknown Yes None
Ready to use √ √ √ √ √
Training requirement + + + +++ ++
Lightweight and durable ++ +++ +++ ++ +++
2 years shelf life √ √ √ √ √
Stable in extreme condition √ √ √ √ √
FDA approved √ √ √ √ √
Biodegradable No No Yes No No
Cost ($) ∼30 ∼75 ∼25 30-35 ∼25

Courtesy Dr. Bijan Kheirabadi.

FIGURE 16-5  Dismounted complex blast injury.

tions in Gaza. This case series of 14 uses noted a success rate

FIGURE 16-4  Combat Gauze. (Courtesy Z-Medica.)
powder or granular agents do not work well in wounds where
the bleeding vessel is at the bottom of a narrow tract. Gauze-
type hemostatic agents were believed to be more effective in
this setting. Granular agents also present an ocular hazard
when used in high wind conditions (caused by transport in or
downdraft from evacuation helicopters) and may be problem-
atic to remove from wounds during subsequent operations.
Combat Gauze should be applied with 3 minutes of sus-
tained direct pressure over the bleeding site in order to be
effective. Simply applying the Combat Gauze without main-
taining pressure is not adequate.44 After 3 minutes of direct
manual pressure, a pressure dressing may be applied to cover
the wound and the agent to maintain a degree of pressure.7
Note that wound geography and contour may impact on the
efficacy; Littlejohn found that Combat Gauze did not work
well in an animal bleeding model where the bleeding vessel
was located at the bottom of a narrow wound tract.45 Combat
Gauze was also found to be no different from standard gauze
when the two agents were used without application of direct
manual pressure.44
The first report of Combat Gauze use in combat operations
was published by Ran et al from Israeli Defense Force opera-
of 79%.46 Most dressings were applied in anatomic locations
where tourniquets could not be used and no significant adverse
events were reported. More advanced hemostatic agents may
become available in the future, and it is useful to have a stan-
dardized bleeding model with which to evaluate these agents.
The model currently used by USAISR and NMRC is a 6-mm
femoral arteriotomy model designed to have high lethality
when the wound is left untreated or packed using a standard
gauze dressing. New agents should be tested using this stan-
dardized model so that their relative efficacy to Combat Gauze
may be objectively evaluated.42,47 A key design feature of next
generation hemostatic dressings over present-day agents will
be the ability to stem hemorrhage in coagulopathic bleeding
models.
Junctional Bleeding
“Junctional bleeding” refers to a specific type of vascular
trauma and external hemorrhage in dismounted military
casualties injured by improvised-explosive-device (IED)
weapons.48,49 Dismounted complex blast injury (DCBI) casu-
alties (Fig. 16-5) are often noted to have life-threatening
bleeding from vessels in the groin or very proximal lower
extremity regions, where a tourniquet is difficult or impossible
to apply. The vasculature considered as “junctional” involves
the axillary, proximal femoral/distal iliac, and carotid arteries.
190 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
Casualties with injuries to these areas account for approxi-
mately 20% of potentially survivable deaths on the battlefield.9
These junctional vasculature injuries have been termed “com-
pressible but nontourniquetable” to differentiate these injuries
from extremity wounds that can be addressed by tourniquets
and from penetrating truncal vasculature injuries considered
“noncompressible.” Eastridge and his coauthors reviewed all
of the 4596 U.S. combat fatalities that occurred over a 10-year
period in Iraq and Afghanistan and found that junctional
hemorrhage had surpassed extremity hemorrhage as the
leading cause of potentially preventable death from compress-
ible hemorrhag; many of these junctional hemorrhage deaths
occurred in DCBI casualties from Afghanistan.50
Although anecdotal reports suggest that Combat Gauze
works well for most of these casualties, a backup means of
hemorrhage control is needed for cases where tourniquets
and/or Combat Gauze are not effective.1 USAISR has evalu-
ated a junctional hemostatic device, the Combat Ready Clamp
(CRoC) and has found it to be a promising technology for
controlling hemorrhage in junctional regions such as the
groin and the axilla.51,52 At the level of the groin, this device
stops junctional hemorrhage by applying direct pressure on
the external iliac artery at the inguinal ligament (Fig. 16-6, A
and B). The compressing surface is tightened with a screw
mechanism, and counterpressure is exerted from the portion
A treatment facility where definitive surgical control of the
B
FIGURE 16-6  A, Combat-ready clamp. B, Combat-ready clamp in
place.
of the clamp that is applied to the posterior surface of the
body. The CRoC was presented to the CoTCCC in August
2011 and recommended for inclusion into the TCCC Guide-
lines. This recommendation was approved by the Defense
Health Board in August of 2011.52a More recently, the Junc-
tional Emergency Treatment Tool and the SAM Junctional
Tourniquet have also been recommended for use by the
CoTCCC as junctional hemorrhage control devices.52b
Hemorrhage Control: Direct Pressure
Direct pressure can also be used to control bleeding from
external bleeding sites. This technique works even with bleed-
ing from major vessels such as the carotid or femoral arter-
ies.27 However, casualties with such injuries often bleed to
death despite attempts at direct pressure; because, for direct
pressure to be effective, it must be applied consistently and
with sufficient force to stop the bleeding. Direct pressure is
best applied with the patient on a firm surface so that effec-
tive counterpressure is present; for major bleeding, the pres-
sure must be sustained until the casualty reaches a location
where surgical repair of the vessel can be performed. Direct
pressure is difficult to maintain while the casualty is being
carried or transported on a litter, although consistent self-
applied direct pressure may be used successfully, even in
carotid injuries.27 The need to apply direct pressure may also
prevent the medic from addressing other wounds or other
casualties. For these reasons, tourniquets and hemostatic
agents are the preferred methods for control of life-threatening
external hemorrhage on the battlefield. Wounds with minor
external bleeding that do not involve large arteries or veins
may be dressed with a gauze bandage or simply ignored until
treated during the Tactical Field Care or Tactical Evacuation
Care (TACEVAC) phases.
Noncompressible Hemorrhage
Internal hemorrhage resulting from vascular disruption from
chest and/or abdominal wounds is referred to as noncom-
pressible torso hemorrhage.53 The most important lifesaving
intervention in this setting is rapid transportation to a medical
bleeding can be achieved (i.e., surgical hemostasis). Noncom-
pressible torso hemorrhage may result in shock and subse-
quent death despite a relatively unimpressive entrance wound.
Transport of the casualty with penetrating trauma to the
chest or abdomen should be accomplished on an emergent
basis. Other measures that may help to improve survival in
casualties with noncompressible hemorrhage are avoidance
of overly aggressive prehospital fluid resuscitation, avoidance
of platelet-impairing nonsteroidal antiinflammatory drug
(NSAID) medications, and prevention of hypothermia-related
coagulopathy.7
Currently, the prehospital treatment of noncompressible
torso hemorrhage consists of sufficient fluid resuscitation to
maintain adequate perfusion and to avoid severe ischemia
while avoiding overresuscitation and further hemorrhage.
Development of new methods of resuscitative aortic occlusion
and mechanical hemostasis for noncompressible torso hemor-
rhage are the focus of current U.S. Army Institute of Surgical
Research (USISR) and U.S. Defense Advanced Research Proj-
ects Agency and Department of Defense research efforts.
 16  /  Damage Control: Prehospital Care of the Patient With Vascular Injury 191
Prevention and Treatment of
the Coagulopathy of Trauma
Trauma patients may be coagulopathic for the following
reasons:
• Acidosis (associated with shock)
• Hypothermia (exacerbated in shock patients)
• Large-volume crystalloid resuscitation
• Therapeutic anticoagulation (Coumadin or platelet-
inhibiting medications intended to prevent thromboem-
bolic disease)
• Inadvertent anticoagulation (self-medication with
NSAIDs) for pain or inflammation
• Intrinsic (tissue-factor release caused by trauma)
Coagulopathy on arrival at the emergency department is
common (38%) in combat casualties requiring transfusion
and is associated with a sixfold increase in mortality.54 In one
study the presence of an acute traumatic coagulopathy in
major trauma patients was associated with an odds ratio of
early death of 8.7—independent of injury severity, transfusion
practice, or other physiological markers for hemorrhage.55
The need to avoid platelet-impairing agents in both combat
casualties and troops actively engaged in combat operations
has also been stressed in TCCC practice since 1996.14,7
Hypothermia-induced coagulopathy is also well described and
results from decreased platelet function, slower activity of
coagulation cascade enzymes, and alterations of the fibrino-
lytic system. The development of hypothermia is not merely
due to exposure to a cold environment but can also occur in
warm ambient temperatures as a sequela of hypovolemic
shock resulting in decreased ability to produce heat to main-
tain body temperature. Shock predisposes victims to hypo-
thermia and can contribute to worsening of the hypovolemic
state as a result of ensuing coagulopathy. TCCC recommends
aggressive strategies to combat hypothermia in combat casual-
ties, including the use of an active heating device combined
with a passive insulating blanket.7
Exacerbation of the coagulopathy of trauma may also be
caused by the administration of large volumes of fluid that do
not replace clotting factors lost through hemorrhage, as dis-
cussed in the following section. The standard of care for treat-
ing coagulopathy of trauma is plasma.56,57 Early and aggressive
use of plasma is associated with increased survival in trauma
patients.56-58 Plasma derived from fresh-frozen stocks is not
feasible for use by combatant medics administering Tactical
Field Care, prompting recent efforts to develop a more practi-
cal dried plasma option.
Intravenous Hemostatic Agents
Intravenous (IV) agents that either promote clotting or
prevent the lysis of formed clots assume a greater importance
when the vascular injury is sustained at a noncompressible
site. Recombinant factor VIIa (rVIIA) has been used in medical
treatment facilities to help promote hemostasis in non­
compressible hemorrhage patients requiring massive trans­
fusion.59,60,61a Although an increase in arterial (but not venous)
thromboembolic complications was found on a recent meta-
analysis,61 a randomized control trial of rVIIa use in patients
with severe blunt or penetrating trauma found that it signifi-
cantly improved bleeding control (as reflected by the decrease
in RBC transfusion requirements and the number of patients
requiring massive transfusion), without causing an increase of
adverse events, including thromboembolic events.62 A second
randomized, controlled trial of rVIIa use in trauma patients
also found a decrease in blood product usage for bluntly
injured patients who received rVIIa and did not find an
increase in thrombotic events.63 Use of this agent in current
combat operations may be indicated for hospitalized patients
who are in extremis. Factor VIIa’s very high cost and lack of
documented survival advantage make it impractical for
routine prehospital use.
Tranexamic acid (TXA) is an antifibrinolytic agent (with
antiinflammatory properties) that prevents the lysis of formed
clots. The CRASH-2 trial was a large (20,000+ patients) pro-
spective test of TXA administered to trauma patients who
either had hemorrhage or were felt to be at risk of hemor-
rhage.64 A subsequent subgroup analysis of the data looked at
the effects of timing of TXA administration on outcomes. In
this analysis, the focus was on 1063 patients where death was
due to hemorrhage. The risk of death due to bleeding was
significantly reduced if TXA was given within 1 hour of injury
(5.3% versus 7.7%). At 1 to 3 hours after injury, there was
also a significant decrease in mortality (4.8 versus 6.1%). At
times greater than 3 hours, however, mortality was found to
be increased in the TXA group. The CRASH-2 subgroup anal-
ysis paper concluded: “Our results strongly endorse the
importance of early administration of tranexamic acid in
bleeding trauma patients and suggest that trauma systems
should be configured to facilitate this recommendation.”65 A
2011 Cochrane Review noted: “The review concluded that
tranexamic acid safely reduces mortality in bleeding trauma
patients without increasing the risk of adverse events”.65a
TXA is used routinely by the U.K. Forces in Helmand Prov-
ince, Afghanistan, usually given by the prehospital medical
emergency response team (MERT) during Tactical Casualty
Evacuation or with the first shock pack in the emergency
department at the Role 3 medical treatment facility in Camp
Bastion. The MATTERS study is a joint U.K.–U.S. retrospec-
tive examination of the benefits of TXA administration in
trauma patients admitted to this hospital from January 2009
to December 2010.66,67 The study examined both 24-hour and
28-day mortality in 896 casualties of whom 293 received TXA
and 603 did not. Findings from this study included the
following:
• TXA administration is associated with a trend in reduc-
tion in blood product use for massive transfusion
patients.
• TXA administration is associated with decreased all-
cause mortality at 28 days: 16.4% versus 23.2%, p = 0.018.
• In patients who received massive transfusions (≥10u
PRBC), 28-day mortality was significantly decreased with
TXA: 13.6% versus 27.6%, p = 0.003 (Fig. 16-7).
• TXA administration was an independent predictor
of survival in this study: odds ratio 0.08 (0.02 to 0.42),
p = 0.003.
After having reviewed the above studies, the Committee on
TCCC recommended TXA for use in the prehospital setting.
(Dorlac, CoTCCC Minutes, August 2011).67a The revised
TCCC Guidelines now call for TXA use in both Tactical Field
Care and TACEVAC Care as follows:
Tranexamic Acid (TXA)
If a casualty is anticipated to need significant blood
transfusion (for example: presents with hemorrhagic shock,
192 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT

Survival Function resuscitation with Hextend was recommended by the U.S.

Army Medical Research and Materiel Command (MRMC)—
1.00 Office of Naval Research series of Fluid Resuscitation Confer-
TXA
No ences in 2001-200276,77 and was subsequently adopted by the
0.95
Yes CoTCCC.78 The current TCCC recommendations for fluid
resuscitation in TFC are as follows77a:
• The most recent recommendations for prehospital fluid
0.90 resuscitation from the CoTCCC have made the recom-
Cumulative Survival

mendations identical for both the Tactical Field Care and

the Tactical Evacuation Care phases.77a These recommen-
0.85 dations are outlined in the Care During Transport section
below. Blood products are the preferred fluid for resus-
citation from hemorrhagic shock when they are logisti-
0.80 cally feasible. In the Tactical Field Care phase of casualty
care, however, blood products are typically not available
to most U.S. military corpsmen and medics. In that cir-
0.75
cumstance, Hextend is the preferred fluid, followed by
Lactated Ringers and PlasmaLyte A solutions.77a
0.70 In a large but nonrandomized study at Ryder Trauma
Center in Miami, the use of resuscitation with Hextend was
0 5 10 15 20 25 30 found to produce a trend toward improved early survival with
Days no adverse impact on coagulation status.79 However, interpret-
Number at risk ing the results from this paper is complicated as the authors
TXA: 125 100 78 74 72 72 71 did not control for administration of other resuscitation fluids
No-TXA: 169 106 87 78 74 74 71 to the study population. Hetastarch has also been associated
FIGURE 16-7  MATTERS: Kaplan-Meier survival curve of the massive with increased renal injury and mortality; although in this
transfusion group receiving TXA. (From Morrison JJ, Dubose JJ, Rasmus-
sen TE, et al: Tranexamic acid decreases mortality following wartime
report use of hetastarch was limited to the hospital (rather
injury: the military application of tranexamic acid in trauma and emer- than the prehospital) domain, hetastarch patients were more
gency resuscitation study (MATTERS). Archives of Surgery 2012. 147:113– severely injured than the nonhetastarch population; and no
119, 2012.) defined resuscitation protocol was in place for patients with
hypovolemic shock.80
An RCT evaluating a permissive hypotensive resuscitation
one or more major amputations, penetrating torso trauma, strategy has recently been shown to decrease postoperative
or evidence of severe bleeding): coagulopathy and to lower the risk of early postoperative
- Administer 1 gram of tranexamic acid in 100 cc death.74 Prehospital trauma resuscitation strategies limiting IV
Normal Saline or Lactated Ringers as soon as possible access (as recommended in the 1996 TCCC paper14) and
but NOT later than 3 hours after injury. employing hypotensive resuscitation protocols have been
- Begin second infusion of 1 gram TXA after Hextend or adopted by some civilian organizations.69 Despite this, use of
other fluid treatment. crystalloid to treat hemorrhagic shock remains widespread,
This proposed change was approved by the Defense with investigators noting that in the ongoing ISR prehospital
Health Board in August 2011.67b trauma interventions study 87% of casualties who received
prehospital fluids received crystalloid.81
Prehospital Fluid Resuscitation:
Crystalloids and Colloids Prehospital Fluid Resuscitation:
Despite its widespread use, there is no evidence from human
Plasma
trials that aggressive prehospital administration of crystalloids Research on the use of freeze-dried plasma in the setting of
improves survival in trauma patients.4,14,68-70 There is some prehospital fluid resuscitation was identified as a top priority
evidence that aggressive fluid resuscitation with crystalloids by the USAISR-MRMC sponsored fluid resuscitation confer-
decreases survival.71-73 Part of the mechanism for this finding ence held in Dallas in January 2010.75 It was also similarly
may be dilution of clotting factors and contribution to the categorized by the U.S. Special Operations Command Surgeon
coagulopathy of trauma,74 the latter associated with a sixfold who noted that Special Operations forces must often operate
increase in mortality.54 Use of large-volume crystalloid for in immature theaters and austere environments far from fixed
prehospital fluid resuscitation of shocked patients is a likely medical care facilities.82 Plasma, even in the absence of trans-
cause of preventable death in some casualties and is therefore fused red blood cells, has been shown to be superior to
not promulgated in TCCC.7,75 Hextend at reversing the coagulopathy of trauma and improv-
Hextend (BioTime, Inc., Alameda, CA) is a solution of 6% ing survival in an animal model.83 Early and aggressive use
hetastarch in a lactated crystalloid carrier, offering greater of plasma is associated with increased survival in trauma
oncotic pressure and potentially better retention of intravas- patients.56-58 Plasma, including dried plasma, is recommended
cular fluid than standard electrolyte-only crystalloid. Use of by the CoTCCC for fluid resuscitation over Hextend and crys-
this solution permits smaller-volume (hypotensive) resuscita- talloids when whole blood and red blood cells are not
tion than with standard crystalloid solutions. Hypotensive available.84
 16  /  Damage Control: Prehospital Care of the Patient With Vascular Injury 193
The clotting factors in plasma have been shown to be pre-
served during a spray-drying technique of producing dried
plasma.56 Coagulation studies in a porcine model have shown
that infusion of spray-dried plasma reconstituted to its initial
volume produced clotting studies similar to FFP.56 Accelerated
fielding of a dried plasma product has been identified by the
Army Surgeon General’s Dismounted Complex Blast Injury
Task Force as a top priority for battlefield trauma care.48
Dubick notes: “The consensus of discussants at the USAISR-
sponsored symposium on prehospital fluid resuscitation over-
whelmingly favored the development of a dried plasma
product that could expand and maintain blood volume while
providing lost coagulation factors resulting from the traumatic
injury.”85 A recommendation that the DoD take all necessary
steps to expedite the fielding of a dried plasma product to
medics and evacuation platforms that do not have blood prod-
ucts was recently approved by the Defense Health Board.16,17
Care During Transport
Damage Control Resuscitation
Definitive resuscitation in patients with significant vascular
trauma and hemorrhage consists of replacing what has been
lost—either fresh whole blood or balanced 1 : 1 : 1 plasma/
platelet/PRBC transfusion. This balanced transfusion strategy,
when used with limiting crystalloids and when avoiding over-
resuscitation, is called damage control resuscitation (DCR).30
Transfusing plasma and PRBCs in a 1 : 1 ratio has been shown
to increase survival in massively transfused patients.86 DCR is
now the standard of care in Iraq and Afghanistan and in a
growing number of civilian trauma centers.30,71,86,87 Reducing
the amount of crystalloids used and avoiding overresuscita-
tion while administering a 1 : 1 : 1 balanced DCR strategy has
been shown to reduce mortality in a recent series of damage
control laparotomy patients.71 The current Joint Theater
Trauma System Clinical Practice Guideline (CPG) on DCR
also notes that large-volume crystalloid resuscitation increases
rates of abdominal compartment syndrome, multiple organ
failure, and death and emphasizes the need to limit both crys-
talloid and colloid therapy in the emergency department (ED)
for patients with significant ongoing bleeding.88 In patients
with vascular injury DCR resulted in improved postoperative
physiology, correction of coagulopathy, acidosis, and anemia—
without an increase in vascular thrombosis—in a case con-
trolled study from a Combat Support Hospital (CSH) in
Iraq.89 Outcomes have improved in combatants with extrem-
ity vascular injury as prehospital tourniquet use, damage
control resuscitation, and temporary vascular shunting has
become standardized.21,90
While DCR has become an established protocol for
in-hospital management of bleeding trauma patients, the
ability to administer blood products in the prehospital trans-
port setting has been historically limited. Recently the U.K.
MERT has introduced routine in-flight administration of
PRBCs and plasma in a 1 : 1 ratio for casualties in hemorrhagic
shock.91 Recognizing the importance of definitive resuscita-
tion of shock patients to be started as soon as possible, the
current TCCC recommendations for fluid resuscitation in
both TFC and TACEVAC are as follows91a:
7. Fluid resuscitation
a. The resuscitation fluids of choice for casualties in
hemorrhagic shock, listed from most to least pre-
ferred, are: whole blood*; plasma, RBCs and platelets
in 1 : 1 : 1 ratio*; plasma and RBCs in 1 : 1 ratio;
plasma or RBCs alone; Hextend; and crystalloid
(Lactated Ringers or Plasma-Lyte A).
b. Assess for hemorrhagic shock (altered mental status
in the absence of brain injury and/or weak or absent
radial pulse).
1. If not in shock:
• No IV fluids are immediately necessary.
• Fluids by mouth are permissible if the casualty
is conscious and can swallow.
2. If in shock and blood products are available under
an approved command or theater blood product
administration protocol:
• Resuscitate with whole blood,* or, if not
available
• Plasma, RBCs and platelets in a 1 : 1 : 1 ratio,* or,
if not available
• Plasma and RBCs in 1 : 1 ratio, or, if not
available;
• Reconstituted dried plasma, liquid plasma or
thawed plasma alone or RBCs alone;
• Reassess the casualty after each unit. Continue
resuscitation until a palpable radial pulse,
improved mental status or systolic BP of
80-90 mm Hg is present.
3. If in shock and blood products are not available
under an approved command or theater blood
product administration protocol due to tactical or
logistical constraints:
• Resuscitate with Hextend, or if not available;
• Lactated Ringers or Plasma-Lyte A;
• Reassess the casualty after each 500 mL IV
bolus;
• Continue resuscitation until a palpable radial
pulse, improved mental status, or systolic BP of
80-90 mm Hg is present.
• Discontinue fluid administration when one or
more of the above end points has been achieved.
4. If a casualty with an altered mental status due to
suspected TBI has a weak or absent peripheral
pulse, resuscitate as necessary to restore and main-
tain a normal radial pulse. If BP monitoring is
available, maintain a target systolic BP of at least
90 mmHg.
5. Reassess the casualty frequently to check for
recurrence of shock. If shock recurs, recheck all
external hemorrhage control measures to ensure
that they are still effective and repeat the fluid
resuscitation as outlined above.
As resuscitation protocols continue to improve, advances
in blood product availability occur, physiologic monitoring
techniques evolve, and communications/information technol-
ogy capabilities mature, prehospital personnel may be able
to use the concept of remote damage control resuscitation
(RDCR) to better guide their resuscitative efforts.92 More
*Neither whole blood nor apheresis platelets as these products are currently
collected in theater are FDA-compliant. Consequently, whole blood and
1 : 1 : 1 resuscitation using apheresis platelets should be used only if all of the
FDA-compliant blood products needed to support 1 : 1 : 1 resuscitation are not
available, or if 1 : 1 : 1 resuscitation is not producing the desired clinical effect.
194 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
precise definitions of the different pathophysiologies of death
from hemorrhage—including “exsanguination shock”—may
allow additional interventions to be undertaken targeted to
the unique pathophysiology of exsanguination.93
Comprehensive Tactical Evacuation   TXA.
Care Considerations
In the setting of military trauma, the term “Tactical Evacua-
tion Care” (TACEVAC) encompasses two types of evacuation.
Medical evacuation (MEDEVAC) is the use of a dedicated air
ambulance unit to transport the casualty from or near the
point of injury to the first medical treatment facility with a
surgical capability. These platforms typically carry no offen-
sive weaponry and are marked with a Red Cross. Casualty
evacuation (CASEVAC) platforms, in contrast, are platforms
that are not dedicated solely to evacuation of casualties and
are not marked with a Red Cross, but are typically equipped
with weapons and armor. The term “Tactical Evacuation”
encompasses both MEDEVAC and CASEVAC.7
TACEVAC capabilities are not standardized in the Afghani-
area of operations at present. The Army “DustOff ” evacuation
platforms fly smaller HH-60 helicopters that are staffed with
EMT-B trained flight medics, although the Army is presently
transitioning to staffing TACEVAC platforms with critical-
care flight paramedics instead of the EMT-B trained flight
medics used previously. Air Force “Pedro” helicopters also use
HH-60 aircraft but with two paramedic-trained Pararescue-
men (PJs) on board. Training evacuation flight crews to the
critical care flight paramedic level was associated with better
outcomes, with a 48-hour mortality of 7.9% in patients trans-
ported by critical care trained flight paramedics (CCFP) com-
pared to a 15.1% mortality for basic EMT-treated casualties.94
Notably, TACEVAC unit supervising physicians often have no
training in emergency medicine or EMS supervision and are
not taught TCCC concepts as a requirement.95
The U.K.’s MERT was initiated in 2006 in Helmand Prov-
ince because of very long TACEVAC times in that area of
operations. In essence, U.K. Defence Medical Services sought
to use MERT as a means of taking the resuscitation room to
the casualty. A typical MERT is staffed with a prehospital
physician (emergency medicine or anesthesia), an emergency
medicine nurse, and two paramedics. This staff provides the
casualty with four pairs of experienced hands and extra
medical decision-making capabilities as well as advanced
airway management (including mechanical ventilation and
oxygen), thoracotomy and/or thoracostomy, intraosseous
access, splinting (including pelvic), spinal immobilization,
hypothermia prevention, and resuscitation with PRBCs
and fresh frozen plasma during the TACEVAC flight. The
MERT typically uses a larger CH-47 helicopter.95 In Regional
Command-Southwest in Afghanistan, where many of the
most severe casualties from dismounted IED attacks occur, the
U.K. MERT team is used preferentially to evacuate the most
severely wounded casualties.95
The CoTCCC and the Trauma and Injury Subcommittee
of the Defense Health Board have reviewed the current status
of TACEVAC care and made the following recommendations
with respect to care provided during evacuation flights:
1. Develop a pilot U.S. Advanced TACEVAC Care Capa-
bility structured after the successful MERT model
insofar as possible. This platform would have an Emer-
gency Medicine or Critical Care physician-led team
and use the most capable airframe available (CH-47/
CH-53/CV-22). It would conceptually be used for the
most critical casualties and have the capability to
provide blood products, advanced airway capability,
and IV medications such as morphine, ketamine, and
2. Optimize TACEVAC response times. There is a Secre-
tary of Defense directed 60-minute maximum time for
evacuation, but faster transport to optimal care may be
lifesaving for critical casualties. This is especially
important in immature theaters.
3. A Hostile Fire Evacuation Option should be identified
in the mission planning phase to avoid evacuation
delays due to ground fire. Armed, armored aircraft
with no Red Crosses should be planned for if necessary
and modular medical packages may be employed on
these airframes.
4. Staff TACEVAC platforms with in-flight care providers
that meet or exceed the civilian standard:
• Critical care trained flight paramedic
• Critical care trained flight nurse
• Critical care capable flight-trained physician
• PAs CCFT trained are also an option
• At least 2 of the above providers should be pres-
ent on the platform when transporting critical
casualties.
• At least 1 of the above providers should be present
for each critical casualty.
5. Provide for routine availability of PRBCs and plasma
on TACEVAC platforms for critical casualties. Limit
the amount of crystalloid infused and use hypotensive
resuscitation with Hextend if no blood available.
6. Ensure robust predeployment trauma experience for
TACEVAC providers in air evacuation units in one or
more of the following:
• Service Trauma Training Centers
• Ongoing ICU/trauma experience
• Other trauma rotations to provide ongoing trauma
patient contact
• TCCC training
• Hands-on trauma should be the primary focus for
deployment work-up for designated flight medical
personnel
7. Establish a standard protocol for TACEVAC care as
outlined in TACEVAC section of the TCCC Guidelines.
These guidelines are evidence-based, reviewed on an
ongoing basis and modified as necessary.
8. Provide for oversight of TACEVAC Care in theater to
be carried out by a qualified EMS medical provider
who is part of the deployed JTS team.
9. Improve the documentation of TACEVAC Care to
facilitate process improvement measures.
10. Ensure that physicians providing medical oversight in
TACEVAC units are trained and experienced in trauma
care, to include TCCC.
11. There should be a standardized TACEVAC capability
in theaters of conflict. This capability is a joint require-
ment. Not all services need to be provided, but all
service casualties should receive the same quality of
care.
12. Flight reviews of TACEVAC care should be part
of JTTS Quality Assurance process. This requires
 16  /  Damage Control: Prehospital Care of the Patient With Vascular Injury 195
adequate documentation of care. The lack of this docu-
mentation should be a trigger for follow-up.
These recommendations were approved by the Defense
Health Board at their June 14 2011 meeting as noted in the
Board’s 2011 memorandum on this topic.95a
Future Directions
After a decade of war, vascular trauma or disruption with
noncompressible torso hemorrhage and junctional hemor-
rhage remain a challenge to those caring for the combat
wounded.10 Ameliorating the deleterious effects of blood loss
and ischemia from vascular injury will need to have a
2-pronged approach. The short-term goal is better resuscita-
tion fluids to avoid exsanguination and severe ischemia with
special emphasis on improving coagulation status. The longer-
term goal is to explore mechanical means of hemostasis for
penetrating, nonextremity trauma, from external compres-
sion of blood vessels (e.g., newer junctional tourniquets) to
luminal occlusion (e.g., balloon catheters).51,96
REFERENCES
1. Blackbourne LH, Mabry R, Sebesta J, et al: Joseph Lister, noncompressible
arterial hemorrhage, and the next generation of tourniquets. AMEDD J
56–59, 2008.
2. Borgman M, Spinella P, Holcomb J, et al: The effect of FFP:RBC ratio on
morbidity in trauma patients based on transfusion prediction score. Vox
San 101(1):44–54, 2011.
3. Peden MM, McGee K, Krug E, et al: Injury—a leading cause of the global
burden of disease; 2000, Geneva, 2002, Department of Injuries and Vio-
lence Prevention, Noncommunicable Diseases and Mental Health Cluster,
World Health Organization, p 9.
4. Holcomb J, Spinella P: Optimal use of blood in trauma patients. Biologi-
cals 38:72–77, 2010.
5. Centers for Disease Control and Prevention: Deaths: final data for 2004,
Atlanta, GA, 2007, U.S. Department of Health and Human Services, CDC,
National Center for Health Statistics.
6. Butler FK, Giebner SD, McSwain N, et al, editors: Prehospital trauma life
support manual, ed 8, Military Version, 2014.
7. http://www.usaisr.amedd.army.mil/assets/pdfs/TCCC_Guidelines
_140602.pdf. Accessed 15 January 2015.
8. Holcomb JB, McMullen NR, Pearse L, et al: Causes of death in special
operations forces in the global war on terror. Ann Surg 245:986–991,
2007.
9. Kelly JF, Ritenhour AE, McLaughlin DF, et al: Injury severity and causes
of death from Operation Iraqi Freedom and Operation Enduring
Freedom: 2003-2004 versus 2006. J Trauma 64:S21–S27, 2008.
10. Eastridge B, Hardin M, Cantrell J, et al: Died of wounds on the battlefield;
causation and implications for improving combat casualty care. J Trauma
71:S4–S8, 2011.
11. Owens B, Kragh J, Wenke J, et al: Combat wounds in Operation Iraqi
Freedom and Operation Enduring Freedom. J Trauma 64:295–299,
2008.
12. Martin M, Oh J, Currier H, et al: An analysis of in-hospital deaths at a
modern combat support hospital. J Trauma 66:S51–S61, 2009.
13. Butler F: Tactical Combat Casualty Care: update 2009. J Trauma
69(Suppl):S10–S13, 2010.
14. Butler FK, Hagmann J, Butler EG: Tactical Combat Casualty Care in
special operations. Mil Med 161(Suppl):3–16, 1996.
15. Kotwal RS, Montgomery HR, Mabry RL, et al: Eliminating preventable
death on the battlefield. Arch Surg 146(12):1350–1358, 2011. [E-pub 15
August 2011].
16. Dickey N, Jenkins DJ, Butler FK: Defense Health Board Memo on Tactical
Combat Casualty Training for Deploying Military Personnel, 14 June
2011.
17. Dickey N, Jenkins DJ, Butler FK: Defense Health Board Memo on Dried
Plasma, 14 June 2011.
18. Wilensky G: Defense Health Board Memo on Tactical Combat Casualty
Care and Minimizing Preventable Fatalities, 6 August 2009.
19. Robinson AR: Policy Guidance on updates to the Tactical Combat Casu-
alty Care (TCCC) course curriculum. BUMED letter Ser M3/5/10UM35810
dated, 10 March 2010.
20. Green CB: Incorporating Tactical Combat Casualty Care (TCCC) course
curriculum updates into Air Force medical training. Air Force Surgeon
General letter dated, 21 August 2010.
21. Fox RC: Tactical Combat Casualty Care (TCCC) guidelines and updates.
Marine Corps Administrative message 016/11 dated, 10 January 2011.
22. Dempsey ME: Improvements to Tactical Combat Casualty Care (TCCC)
and the Combat Lifesaver Course; TRADOC ltr, 8 April 2010.
23. U.S. Special Operations Command message: Tactical Combat Casualty
Care Training and Equipment, 22 March 2005.
24. Amor SP: ABCA Armies’ Program Chief of Staff letter dated, 22 February
2011.
25. Ali J, Adam RU, Gana TJ, et al: Trauma patient outcome after the Prehos-
pital Trauma Life Support program. J Trauma 42:1018–1021, 1997.
26. Mabry RL: Tourniquet use on the battlefield. Mil Med 171:352–356,
2006.
27. Maughon JS: An inquiry into the nature of wounds resulting in killed in
action in Vietnam. Mil Med 135(1):8–13, 1970.
28. Mabry RL, Holcomb JB, Baker AM, et al: United States Army Rangers
in Somalia: an analysis of combat casualties on an urban battlefield.
J Trauma 49:515–529, 2000.
29. Beekley AC, Sebesta JA, Blackbourne LH, et al: Prehospital tourniquet use
in Operation Iraqi Freedom: effect on hemorrhage control and outcomes.
J Trauma 64:S28–S37, 2008.
30. Holcomb JB: Damage control resuscitation. J Trauma 62:S36–S37,
2007.
31. Walters TJ, Wenke JC, Greydanus DJ, et al: Laboratory evaluation of
battlefield tourniquets in human volunteers. U.S. Army Institute of Surgi-
cal Research Technical Report 2005-05, September 2005.
32. Kragh JF, Jr, Walters TJ, Baer DG, et al: Survival with emergency
tourniquet use to stop bleeding in major limb trauma. Ann Surg 249:1–7,
2009.
33. Taylor D, Vater G, Parker P: An evaluation of two tourniquet systems for
the control of prehospital lower limb hemorrhage. J Trauma 71(3):591–
595, 2011. [Epub ahead of print.]
34. Kragh JF, Walters TJ, Baer DG, et al: Practical use of emergency tourni-
quets to stop bleeding in major limb trauma. J Trauma 64:S38–S50, 2008.
35. Butler FK, Holcomb JB, Giebner SG, et al: Tactical Combat Casualty Care
2007: evolving concepts and battlefield experience. Mil Med 172(S):1–19,
2007.
36. Beekley AC, Starnes BW, Sebesta JA: Lessons Learned from modern mili-
tary surgery. Surg Clin N Am 87:157–184, 2007.
37. Alam HB, Uy GB, Miller D, et al: Comparative analysis of hemostatic
agents in a swine model of lethal groin injury. J Trauma 54:1077, 2003.
38. Pusateri AE, Modrow HE, Harris RA, et al: Advanced hemostatic dressing
development program: animal model selection criteria and results of a
study of nine hemostatic dressings in a model of severe large venous
hemorrhage and hepatic injury in swine. J Trauma 55(3):518, 2003.
39. Rhee P, Brown C, Martin M, et al: QuikClot use in trauma for hemor-
rhage control: case series of 103 documented uses. J Trauma 64:1093–
1099, 2008.
40. Wedmore I, McManus JG, Pusateri AE, et al: A special report on the
chitosan based hemostatic dressing: experience in current combat opera-
tions. J Trauma 60:655–658, 2006.
41. McManus J, Hurtado T, Pusateri A, et al: A case series describing thermal
injury resulting from zeolite use for hemorrhage control in combat opera-
tions. Prehosp Emerg Care 11:67–71, 2007.
42. Kheirabadi B, Scherer M, Estep J, et al: Determination of efficacy of new
hemostatic dressings in a model of extremity aterial hemorrhage in swine.
J Trauma 67(3):459–460, 2009.
43. Kheirabadi B, Mace J, Terrazas I, et al: Safety evaluation of new hemo-
static agents, smectite granules, and kaolin-combat gauze in a vascular
injury wound model in swine. J Trauma 68(2):269–278, 2010.
44. Watters J, Van P, Hamilton G, et al: Advanced hemostatic dressings are
not superior to gauze for care under fire scenarios. J Trauma 70:1413–
1419, 2011.
45. Littlejohn L, Devlin J, Kircher S, et al: Comparison of Celox, ChitoFlex,
WoundStat, and Combat Gauze hemostatic agents versus standard gauze
in control of hemorrhage in a swine model of penetrating trauma. Acad
Emerg Med 18:340–350, 2011.
46. Ran Y, Hadad E, Daher S, et al: QuikClot Combat Gauze for hemorrhage
control in military trauma: January 2009 Israel Defense Force experience
in the Gaza Strip—a preliminary report of 14 cases. Prehosp Disaster Med
25:584–588, 2010.
47. Kheirabadi B, Arnaud F, McCarron R, et al: Development of a standard
swine hemorrhage model for efficacy assessment of topical hemostatic
agents. J Trauma 71:S139–S146, 2011.
196 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
48. Caravalho J: OTSG Dismounted Complex Blast Injury Task Force Report,
2011.
49. Holcomb J: Devastating Dismounted IED Injuries in OEF; Defense
Health Board presentation, 8 March 2011.
50. Eastridge BJ, Mabry R, Seguin P, et al: Pre-hospital death on the battle-
field: implications for the future of combat casualty care. J Trauma Acute
Care Surg 73:S431–S437, 2012.
51. Kragh JF, Murphy C, Dubick MA, et al: New tourniquet device concepts
for battlefield hemorrhage control. AMEDD J 38–48, 2011.
52. Kinzle R: Development of a Field Packable Junctional Tourniquet. ISR
MilTech report, 21 Jan 2011.
52a.  Dickey N, Jenkins D: Combat ready clamp. Defense Health Board Mem-
orandum of 23 September 2011.
52b.  Kotwal R, Butler F, Gross K, et al: Management of junctional hemor-
rhage in Tactical Combat Casualty Care: TCCC Guidelines-proposed
change 13-03. J Spec Oper Med 13:85–93, 2013.
53. Morrison JJ, Rasmussen TE: Noncompressible torso hemorrhage: a
review with contemporary definitions and management strategies. Surg
Clin North Am 92(4):843–858, 2012.
54. Niles SE, McGlaughlin DF, Perkins JG, et al: Increased mortality associ-
ated with early coagulopathy of trauma in combat casualties. J Trauma
64:1459–1465, 2008.
55. Mitra B, Cameron P, Mori A, et al: Acute coagulopathy and early deaths
post major trauma. Injury 43(1):22–25, 2010.
56. Shuja F, Finkelstein RA, Fukudome E, et al: Development and testing of
low-volume hyperosmotic spray-dried plasma for the treatment of
trauma-associated coagulopathy. J Trauma 70:664–671, 2011.
57. Gonzalez EA, Moore FA, Holcomb JB, et al: Fresh frozen plasma should
be given earlier to patients requiring massive transfusion. J Trauma 62:
112–119, 2007.
58. Wafaisade A, Maegele M, Lefering R, et al: High plasma to red blood cell
ratios are associated with lower mortality rates in patients receiving mul-
tiple transfusion (4 < red blood cell units < 10) during acute trauma
resuscitation. J Trauma 70:81–89, 2011.
59. Perkins JG, Schreiber MA, Wade CE, et al: Early versus late recombinant
factor VIIa in combat trauma patients requiring massive transfusion.
J Trauma 62:1099–1101, 2007.
60. Holcomb JB: Use of recombinant activated Factor VIIa to treat the
acquired coagulopathy of trauma. J Trauma 58:1298–1303, 2005.
61. Levi M, Levy J, Andersen H: Truloff D: Safety of recombinant activated
Factor VII in randomized clinical trials. NEJM 363:1791–1800, 2010.
61a.  Martinowitz U, Zaarur M, Yarun BL, et al: Treating traumatic bleeding
in a combat setting: possible role of recombinant activated Factor VII.
Mil Med 169:8–16, 2004.
62. Boffard KD, Riou B, Warren B, et al: Recombinant Factor VIIa as adjunc-
tive therapy for bleeding control in severely injured trauma patients: two
parallel randomized, placebo controlled, double-blind clinical trials.
J Trauma 59:8–18, 2005.
63. Hauser CJ, Boffard K, Dutton R, et al: Results of the CONTROL Trial:
efficacy and safety of recombinant Factor VII in the management of
refractory traumatic hemorrhage. J Trauma 69:489–500, 2010.
64. CRASH-2: Effects of tranexamic acid on death, vascular occlusive events,
and blood transfusion in trauma patients with significant hemorrhage
(CRASH-2): a randomized, placebo-controlled trial. Lancet 376(9734):23–
32, 2010. Online.
65. CRASH-2 Collaborators: The importance of early treatment with
tranexamic acid in bleeding trauma patients: an exploratory analysis of
the CRASH-2 randomised controlled trial. Lancet 377:1096–1101, 2011.
65a.  Roberts I, Shakur H, Ker K, et al: CRASH 2 Trial collaborators: Antifi-
brinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev
2011.
66. Morrison JJ, Dubose JJ, Rasmussen TE, et al: Tranexamic acid de-
creases mortality following wartime injury: the military application
of Tranexamic acid in trauma and emergency resuscitation study
(MATTERS). Arch Surg 147(2):113–119, 2012.
67. Morrison JJ, Ross JD, DuBose JJ, et al: Association of cryoprecipitate and
tranexamic acid with improved survival following wartime injury: find-
ings from the MATTERs II Study. JAMA Surg 148(3):218–225, 2013.
67a.  Dorlac W: Proposed addition of TXA to the TCCC Guidelines; CoTCCC
Minutes, August 2011.
67b.  Dickey N: Defense Health Board Memorandum: Prehospital recom-
mendations regarding the addition of tranexamic acid to the TCCC
Guidelines. 23 November 2011.
68. Haut ER, Kalish BT, Cotton BA, et al: Prehospital intravenous fluid
administration is associated with higher mortality in trauma patients: a
national trauma data bank analysis. Ann Surg 2011. In press.
69. Cotton BA, Jerome R, Collier BR, et al, Eastern Association for the
Surgery of Trauma Practice Parameter Workgroup for Prehospital Fluid
Resuscitation: guidelines for prehospital fluid resuscitation in the injured
patient. J Trauma 67(2):389–402, 2009.
70. Dries DJ: Hypotensive resuscitation. Shock 6:311–316, 1996.
71. Cotton BA, Reddy N, Hatch QM, et al: Damage control resuscitation is
associated with a reduction in resuscitation volumes and improvement
in survival in 390 damage control laparotomy patients. Ann Surg 254:
598–605, 2011.
72. Ley EJ, Clond MA, Sprour MK, et al: Emergency department crystalloid
resuscitation of 1.5 L or more is associated with increased mortality in
elderly and non-elderly trauma patients. J Trauma 70:398–400, 2011.
73. Bickell WH, Wall MJ, Pepe PE, et al: Immediate versus delayed fluid
resuscitation for hypotensive patients with penetrating torso injuries.
N Engl J Med 331:1105, 1994.
74. Morrison CA, Carrick MM, Norman MA, et al: Hypotensive resuscitation
strategy reduces transfusion requirements and severe postoperative coag-
ulopathy in trauma patients with hemorrhagic shock: preliminary results
of a randomized controlled trial. J Trauma 70:652–663, 2011.
75. McSwain N, Champion HR, Fabian TC, et al: State of the art fluid resus-
citation 2010: Prehospital and Immediate Transition to the Emergency
Department. J Trauma 70:S2–S10, 2011.
76. Holcomb J: Fluid resuscitation in modern combat casualty care: lessons
learned in Somalia. J Trauma 54:S46–S51, 2003.
77. Champion HR: Combat fluid resuscitation: introduction and overview of
conferences. J Trauma 54(5, Suppl):7, 2003.
77a.  Butler F, Holcomb J, Schreiber M, et al: Fluid resuscitation for hemor-
rhagic shock in Tactical Combat Casualty Care: TCCC Guidelines Change
14-01 2 June 2014. J Spec Oper Med 14:13–38, 2014.
78. Butler FK: Fluid resuscitation in Tactical Combat Casualty Care: brief
history and current status. J Trauma 70:S11–S12, 2011.
79. Ogilvie M, Perira B, McKenney M, et al: First report on safety and efficacy
of hetastarch solution for initial fluid resuscitation at a level 1 trauma
center. J Am Coll Surg 210:870–880, 2010.
80. Lissauer M, Chi A, Kramer M, et al: Association of 6% hetastarch resus-
with adverse outcomes in critically ill trauma patients. Am J Surg 202:53–
58, 2011.
81. Lairet JR, Bebarta VS, Burns CJ, et al: Prehospital interventions per-
formed in a combat zone: a prospective multicenter study of 1,003
combat wounded. J Trauma Acute Care Surg 73:S38–S42, 2012.
82. Deal V: USSOCOM TCCC Issues; CoTCCC meeting minutes, November
2010.
83. Alam H, Bice L, Butt M, et al: Testing of blood products in a polytrauma
model: results of a multi-institutional randomized preclinical trial.
J Trauma 67:856–864, 2009.
84. Butler F, Holcomb J, Schreiber M, et al: Fluid resuscitation for hemor-
rhagic shock in Tactical Combat Casualty Care: TCCC Guidelines Change
14-01-2 June 2014. J Spec Oper Med 14:13–38, 2014.
85. Dubick MA: Current concepts in fluid resuscitation for prehospital care
of casualties. AMEDD J 18–24, 2011.
86. Borgman MA, Spinella PC, Perkins JG, et al: The ratio of blood products
transfused in patients receiving massive transfusions at a combat support
hospital. J Trauma 63:805–813, 2007.
87. Holcomb JB: Optimal use of blood products in severely injured trauma
patients. Hematology 2010:465–469, 2010.
88. Joint Theater Trauma System Clinical Practice Guideline for Damage
Control Resuscitation, March 2011.
89. Fox C, Gillespie D, Cox D, et al: The effectiveness of damage control
resuscitation strategy for vascular injury in a combat support hospital:
results of a case control study. J Trauma 64:S99–S107, 2008.
90. Fox C, Perkins J, Kragh J, et al: Popliteal artery repair in massively trans-
fused military trauma casualties: a pursuit to save life and limb. J Trauma
69:S123–S134, 2010.
91. Calderbank P, Woolley T, Mercer S, et al: Doctor on board? What is the
optimal skill-mix in military pre-hospital care? Emerg Med 28(10):882–
883, 2010. [Epub ahead of print].
91a.  http://www.usaisr.amedd.army.mil/assets/pdfs/TCCC_Guidelines
_140602.pdf. Accessed 15 December 2014.
92. Gerhardt RT, Berry JA, Blackbourne LH: Analysis of life-saving interven-
tions performed by out of-hospital medical personnel. J Trauma 71:S109–
S113, 2011.
93. Blackbourne L, Baer D, Cestero R, et al: Exsanguination shock: the next
frontier in prevention of battlefield mortality. J Trauma 71:S1–S3, 2011.
94. Mabry R, Apodaca A, Penrod J, et al: Impact of critical care trained flight
paramedics on casualty survival during helicopter evacuation in the
current war in Afghanistan. J Trauma Acute Care Surg 73:S32–S37, 2012.
 16  /  Damage Control: Prehospital Care of the Patient With Vascular Injury 197
95. Mabry R: OEF MEDEVAC and Enroute Care Director After-Action
Report dated, 7 February 2011.
95a.  Dickey N, Jenkins D, Butler F: Tactical evacuation care improvements
within the Department of Defense. Defense Health Board Memo, 8
August 2011.
96. Blackbourne LH, Czarnik J, Mabry R, et al: Decreasing killed in action
and died of wounds rates in combat wounded. J Trauma 69(1):S1–S4,
2010.
BIBLIOGRAPHY
Arnaud F, Teranishi K, Tomori T, et al: Comparison of 10 hemostatic dress-
ing in a groin puncture model in swine. J Vasc Surg 50(3):632–639,
2009.
Arnaud F, Parrento-Sadalan D, Tomori T, et al: Comparison of 10 hemostatic
dressings in a groin transaction model in swine. J Trauma 67:848–855,
2009.
Bellamy RF: The causes of death in conventional land warfare: implications
for combat casualty care research. Mil Med 149:55–62, 1984.
Clarke JE, Davis PR: Medical evacuation and triage of combat casualties in
Helmand, Afghanistan: October 2010-April 2011. Mil Med 177:1261–
1266, 2012.
Fox CJ, Patel B, Clouse WD: Update on wartime vascular surgery. Perspect
Vasc Endovasc Ther 23(1):13–25, 2011. [E-pub 17 April 2011].
Owens B, Kragh J, Macaitis J, et al: Characterization of extremity wounds
in operation Iraqi Freedom and Operation Enduring Freedom. J Orthop
Trauma 21:254–257, 2007.
Wafaisade A, Lefering R, Tjardes T, et al: Acute coagulopathy in isolated blunt
traumatic brain injury. Neurocrit Care 12:211–219, 2010.
 Surgical Damage Control and
17  Temporary Vascular Shunts
DANIEL J. SCOTT AND TODD E. RASMUSSEN
“We should not rest content with the work of our
predecessors, or assume that it has proved everything
conclusively, on the contrary it should serve only as a
stimulus to further investigation.”
Ambroise Paré
Introduction
The past 20 years has witnessed a fundamental change in the
management of the severely injured patient. Perhaps the most
notable change is the concept of the damage control or staged
laparotomy. Stone and colleagues provided the landmark
description of a staged operation in trauma in 1983.1 With
intent to limit the physiologic burden on an already-threatened
patient, they demonstrated a significant survival advantage
in a series of 17 patients. Later coined by Rotondo et al as
“damage control surgery,” this concept of limiting the “bloody
vicious cycle” of hypothermia, acidosis, and coagulopathy has
been embraced by nearly every major trauma center with
reproducible results.2-4 One of the major tenets of staged lapa-
rotomy as described by Stone and colleagues was the attention
to control and repair of major blood vessel injuries. Hemor-
rhage (and, subsequently, hemorrhagic shock) is perhaps the
most significant factor contributing to the triad of coagulo-
pathic bleeding. Incidentally, the management of injured
blood vessels in a severely injured patient is often arduous,
technically demanding, and time-consuming, all of which can
force ligation out of desperation. This chapter provides a
review of a renewed technique that offers a viable alternative
to ligation and that adheres to the mantra of damage control—
temporary intravascular shunts.
Temporary vascular shunts have many benefits in the
multiply-injured patient. Not only do they allow for reperfu-
sion and/or venous decompression across the injured vessel,
but they also afford time to transport a patient to a higher
level of care or to manage concomitant life-threatening inju-
ries. In this context, “extra time” means that flow is restored
across the injured artery and/or vein through the shunt while
resuscitation, orthopedic fixation, cranial decompression, or
other damage control procedures are performed.
Historical Use of Intravascular
Shunts
The concept of an implantable prosthetic conduit has a long
history with first descriptions in World War I by Tuffier and
Makins.5,6 These paraffin-lined silver tubes were initially
198
proposed for the perceived advantages of sutureless technique
and were meant for permanent placement. The goal was not
long-term patency of the conduit but rather a temporary
means of perfusion that would provoke collateralization as the
tube slowly occluded. In 1932, Blakemore and Lord intro-
duced use of a new composite alloy called Vitallium (com-
posed of cobalt, chromium, and molybdenum). Initially, the
Vitallium tube was internally lined with vein graft; but this
was soon followed by a two-tube method with interposed
vein, again as a sutureless technique (Fig. 17-1). Despite theo-
retical advantages and widespread dissemination in World
War II, the use of such tubes was limited by logistics and by
frustratingly prolonged medical evacuation times of the
wounded to the surgical facilities.7-9
Experimental use of intravascular shunts as a means of
temporary restoration of blood flow has roots to both the
French-Algerian war (1954-1962) and more extensively to the
Soviet war in Afghanistan (1981-1985).10,11 An excellent syn-
opsis of the Russian experience with temporary vascular
shunts in Afghanistan and the Northern Caucuses is provided
in the international section of this edition. Both accounts
described use of temporary vascular shunts to maintain blood
flow to allow time either for onward transport or to “admin-
ister antishock therapy.” Among the first modern descriptions
of temporary intravascular shunts is from Eger et al, who in
1971 used a temporary vascular shunt prior to orthopedic
fixation. This practice ultimately demonstrated a decreased
frequency of extremity amputation in the setting of complex
popliteal artery injury.10,12
Modern Use of Intravascular Shunts
Despite advances in civilian damage control surgery, use of
temporary vascular shunts in trauma had been limited to a
few case series prior to the events of September 11, 2001 (Table
17-1).13-20 One bittersweet effect of wartime is the renaissance
of surgical experience, technology, and technique. In a report
from Operation Iraqi Freedom (OIF), Rasmussen et al
described a 1-year experience of 126 extremity vascular inju-
ries, in which 30 temporary vascular shunts were utilized in
the management of vascular injury. In this report, shunts were
used as damage control adjuncts to either facilitate casualty
evacuation or to allow perfusion while other life-threatening
injuries were managed. In this series, 57% of the patients had
patent shunts on arrival to a higher level of care (typically less
than 2 hours after initial surgery). The authors noted that
patency of the shunts hours after placement was higher (86%)
 17  /  Surgical Damage Control and Temporary Vascular Shunts 198.e1

ABSTRACT
The past 30 years has witnessed a fundamental change in
the approach to the multiply-injured patient. With increas-
ing enthusiasm for the dogma of damage control surgery,
surgical strategies to quickly stabilize a severely injured
patient have focused on methods of vascular control and
on cessation of hemorrhage—the latter often meaning a
default to vascular ligation if simple, quick repairs are not
feasible. Use of a temporary vascular shunt to expeditiously
restore perfusion in the setting of a significant axial vessel
injury, however, has now become an accepted alternative
to ligation. While vascular shunts are not novel concepts,
their use has become greatly encouraged by experience
afforded by the wars in Afghanistan and Iraq. Promising
outcomes in the management of complex extremity vas-
cular injury have also been echoed in the civilian literature
where the necessity of shunt use is driven by the damage
control imperative rather than the need to transport
patients to a higher level of care. Some surgeons have
expanded use of these adjuncts to the management of
truncal vascular injuries where ligation often carries signifi-
cant morbidity and mortality in an already-threatened
patient. As such, the intraluminal vascular shunt is a valu-
able concept that provides surgeons with a much-needed
solution to the perpetual dilemma of whether to repair or
to ligate a major vascular injury.

Key Words:  vascular,

injury,
trauma,
blood vessel,
shunt,
damage control surgery,
ligation,
temporary vascular control,
extremity vascular injury,
truncal vascular injury
 17  /  Surgical Damage Control and Temporary Vascular Shunts 199

Artery Artery
Vitallium tube Ligature
Suture Vein
Vitallium tube

A C
Artery
Ligature
Artery Vitallium cuff
Ligature Vein segment
Vitallium tube

B D
FIGURE 17-1  Illustration of the experimental and clinical application of the Vitallium-tube techniques used by Blakemore and Lord. (From
Wolters Kluwer/Lippincott William and Wilkins, annals of Surgery 1945) (Also in Hancock H, Rasmussen TE, Walker AJ, et al: History of temporary
intravascular shunts in the management of vascular injury. J Vasc Surg 52[5]:1405–1409, 2010.)

Table 17-1 Civilian Shunt Small Series Indications

Publication #Number of Damage control—that is, physiologic instability or higher
Series Year Patients operative priorities precluding definitive reconstruction of an
Hossny et al 2004 9 encountered vascular injury—is the primary indication for
Sriussadaporn et al 2002 7 the use of a temporary shunt. The rapid placement of a shunt
Reber et al 1999 7 is useful to reduce the time to reperfusion (i.e., oxygen deliv-
Granchi et al 2000 19 ery) beyond the vascular injury when other higher-priority
Husain et al 1992 5 management steps are required. With the shunt in place, sta-
Khalil et al 1986 5 bilization of associated fractures or performance of a lapa-
Nichols et al 1986 13 rotomy, craniotomy, or thorocotomy can be completed with
Johansen et al 1982 10 the extremity or other end-organ perfused instead of isch-
emic. Finally, expedited placement of a shunt may be useful if
Adapted from Rasmussen TE, Clause WD, Jenkins DH, et al: The use a surgeon desires to curtail the intervention due lack of train-
of temporary vascular shunts as a damage control adjunct in the
management of wartime vascular injury. J Trauma 61:8–12, 2006; ing in or currency with major vascular reconstruction. Place-
discussion 12–15. ment of a shunt in the setting of prolonged ischemia provides
end-organ perfusion and may even allow the infusion of med-
ications designed to limit thrombosis or ischemia-reperfusion
when they had been used in larger, more proximal vessel inju- injury (e.g., heparin or mannitol). Use of a temporary vascular
ries.21 The favorable experience with the use of vascular shunts shunt in an axial vessel of a severely mangled extremity allows
in this initial report was corroborated by subsequent series for the limb to be stabilized, débrided, and reassessed at a
provided by other combat surgical teams.22-24 Figures 17-2, second-look operation if needed. This strategy allows for a
A-C detail a case example in which a midsubclavian injury was more-organized mobilization requisite of surgical disciplines
initially treated at a forward surgical location with the inser- to assess the limb at a scheduled time after the initial opera-
tion of an intraluminal shunt and subsequently was repaired tions has been performed. The indications for the use of tem-
with interposition graft at a higher level of care. porary shunts are provided in Table 17-3.12
Gifford and colleagues provided one of the only studies to
characterize longer-term extremity outcomes following the
use of temporary vascular shunts. In their study, the authors
Shunt Materials
used case-controlled methodology to show that the use of Many hollow tubular devices have been described to function
temporary vascular shunts had no adverse outcome in the as temporary vascular shunts including large-bore angiocath-
years following vascular repair and likely extended the window eters, sterile intravenous tubing, endotracheal tubes, feeding
for limb salvage, especially in the most severely injured tubes, and small-caliber chest tubes. While these improvised
extremities.25 Finally in a recent and larger 10-year review of shunts may provide temporary flow, they are not designed for
the civilian experience from Feliciano’s group at Grady Memo- this purpose, are predisposed to causing vessel injury, and are
rial, Subramanian et al confirmed the utility of temporary prone to thrombosis due to a number of physical characteris-
vascular shunts in certain patterns of vascular injury. This tics. Currently there are no commonly used FDA-approved
study demonstrated a 95% patency rate of shunts and an shunts for trauma, and surgeons must rely on off-label use of
overall survival rate of 88% following major vascular injury. devices designed for use during carotid endarterectomy and
In this series of 101 vascular shunts, the authors documented other cardiovascular operations for age-related disease. Exam-
a secondary amputation rate of 18% (Table 17-2).21-26 ples include the Javid (Bard PV, Tempe, AZ), Argyle (Covidien,
200 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
A
B and 17-4). Looped shunts are longer with a significant portion
C respected. The injured blood vessel should be carefully dis-
Mansfield, MA), Sundt (Integra, Plainsboro, NJ), and Pruitt-
Inahara (LeMaitre Vascular, Burlington, MA) shunts. There
are no studies that have compared the effectiveness of these
shunts to one another in the setting of trauma, and any one
or more may be used for vascular trauma even at the same
institution.26 Nevertheless, extrapolation from translational
FIGURE 17-2  A, The distal aspect of a Javid shunt inserted into the
right axillary artery is shown in this image. The proximal aspect of the
shunt had been placed in the proximal-most right subclavian artery
and routed in an extraanatomic fashion above the clavicle, under-
neath the pectoralis major muscle, and out of the zone of injury which
was the mid-right subclavian artery. B, A wider image of the same
case showing the proximal aspect of the exposure, which was median
sternotomy. The proximal Javid shunt has been removed and is
secured with a hemostatic clamp in the upper portion of the photo-
graph. The proximal anastomosis of a 6-mm ePTFE graft has been
created to the origin of the right subclavian artery with the graft
routed in an anatomic fashion in preparation for the distal anastomosis
to the right axillary artery. C, A completion image following successful
reconstruction using 6-mm ePTFE from the proximal-most right sub-
clavian artery to the right axillary artery. The subclavian artery injury
in this case was oversewn just proximal to the clavicle. (Photographs
courtesy Todd E. Rasmussen.)
hemodynamic and hydrodynamic studies of commonly used
shunts seems to favor larger-diameter, in-line (shorter) shunts
as they tend to produce higher flow rates and distal perfusion
pressures.27 Aufiero et al also recommend the use of tapered
shunts when smaller diameter shunts (<12 Fr) are required.28
Several physical characteristics must be weighed when
selecting the type of shunt to use, and a list of features of
commonly used devices is provided in Table 17-4. In-line
shunts are shorter and useful when operative space is limited
and when the gap in or injury to the vessel is short. In-line
shunts lie inside of the injured vessel and, once in place, are
not likely to become entangled with wound dressing material,
surgical retractors, orthopedic fixator devices, or monitor
wires, which often surround the injured extremity (Figs. 17-3
outside of the vessel and therefore are more prone to becom-
ing entangled. However, looped shunts are more effective at
bridging longer injuries or segments of missing vessel, and this
design may be preferable when the vascular injury crosses a
joint or an unstable fracture prone to significant motion. In
these instances, the longer, looped shunt allows for motion
across this defect with a lower likelihood of being dislodged.
Finally, looped shunts allow visualization of arterial or venous
flow and are readily assessed by continuous-wave Doppler
(Fig. 17-5). A unique design, the Pruitt-Inahara shunt is a
side-arm port that may prove useful when angiography or
drug infusion is required. Secured by proximal and distal bal-
loons, placement of the Pruitt-Inahara may be more easily
performed and avoids the need for excessive proximal and
distal vessel dissection (Fig. 17-6).
Insertion Technique
Inserting a vascular shunt, although seemingly straightfor-
ward, has the potential to cause injury if tissues are not
sected to allow vascular clamp application. This step may be
circumvented by endovascular balloon occlusion if proximal
control is likely to be lengthy or technically challenging (i.e.,
proximal subclavian injuries). Once controlled and opened,
the vessel should be subjected to Fogarty balloon catheter
thrombectomy with confirmation of both inflow and back-
bleeding. Several sweeps with the thromboembolectomy cath-
eter can be performed if necessary. Instillation of a heparinized
saline solution into the proximal and distal ends of the injured
 17  /  Surgical Damage Control and Temporary Vascular Shunts 201

Table 17-2 Combat Versus Civilian Use of Temporary Vascular Shunts

Average Early (<30d)
Shunt Shunt Type and Shunt Secondary Shunt-Related
Review Year Location Number % Patency* Time Amputations† Complications‡
Rasmussen 2004-2005 30 arterial Javid 16 Arterial Proximal 86% <2 hr 2 0
et al 4 venous Argyle 12 Distal 12%
(combat) Sundt 2 Venous Proximal 100%
Taller et al 2006-2007 14 arterial Javid NL Arterial Proximal 100% ~5 hr 0 0
(combat) 9 venous Argyle NL Venous 89%
Unknown NL
Chambers 2004-2005 18 arterial Javid NL Arterial Proximal 86% ~1.5 hr 3 (1) 0
et al 11 venous Distal 50%
(combat) Sundt NL Venous 82%
Borut et al 2003-2007 42 arterial Argyle NL NL NL NL 4 (0) NL
(combat) 8 venous Sundt NL
Javid NL
12 Fr feeding NL
tube
Subramanian 1997-2007 72 arterial Argyle 61 Arterial 91% 23.5 hr 10 (1) 0
et al 29 venous Chest tube 16
(civilian) Pruitt-Inahara 20
5 Fr feeding 1 Venous 100%
tube
16 ga 1
Angiocath

Data from References 21-26.

d, Day; Fr, french; ga, gauge; hr, hour; NL, not listed.
*Proximal = brachial artery and proximal in upper extremity or popliteal artery and proximal in lower extremity.
†
Parentheses = secondary amputations attributable to shunt thrombosis.
‡
Shunt-related complications = shunt displacement, bleeding, or thromboembolism.

Table 17-3 Indications for Temporary Vascular

Shunts
Damage control surgery
Complex skeletal injury requiring fixation (e.g., Gustilo IIIc)
Temporary restoration of flow during vein harvest
Management of other injuries
Multiple vascular injuries
Prolonged ischemia (>6 hours)
Replantation of avulsed limbs
Temporary flow for delayed reevaluation in a mangled extremity

Adapted from Eger M, Golcman L, Goldstein A: The use of a tempo-

rary shunt in the management of arterial vascular injuries. Surg
Gynecol Obstet 132(1):67–70, 1971.

vessel (also referred to as regional heparinization) should be

performed followed by reclamping. The vessel ends should be
inspected and carefully cut or débrided back to healthy or
normal-appearing vessel. Selection of an appropriately sized
and contoured shunt is mandatory. The shunt should be care-
fully inserted into the distal vessel, secured with thick (size 0)
silk tie, and allowed to back-bleed. The proximal end is then
inserted and also secured with a silk tie and antegrade flow
reestablished. Hand-held Doppler evaluation of flow is per-
formed to confirm patency; marking of distal arterial signals
in the extremity facilitates repeat Doppler examination at a
later point in time. If the shunt traverses a noninjured joint,
splinting of the joint is performed to avoid dislodgement.
Ideally, the wound should be stapled closed and soft-tissue
coverage of the shunted vessel secured. If left open, wound-
vacuum dressings should not be applied directly to the vessel.
The need for fasciotomy should be considered and time of
shunt placement marked both on the patient and on the
chart.
FIGURE 17-3 Photograph of a 12 Fr Argyl shunt within a left external
iliac artery injury just above the inguinal ligament. This shunt is truly
in the “in-line” configuration placed within the short segment arterial
defect and out of the way of retractors, packs, or other operative
apparatus. This shunt, which is seen secured with silk ties, was patent
approximately 6 hours after placement. (Photographs courtesy Todd E.
Rasmussen.)
Dwell Time
There is no consensus on how long a shunt can remain in
place (i.e., dwell time), and this depends on the type of vessel
shunted and the clinical scenario. In general, a shunt should
be removed as soon as circumstances allow for definitive
202 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT

Table 17-4 Shunt Types

Manufacturer Type Features Composition Sizes
Bard Straight +/− bevel tip; +/− side holes; Polyvinyl chloride Diameter: 9F, 10F, 12F, 14F, 16F
+/− balloon tip (+/− latex balloon) Length: 13 cm
Javid Tapered +/− loop
Brener Tapered w/side arm
Burbank Tapered; depth markings
Covidien Argyle +/− loop; kit with all 4 sizes Polyvinyl chloride Diameter: 8F, 10F, 12F, 14F
Length: 11 in (loop), 6 in (straight)
Integra Sundt +/− loop; steel reinforcement Silicone elastomer Diameter: 3 × 4 mm, 3 × 5 mm, 4 × 5 mm
+/− nonreinforced segment; Length: 30 cm (loop), 10 cm (straight)
cone-shaped ends
LeMaitre Pruitt-Inahara +/− T-port; color coding; depth Polyurethane (latex Diameter: 8F, 9F, 10F, 12F, 14F
marks; balloon with safety balloon) Length: 31 cm (outlying), 15 cm (inlying),
sheath; kit with 4 sizes 13 cm (inlying)

Data from manufacturer websites www.bard.pv.com/_vascular/product.php=37; www.kendall-ltp.com/Kendall-LTP/pageBuilder.aspx?topicID

=67419&breadcrumbs=81035:0,67418:0; integalive.com/Neurosurgeon/Neurosurgeon-Product-Detail.asp; www.lemaitre.com/medical
_shunts.asp.
cm, Centimeter; F, french; in, inch; mm, millimeter.

FIGURE 17-4 Photograph of a 12 Fr Argyl shunt within a left prox-

imal superficial femoral artery injury just distal to the origin of the
left profunda femorus artery. A shunt in the proximal superficial
femoral vein is present but difficult to observe in this photograph
deep to the arterial shunt. Also observed in this image is the left
greater saphenous vein, which was exposed and used as interposi-
tion conduit for reconstruction of this injury pattern. Although the
FIGURE 17-5  Looped (30-cm) Sundt shunt placed to bridge a defect
arterial shunt in this case was patent 5 hours after placement, the
in the right superficial femoral artery. Although it is difficult to observe
venous shunt had thrombosed. Both artery and vein were success-
anatomic context, this injury is exposed through an above-knee pop-
fully reconstructed in this case after shunt removal. (Courtesy Todd E.
liteal artery exposure. Note that this shunt can be elevated out of the
Rasmussen.)
wound and has ample length should the arterial injury or defect
be over a long length or an unstable fracture prone to movement.
(Photographs courtesy Todd E. Rasmussen.)

vascular repair understanding that shunt-related complica-

tions such as thrombosis or dislodgement increase with time.
Reports exist documenting effective shunt dwell times from
30 minutes to 24 hours; however, the premise is to remove the
device and to attempt vascular repair as soon as the clinical
scenario allows. Average shunt times from reports in combat
generally reflect the time required for transportation of the
patient to a higher or appropriate level of care (with averages
of 2 to 5 hours). Civilian case series report dwell times that
more typically reflect the time required to establish physiolog-
ical normality in the setting of damage control (with averages
of 24 hours). Anecdotally, patency rates as long as 52 hours
have been documented.16
Special Considerations
Anatomic Location (Proximal Large Vessels
Versus Distal Small Vessel)
The most important consideration regarding whether or not
to use a temporary vascular shunt as a damage control adjunct
relates to the anatomic location of the injury. The use of tem-
porary shunts is not applicable to all injuries and should be
focused on larger more proximal or axial vessels. Injuries in
these locations have higher impacts on the distal extremities
or end-organs because these are often the axial or watershed
vessels on which the extremities or end-organs depend. As
 17  /  Surgical Damage Control and Temporary Vascular Shunts 203
B Sundt shunt without full anticoagulation.31 Additionally,
A that temporary vascular shunts remain patent and effective
C
FIGURE 17-6  Modern (carotid) shunt types. A, Looped (Sundt)
shunt. B, In-line (Sundt) shunt. C, Looped Pruitt-Inahara shunt. (Cour-
tesy Daniel J. Scott and Todd E. Rasmussen.)
such, ligations or continuation of tourniquets on these larger
injuries has more severe consequences, consequences that may
be mitigated by expeditious restoration of flow using tempo-
rary vascular shunts.
In contrast, injury to small or distal arteries in anatomic
locations where there is often duplicate circulation is of less
consequence to the extremity or end-organ. Examples include
the forearm where the ulnar and radial arteries supply the
hand and the leg where the tibial and peroneal arteries provide
perfusion to the foot. Injury to one of these arteries typically
does not threaten limb viability, and ligation may be the
favored damage control strategy. Lavenson and colleagues
were among the first to demonstrate the usefulness of
continuous-wave Doppler in determining limb viability in the
setting of wartime vascular injury.29 The presence or absence
of an audible Doppler signal distal to the injury provides
important information while deciding whether to shunt or to
ligate a distal vascular injury. In this context, use of temporary
vascular shunts in small or distal arteries should be the excep-
tion. If nothing else, such distal vessels are small, making the
placement of the shunt technically difficult. In the authors’
experience a minority of shunts in distal vascular injuries
remained patent on reexploration, an observation which likely
reflects the challenges of shunt placement and perhaps of
limited outflow.21
Anticoagulation
The use of full-dose or systemic anticoagulation in the setting
of temporary vascular shunts should be approached with
caution. While the use of anticoagulation in this setting is
intuitive, one must always consider the risk of bleeding com-
plications from other injury sites. Most importantly, systemic
anticoagulation may cause life-threatening bleeding from
associated closed head or solid organ injury. However, even
bleeding from soft-tissue wounds and fracture or fasciotomy
sites can be significant. Bleeding from soft-tissue, fracture or
fasciotomy sites caused by systemic heparin is often slow and
persistent and thus easily overlooked by the trauma and anes-
thesia teams, which causes the patient to fall behind from a
resuscitation standpoint.
Most translational data and clinical observations do not
support the need for systemic anticoagulation. Early transla-
tional work from Dawson et al confirmed the patency of the
Argyl shunt in a swine model for 24 hours without the use of
systemic heparin.30 Gifford and colleagues confirmed similar
findings demonstrating consistent 18-hour patency of the
most clinical series in the military and civilian settings show
without systemic doses of heparin. Most of these reports
acknowledge the selective use of systemic heparin in rare
instances of isolated vascular injury with some compelling
factor such as initial shunt thrombosis or a documented
heavy clot burden in the distal circulation. It is the authors’
recommendation that systemic anticoagulation not be a
routine part of temporary vascular shunt placement and use.
Instead, the authors recommend generous use of regional
heparin using full anticoagulation only in rare cases of iso-
lated vascular injury with close monitoring for bleeding
complications.
Venous Shunting
Attendant with the success of extremity arterial shunting is the
question of the value of temporary vascular shunts in isolated
or concomitant venous injuries. The majority of experience
with shunting in venous injuries comes from the wartime
setting where venous injuries frequently accompany those to
the axial vessels of the extremities. Temporary shunting of the
venous system provides several theoretical benefits including
decreased venous hypertension that follows ligation of a large
venous injury. Reduced venous pressure leads to less bleeding
from wounds distal to the injury, including fasciotomy
wounds. In theory, venous outflow also improves arterial
inflow to the extremity or end-organ and ultimately improves
perfusion. Like arterial shunts, placement of these devices in
venous injuries is relatively straightforward. While flow rates
are lower than their arterial counterparts, the patency of
venous shunts is comparable.21-23 Successful use of vascular
shunts in venous injuries has also been reported the civilian
sector as Parry and colleagues have described 18 cases either
to allow for orthopedic fixation or to control hemorrhage
during a damage control operation. All venous shunts in their
series were patent on reexploration at a mean 22 hours dwell
time.32
In select distal vascular injuries, use of temporary vascular
shunts is acceptable or even preferred. Specifically, injuries in
which more than one of the redundant vessels to the extremity
or end-organ are injured may result in a scenario in which
viability depends on restoration of flow through one of the
severed vessels. This determination can often be aided by the
use of continuous-wave Doppler.21-29 In cases where there is
injury to more than one of the small distal arteries (e.g., both
ulnar and radial arteries) resulting in an absence of Doppler
signal beyond the injury, use of a vascular shunt is recom-
mended.33 Those who have extensive experience with placing
shunts frequently state that in the setting of penetrating vas-
cular injury, the two ends of the severed vessel must be exposed
for ligation anyway. In this context they emphasize that placing
a shunt in the vessel to bridge the defect is not difficult and
adds no extra time. In our own, experience even when shunts
in distal vessels fail it does not prevent limb-salvage attempts,
which means that the thrombosed shunt is removed, a throm-
bectomy is performed, and vascular reconstruction is carried
out if needed.21
204 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
Role in Limb Salvage
Decision making in the setting of a mangled extremity is
complex. Multiple individuals and circumstance-specific vari-
ables influence the choice of treatment algorithm, whether
that is limb salvage or amputation. Perhaps the most influen-
tial factor is the perfusion status of the extremity. Timely
restoration of blood flow is arguably the most critical proce-
dure on which the viability and ultimate functional outcome
hinges. Glass et al performed a review of 101 cases of severe
lower extremity injury and found that limb salvage was
greatly influenced by ischemic time. When ischemic times
passed beyond 6 hours, limb-salvage rates decreased from
87% to 61%. In this report, the use of temporary vascular
shunts was associated with a decrease in amputation rates
from 27% to 13%.34 In this context, the early use of tempo-
rary vascular shunts to restore perfusion in select vascular
injury patterns serves as an initial step in determining whether
or not to press on with salvage attempts of a mangled
extremity.
Fasciotomy (Prophylactic)
The development of extremity compartment syndrome has
profound implications for limb salvage. When diagnosed,
extremity compartment syndrome demands immediate thera-
peutic fasciotomy to relieve elevated pressures and to restore
perfusion to affected tissue beds. However, recognizing the
onset of compartment syndrome is challenging, especially in
patients who are being moved through multiple levels of care
often at different medical facilities. Prophylactic fasciotomy
has therefore been accepted as a standard practice whenever
temporary vascular shunts are required. While no prospective
studies have been performed, the benefit of prophylactic fas-
ciotomy has recently been emphasized by a report document-
ing a fourfold increase in mortality associated with the delayed
or missed diagnosis of compartment syndrome.35
Patients requiring temporary shunt placement are self-
selected to have the greatest number of risk factors for the
development of extremity compartment syndrome. These
patients have a vascular injury with ischemia, underlying
muscle, and possibly bone contusion from the injury and
often require large-volume resuscitation. These factors explain
the high prophylactic fasciotomy rates reported in both mili-
tary and civilian series, ranging from 60% to 100%.21,25,26 It is
recommended that prophylactic fasciotomy be considered in
patients requiring shunt placement and any of the following:
severe extremity injuries (Abbreviated Injury Scale [AIS] score
of ≥3 or Mangled Extremity Severity Score [MESS] of ≥5),
combined arterial and/or venous injury, prolonged ischemia
or tourniquet time (>1 to 2 hours), penetrating or crush
mechanisms of injury, injury to proximal below-knee or
forearm vasculature, associated open fractures or nerve inju-
ries, and significant intraoperative blood loss.36-39
Vascular Branch Points
Injuries in proximity to bifurcations such as the common into
the superficial and profunda femorus arteries or the brachial
artery into the ulnar and radial arteries require special con-
sideration. While ligation of one branch and shunting of the
other is an option, circumstances may dictate restoration of
blood flow to both. Choudry et al described one instance in
which an improvised shunt was fashioned from a dual lumen
14.5 Fr Mahurkar (Covidien, Mansfield, MA) dialysis catheter
to restore flow after a penetrating injury to the common
femoral artery.40 These injuries are rare enough that there is
little clinical experience to guide the use of shunts. If a large
proximal arterial branch point injury is encountered, such as
the femoral bifurcation, the authors recommend vessel loop
occlusion of back-bleeding from the profunda femorus artery
with shunt placement into the main axial vessel of the extrem-
ity. Vessel loop or some other method of temporarily occlud-
ing the large bifurcating branch should allow its reconstruction
at a later time when the wound is explored and the shunt
removed. Creativity can and should be used in these challeng-
ing injuries; however, the surgeon must be mindful that these
are damage control situations and whatever option is chosen
should be basic and quick.
Truncal Vascular Injuries
Temporary vascular shunts also have proven utility as an
alternative to ligation for the management of torso injuries.
Torso vascular injuries may be associated with genitourinary
or gastrointestinal contamination, significant blood loss (he-
modynamic instability and coagulopathy) and challenging
operative exposures. While these situations may force sur-
geons to contemplate “ligation in desperation” accepting the
physiologic cost of end-organ ischemia, placement of a vascu-
lar shunt may be a better option. In a 2005 report from Feli-
ciano at Grady Memorial, the use of temporary vascular
shunts to manage iliac artery injuries resulted in a dramatic
decrease in rates of amputation (47% to 0%) and death (73%
to 43%).41
Mesenteric arterial injuries are rare but have high associ-
ated mortality. Again, strategies are historically limited to the
decision of whether to repair or ligate the injury. Reports of
intraluminal shunting of the mesenteric vessels (SMA) are few
but include translational research and clinical experiences.42
Subramanian and colleagues describe 2 patients with shunts
that were placed in the superior mesenteric artery. Although
both shunts thrombosed, only 1 patient expired (after care was
withdrawn).26 Reilly et al described the successful use of an
SMA shunt during damage control surgery for a penetrating
injury to the abdomen. Despite a dwell time of nearly 36
hours, the shunt remained patent with demonstrable viability
of both the small and large bowels on reexploration.43 Shunt-
ing of superior mesenteric arterial injuries is generally recom-
mended as an alternative to reconstruction in the damage
control setting and should be limited to injuries within Ful-
len’s zones I and II of the artery (i.e., origin at the aorta to the
origin of the middle colic artery).
Injuries to the major visceral venous structures, including
the superior mesenteric and portal vein, are also highly lethal.
Asensio et al, in a retrospective study of 51 patients with
superior mesenteric venous injuries, found a survival rate of
55% and noted that mortality worsened with each additional
vascular injury. The authors found a survival benefit in
primary repair of superior mesenteric venous injuries
although they advocated rapid ligation in the unstable patient
afflicted by multiple other life-threatening injuries. Expect-
edly, ligation resulted in significant bowel edema and venous
engorgement with potential for splanchnic hypertension syn-
drome and bowel necrosis.44 Additional reports of portal
venous injuries also recommend venorrhaphy when possible,
although ligation was also described and noted to be consis-
tent with subsequent survival likely resulting from venous
collateralization.45-47 There is a paucity of research with regard
 17  /  Surgical Damage Control and Temporary Vascular Shunts 205
to the evaluation of the use of temporary intravascular shunts
for visceral venous injury, and further endeavor is required.
Conclusion
Once again spurred by the burden of vascular trauma experi-
enced during war, a renaissance in the management of this
injury pattern has occurred and is continuing. It is a renais-
sance that has favorably impacted patient morbidity and mor-
tality. Temporary intraluminal shunts have effectively forced
the reappraisal of operative decision making and repair strate-
gies relating to vascular injury in the larger context of trauma.
The vascular shunt has bridged the gap between the compet-
ing tactics of repair and ligation. As the application and accep-
tance of shunts grow, so too will expertise and technology;
and, with these advances, improved outcomes in an otherwise-
morbid and lethal injury pattern are sure to follow.
REFERENCES
1. Stone HH, Strom PR, Mullins RJ: Management of the major coagulopathy
with onset during laparotomy. Ann Surg 197(5):532–535, 1983.
2. Rotondo MF, Schwab CW, McGonigal MD: “Damage Control”: an
approach for improved survival in exsanguinating penetrating abdominal
injury. J Trauma 35(3):375–382, 1993.
3. Moore EE, Thomas G: Orr Memorial lecture. Staged laparotomy for the
hypothermia, acidosis, and coagulopathy syndrome. Am J Surg 172(5):
405–410, 1996.
4. Diaz JJ, Jr, Cullinane DC, Dutton WD, et al: The management of the open
abdomen in trauma and emergency general surgery: part 1–damage
control. J Trauma 68(6):1425–1438, 2010.
5. Tuffier: French surgery in 1915. Br J Surg 4:420–432, 1917.
6. Makins GH: On gunshot injuries to the blood-vessels, founded on experi-
ence gained in France during the Great War, 1914–1918, Bristol, 1919,
John Wright and Sons, pp 109–111.
7. Hancock H, Rasmussen TE, Walker AJ, et al: History of temporary intra-
vascular shunts in the management of vascular injury. J Vasc Surg 52(5):
1405–1409, 2010.
8. Blakemore AH, Lord JW: A nonsuture method of blood vessel anastomo-
sis: review of experimental study report of clinical cases. Ann Surg 121:
435–452, 1945.
9. Debakey ME, Simeon FA: Battle injuries of the arteries in World War II.
Ann Surg 123:534–579, 1946.
10. Rich NM, Spencer FC: Vascular trauma, Philadelphia, PA, 1978, WB
Saunders.
11. Brusov PG, Nikolenko VK: Experience of treating gunshot wounds of
large vessels in Afghanistan. World J Surg 29(Suppl 1):S25–S29, 2005.
12. Eger M, Golcman L, Goldstein A: The use of a temporary shunt in the
management of arterial vascular injuries. Surg Gynecol Obstet 132(1):67–
70, 1971.
13. Hossny A: Blunt popliteal artery injury with complete lower limb isch-
emia: is routine use of temporary intraluminal arterial shunt justified?
J Vasc Surg 40(1):61–66, 2004.
14. Sriussadaporn S, Pak-art R: Temporary intravascular shunt in complex
extremity vascular injuries. J Trauma 52(6):1129–1133, 2002.
15. Reber PU, Patel AG, Sapio NL, et al: Selective use of temporary intravas-
cular shunts in coincident vascular and orthopedic upper and lower limb
trauma. J Trauma 47(1):72–76, 1999.
16. Granchi T, Schmittling Z, Vasquez J, et al: Prolonged use of intraluminal
arterial shunts without systemic anticoagulation. Am J Surg 180(6):493–
496, 2000.
17. Husain AK, Khandeparker JM, Tendoldar AG, et al: Temporary intravas-
cular shunts for peripheral vascular trauma. J Postgrad Med 38:68–69,
1992.
18. Khalil IM, Livingston DH: Intravascular shunts in complex lower limb
trauma. J Vasc Surg 4:582–587, 1986.
19. Nichols JF, Svodoba JA, Parks SN: Use of temporary intraluminal shunts
in selected peripheral arterial injuries. J Trauma 26:1094–1096, 1986.
20. Johansen K, Bandyk D, Thiele B, et al: Temporary intraluminal shunts:
resolution of a management dilemma in complex vascular injuries.
J Trauma 22:395–402, 1982.
21. Rasmussen TE, Clouse WD, Jenkins DH, et al: The use of temporary
vascular shunts as a damage control adjunct in the management of
wartime vascular injury. J Trauma 61(1):8–12, discussion 12–15, 2006.
22. Taller J, Kamdar JP, Greene JA, et al: Temporary vascular shunts as initial
treatment of proximal extremity vascular injuries during combat opera-
tions: the new standard of care ad Echelon II facilities? J Trauma 65(3):
595–603, 2008.
23. Chambers LW, Green DJ, Sample K, et al: Tactical surgical intervention
with temporary shunting of peripheral vascular trauma sustained during
Operation Iraqi Freedom: one unit’s experience. J Trauma 61(4):824–830,
2006.
24. Borut J, Acosta JA, Tadlock M: The use of temporary vascular shunts in
military extremity wounds: a preliminary outcome analysis with 2-year
follow-up. J Trauma 69:174–178, 2010.
25. Gifford SM, Aidinian G, Clouse WD, et al: Effect of temporary shunting
on extremity vascular injury: an outcome analysis from the Global War
on Terror vascular injury initiative. J Vasc Surg 50(3):549–555, discussion
555–556, 2009.
26. Subramanian A, Vercruysse G, Dente C, et al: A decade’s experience with
temporary intravascular shunts at a civilian Level I trauma center.
J Trauma 65:316–326, 2008.
27. Grossi EA, Giangola G, Parish MA: Differences in carotid shunt flow
rates and implications for cerebral blood flow. Ann Vasc Surg 7(1):39–43,
1993.
28. Aufiero TX, Thiele BL, Rossi JA, et al: Hemodynamic performance of
carotid artery shunts. Am J Surg 158(2):95–99, 1989.
29. Lavenson GS, Rich NM, Strandness DE, Jr: Ultrasonic flow detector value
in combat vascular injuries. Arch Surg 103:644–647, 1971.
30. Dawson DL, Putnam AT, Light JT, et al: Temporary arterial shunts to
maintain limb perfusion after arterial injury: an animal study. J Trauma
47:64–71, 1999.
31. Gifford SM, Eliason JL, Clouse WD, et al: Early versus delayed restoration
of flow with temporary vascular shunts reduces circulating markers of
injury in a porcine model. J Trauma 67:259–265, 2009.
32. Parry NG, Feliciano DV, Burke RM, et al: Management and short-term
patency of lower extremity venous injuries with various repairs. Am J
Surg 186(6):631–635, 2003.
33. Burkhardt GE, Cox M, Clouse WD, et al: Outcomes of selective tibial
artery repair following combat-related extremity injury. J Vasc Surg 52:
91–96, 2010.
34. Glass GE, Pearse MF, Nanchahal J: Improving lower limb salvage follow-
ing fractures with vascular injury: a systematic review and new manage-
ment algorithm. J Plast Reconstr Aesthet Surg 62:571–579, 2009.
35. Ritenour AE, Dorlac WC, Fang R, et al: Complications after fasciotomy
revision and delayed compartment release in combat patients. J Trauma
64:S153–S162, 2008.
36. Branco BC, Inaba K, Barmparas G: Incidence and predictors for the need
for fasciotomy after extremity trauma: a 10-year review in a mature Level
I trauma centre.
37. Gonzalez RP, Scott W, Wright A: Anatomic location of penetrating lower-
extremity trauma predicts compartment syndrome development. Am J
Surg 197(3):371–375, 2009.
38. Morin RJ, Swan KG, Tan V: Acute forearm compartment syndrome sec-
ondary to local arterial injury after penetrating trauma. J Trauma 66(4):
989–993, 2009.
39. Kim JYS, Buck DW, Forte AJV, et al: Risk factors for compartment syn-
drome in traumatic brachial artery injuries: an institutional experience
in 139 patients. J Trauma 67:1339–1344, 2009.
40. Choudry R, Schmieder F, Blebea J: Temporary femoral artery bifurca-
tion shunting following penetrating trauma. J Vasc Surg 49(3):779–781,
2009.
41. Ball CG, Feliciano DV: Damage control techniques for common and
external iliac artery injuries: have temporary intravascular shunts replaced
the need for ligation? J Trauma 68:1117–1120, 2010.
42. Ding W, Ji W, Wu X, et al: Prolonged indwelling time of temporary vas-
cular shunts is associated with increased endothelial injury in the porcine
mesenteric artery. J Trauma 70:1464–1470, 2011.
43. Reilly PM, Rotondo MF, Carpenter JP, et al: Temporary vascular continu-
ity during damage control: intraluminal shunting for proximal superior
mesenteric artery injury. J Trauma 39(4):757–760, 1995.
44. Asensio JA, Petrone P, Garcia-Nunez L, et al: Superior mesenteric venous
injuries: to ligate or to repair remains the question. J Trauma 62(3):668–
675, 2007.
45. Mattox KL, Espada R, Beall AR: Traumatic injury to the portal vein. Ann
Surg 181(5):519–522, 1975.
46. Graham JM, Mattox KL, Beall ACJR: Portal venous injuries. J Trauma
18(6):419–422, 1978.
47. Fraga GP, Bansal V, Fortlage D, et al: A 20-year experience with portal and
superior mesenteric venous injuries: has anything changed? Eur J Vasc
Endovasc Surg 37(1):87–91, 2009.
 Damage Control: Considerations
for Vascular Conduit in the
18  Repair of Vascular Injury
NITEN SINGH AND REAGAN W. QUAN
Introduction
In 1949, Jean Kunlin performed the first saphenous vein
bypass in the lower extremity of a patient suffering from isch-
emia.1 The work was not the result of chance alone as his
predecessors in vascular surgery had been working on perfect-
ing the technique of arterial surgery. Individuals such as Alexis
Carrel developed the technique of a meticulous anastomosis,
as well as experimenting with venous interposition grafts and
the use of allografts; and Jay McClean discovered heparin,
which was utilized in Kunlin’s successful procedure.2 In the
same manner, our current treatment of vascular trauma is
based on lessons learned in civilian trauma as well as military
experiences. For example, in World War II (WW II), the
majority of vascular injuries were treated with ligation, leading
to an amputation rate of 49%. During WW II, vein grafts were
employed in a very small number of patients (40), resulting
in an amputation rate of 58%.3,4 At that time, ligation of vas-
cular injuries was felt to be necessary due to the long transport
time required for wounded service personnel. With decreased
transport times and knowledge of these past experiences, Rich
and colleagues successfully implemented arterial repair in the
majority of patients in the Vietnam War and subsequently
reported an amputation rate of 13%. In that experience, nearly
all interposition grafts were reversed great saphenous vein;
and that form of reconstruction was used in 46% of the cases.5
In the civilian setting in the 1960s and 1970s, the abandon-
ment of ligation as treatment for vascular trauma led to
amputation rates that ranged from 2% to 10%.6 It is these
advances, both in the civilian and the military settings, that
have led to the current standard of repairing vascular injury—
in those that will tolerate repair—with interposition or bypass
grafting as needed.
Definition of Problem Identification
of the Optimal Vascular Conduit
The search for the optimal vascular conduit, in both elective
and emergency situations, has been a source of debate and the
source of many research projects. The ideal vascular conduit
should be durable, resistant to infection, and readily accessible
or available. In numerous studies of elective peripheral vascu-
lar bypass, autologous vein has proven superior to prosthetic
modalities in the lower extremities, whereas prosthetic grafts
are generally better suited for the larger caliber central arteries.
Unlike elective situations, trauma cases differ in the sense that
patients are generally younger and have healthy vessels free of
atherosclerotic occlusive disease that can complicate repair.
206
The limiting factor in trauma is the fact that the majority of
individuals may have concomitant orthopedic, soft-tissue, or
abdominal injuries that need to be addressed in addition to
the vascular injury. Furthermore, although vascular repair is
usually feasible, it is the ability to place the repair conduit
through a contaminated wound or soft-tissue deficit that often
limits success. Specifically, the need to assure adequate soft-
tissue coverage to protect the conduit from contamination
and disruption often determines ultimate success or failure.
As documented throughout this text, the approach to vas-
cular trauma is generally straightforward. Approaches to the
injured vessel include primary repair or restoration of perfu-
sion using an interposition or bypass graft. The technique of
patch angioplasty is also a useful approach in select injuries
that are less severe. Finally, ligation may be used as an approach
in select cases. When considering whether to reconstruct or
ligate an arterial injury, one should consider the patient’s
physiologic condition and other coexisting injuries. Also, one
must consider the degree of ischemia likely to result from
vessel ligation. If the artery is minimally disrupted, it may be
able to be débrided, mobilized, and repaired primarily.
In the situation where the artery cannot be repaired pri-
marily or cannot be safely ligated, there is the need for an
interposition or longer bypass graft. Temporary vascular
shunts are useful as bridges to interposition or bypass grafting
when ligation is not an option, but this adjunct is discussed
later in this book. When considering interposition or bypass
grafting, one must address the same technical factors that are
important in elective vascular reconstruction as follows: (1)
inflow vessel, (2) outflow vessel, and (3) conduit. Although the
vascular injury itself may be straightforward, the patient is
often not straightforward and may have suffered multiple
injuries. The overall injury severity and any degree of hemo-
dynamic instability will impact the choice of conduit and the
outcome of the procedure (Fig. 18-1). The ease of availability
and necessary length of conduit needed are also factors to be
considered when pursuing this type of reconstruction. It
would be nice to imagine that one solution applies to both
military and civilian scenario, but the settings (and the nature
of the wounds) are most often different. This chapter will
describe the options for selection of the vascular conduit to
be used for repair of vascular injury.
Types of Conduit
The use of a vascular conduit in vascular trauma is, in prin-
ciple, the same as its use for atherosclerotic occlusive or aneu-
rysmal disease. Vascular conduits can be considered in the
 18  /  Damage Control: Considerations for Vascular Conduit in the Repair of Vascular Injury 206.e1

ABSTRACT
The choice of conduit used to repair vascular trauma
depends on several factors including the anatomic location
of the injury, the degree of soft-tissue wound and contami-
nation, and the caliber of the injured vessel. The categories
of vascular reconstruction are primary repair, patch angio-
plasty, interposition (in situ) graft, and bypass graft. Extrem-
ity vascular injuries are most commonly managed by using
the interposition graft approach with great saphenous vein
as the most common conduit. Prosthetic conduit is more
commonly used for larger-caliber vessels of the abdomen,
pelvis, or thorax. There is controversy over the role of pros-
thetic conduit in the setting of trauma, particularly in
heavily contaminated wounds with soft-tissue defects.
Graft infection leading to thrombosis or anastomotic or
graft disruption can occur with autologous vein or pros-
thetic conduits. Routing of grafts away from or out of the
zone of contamination and assuring viable soft-tissue cov-
erage diminishes this risk of graft-related complications.
Outcomes following the use of the various types of con-
duits are not well characterized, and inherent differences
between trauma and age related disease limit the ability to
compare conduit in these settings. Research and develop-
ment aimed at autogenous, tissue-engineered conduits
may provide an “off-the-shelf” alternative to management
of vascular trauma in the future.

Key Words:  vascular conduit,

autologous vein,
artery,
prosthetic,
ePTFE,
Dacron,
infection
 18  /  Damage Control: Considerations for Vascular Conduit in the Repair of Vascular Injury 207
FIGURE 18-1 Massive soft-tissue destruction from an IED blast.
following categories: (1) autologous vein and artery (i.e., auto-
grafts), (2) prosthetics, and (3) biologics. Vascular trauma has
a rate of wound contamination that is proportional to the
mechanism of injury and to the degree of soft-tissue injury.
The degree of contamination can be minor such as with a
single stab wound or a laceration with a piece of glass, or it
can be major such as with an open femur fracture with soft-
tissue wound. More than a decade of war in Afghanistan and
Iraq has laid bare the complexities associated with vascular
trauma in highly contaminated wounds resulting from impro-
vised explosive devices (IEDs).7 Traditional teaching has
emphasized the use of autologous vein grafts for vascular
repair in the setting of contamination. However, due to the
complexities of different trauma scenarios such as bilateral
lower extremity injury, this conduit may not be feasible or
appropriate. If autologous vein is not available, vascular hem-
orrhage can be controlled by ligation, by the use of temporary
vascular shunts, or by reconstruction using a commercially
available prosthetic or biologic conduit.8
Autologous Conduit
The gold-standard conduit is autologous tissue and most
commonly a vein. In rare cases, one may choose to use an
arterial conduit for vascular reconstruction. Because the
venous system has multiple redundant outflow tracts, there
are several choices for vein harvest. The lower extremity has
the longest and most commonly used options, including the
greater and lesser saphenous veins, the femoral vein, and even
and dorsal foot vein. The cephalic and basilic veins of the
upper extremity can be used independently or as a longer
single segment graft. In the neck, the anterior, exterior, and
internal jugular veins are options for vascular conduit. The
veins of the neck are most commonly used as adjuncts for
carotid artery repair because of their proximity.
Use of autologous vein requires adhering to the tenants of
safe and effective dissection and procurement. In general,
superficial veins may be harvested using a single continuous
incision, skip incisions, or a newer minimally invasive tech-
nique. The single incision is the most expedient and most
commonly described technique for greater saphenous vein
harvest. However, this is associated with wound infection and
dehiscence in 17% to 44% of patients.9,10 In an effort to
decrease wound complications, attempts have been made to
harvest this vein with multiple, shorter incisions and interven-
ing “skin bridges.” Although this technique may take addi-
tional time and familiarity with the approach, it has been
shown to decrease wound complications (9.6%) in at least one
large series.11 The least invasive technique for saphenous vein
harvesting is the endoscopic approach. With this technique
the vein is harvested with electrocautery through several per-
cutaneous incisions. Although risk of wound infection is
decreased with the endoscopic technique, this does carry the
added risk of thermal injury to the vein. Although it is desir-
able to reduce wound morbidity associated with saphenous
vein harvest, it seems that as the method becomes less invasive
and that the time needed for the procedure increases, as does
the need for familiarity or expertise with the procedure.
Because of this, the less-invasive approaches to saphenous vein
harvest are not practical in most centers for cases of vascular
trauma.
Although rarely used, arterial conduits may provide a
better size match for the injured vessel and they do not require
lysis of valves. Arterial conduits may also have improved han-
dling characteristics, better compliance match and even supe-
rior patency. The use of autologous arterial conduit is feasible
and efficacious but remains limited in the setting of trauma
due to the paucity of harvest sites, their challenging anatomic
locations, and the lack of redundancy or length. The internal
mammary (internal thoracic) artery is the most commonly
used arterial conduit. However, due to its confined location,
access is only feasible through a median sternotomy. The gas-
troepiploic artery has also been used with favorable patency
in coronary artery bypass surgery when the internal mammary
artery and the saphenous vein are not available.12 The most
commonly explanted autologous artery is the radial artery,
which ranges from 2 mm to 4 mm. The internal iliac artery
can be used, but this is infrequent except in select cases of
pediatric injury. Klonaris et al described the benefits of using
the internal iliac artery for repair of infected femoral artery
pseudoaneurysm resulting from trauma from repeated access
during illicit drug use. This report describes the use of internal
iliac artery for reconstruction in 9 (5 patch, 4 interposition
graft) of 12 patients. At a mean of 19 months after repair,
Klonaris et al reported no complications or instances of limb
loss.13 Finally, the external carotid artery can serve as an autol-
ogous conduit in repair of proximal internal carotid artery
injuries. In these cases, the external carotid can be transposed
onto the mid or distal internal carotid in situations where the
proximal portion is injured. Other arteries such as the deep
inferior epigastric may be used as a microvascular graft to
replace a damaged arterial segment, but these smaller arteries
are not typically a consideration in trauma.14
Prosthetic Conduits
Since the first prosthetic graft made of woven nylon, a variety
of grafts have been developed, including collagen-impregnated
woven nylon (Hemashield Dacron, Maquet Germany),
heparin-bonded Dacron, expanded polytetrafluoroethylene
(ePTFE), heparin-bonded ePTFE (PROPATEN, Gore Medical,
Flagstaff, AZ), hooded PTFE (Distaflo, Bard PV, Tempe, AZ),
ring reinforced ePTFE, and even a hybrid consisting of woven
nylon and ePTFE (Triplex, Vascutek Terumo, Scotland, UK).
In large vessels such as the aorta and iliac arteries, prosthetic
grafts have been used with great success. However, higher rates
208 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
of thrombosis remain a disadvantage of prosthetic grafts in
smaller vessels regardless of conduit composition. In the
classic studies of Bergen and Veith, comparing vein to ePTFE
for reconstruction of age-related disease, short-term (2-year)
patency was comparable between the conduits. When longer-
term patency rates of these studies were reported, saphenous
vein was found to be superior.15,16 Prosthetic grafts are used
today for elective bypass procedures but mainly in the femoral
and above-knee location. Adjuncts such as heparin bonding
of the luminal surface of the ePTFE have been used with
modest or mixed results in attempts to improve patency. The
use of prosthetic grafts in trauma has been espoused by some
who purport that short segment or length prosthetics are
durable and react more favorably than vein in contaminated
fields. Some of these studies also point to preservation of the
autologous vein for future revascularization as an advantage
of using prosthetic conduits as the initial option.
Biologic Conduits: Allografts
The most modern construct of the vascular conduit is the
biologic graft. These may be allografts or xenografts. Allografts
consist of cryopreserved vein, cryopreserved artery, or pre-
served treated human umbilical vein (HUV). Dardik began
work on HUV as a conduit starting in the 1970s.17 At 37 to 40
weeks of gestation, the HUV (2 mm to 3 mm diameter) is of
similar caliber to that of small arteries and contains moderate
amounts of collagen and elastin to provide elasticity. In a
qualitative analysis of the microstructure of HUVs, Li et al
showed that the collagen : elastin ratio in these vessels is
similar to an artery of the same caliber. Studies by Li and col-
leagues also demonstrated that HUV had comparable mor-
phologic and microstructural indices as similar-size arteries.
These authors concluded that because of similarities HUV
may be a substitute for small-caliber arteries such as coronary,
brachial, radial, and tibial.18 In a review of 211 femoral–
to-popliteal bypass operations (using the second-generation
glutaraldehyde-stabilized HUV grafts), Neufang et al reported
the primary, primary-assisted, secondary patency, and limb
salvage after 5 years as 54%, 63%, 76%, and 92%, respectively,
(with no difference between above-knee and below-knee
grafts).19
Cryopreserved saphenous vein allografts, also referred to
as cadaveric saphenous vein, have been utilized as an alterna-
tive conduit. Early results with this conduit demonstrated
poor patency. Walker et al studied 35 patients who underwent
lower extremity bypass grafts for symptomatic ischemia. The
primary patency was 67% at 1 month, 28% at 12 months, and
14% at 18 months.20 In an effort to improve patency of cryo-
preserved vein, Buckley et al prospectively enrolled patients
for femoral to below-knee popliteal artery bypass using an
anticoagulation protocol. Twenty-four patients with ischemic
lower limbs underwent bypass with cryopreserved vein and
were treated with aspirin, low-dose heparin, low-molecular-
weight dextran 40, dipyridamole, and warfarin. The limb
salvage rate in this study was 88% at 6 months and 80% at
24 months.21 Although this report demonstrated improved
patency, it enrolled a small number, and patients required high
levels of anticoagulation to obtain the results.
Cryopreserved arterial allografts have been developed as an
alternative to cryopreserved vein. Cryopreserved artery is
derived from the descending thoracic and infrarenal aorta, as
well as the iliac and femoral arteries of human cadavers. Due
to the variety of diameters, one can find an appropriately sized
cryopreserved allograft for any vessel in the body. Cryopre-
served allografts are commonly used for in-line arterial recon-
struction in the treatment of prosthetic graft infections or
contaminated wounds such as a mycotic aneurysm or aorto-
enteric fistula. Although cryopreserved arterial allografts have
been anecdotally reported in the repair of vascular trauma
with contaminated wounds, there are no large series. Reports
on the use of this conduit in infected abdominal and extremity
vascular beds suggest that it would be a safe consideration in
the setting of resistant or recurrent infection and that it may
have applicability in trauma.22
Biologic Conduits: Xenografts
Animal-derived conduits (xenografts) include bovine carotid
artery (Artegraft, North Brunswick, NJ), bovine pericardium,
bovine jugular vein (Contegra, Contegra, Medtronic, Santa
Rosa, CA) as well as a porcine pulmonic xenograft. The use of
bovine carotid as a hemodialysis graft was initially reported
by Chinitz.23 The patency of bovine carotid has been com-
pared to ePTFE in hemodialysis grafts by Kennealey. Although
there was no difference in secondary patency, primary and
assisted primary patency were higher with bovine carotid than
with ePTFE (60% versus 10% and 60% versus 21% at 1 year,
respectively).24 Although bovine carotid has not been studied
in vascular trauma, experience suggests that it may be a valid
consideration in select cases. Similarly, bovine jugular vein
plays a role in reconstruction of the right ventricular outflow
tract in congenital heart surgery.25 Although its use in trauma
remains to be defined, this conduit is available in diameters
from 12 mm to 22 mm and would appear to be an appropriate
size match for torso vascular structures.26
Decision Making in the Choice
of Conduit
Location and Nature of the Injury
The anatomic location of the vascular injury plays an impor-
tant role in consideration of conduit. If the environment in
which conduit will be used is relatively innocuous, such as a
low-velocity penetrating wound, the injury may be amenable
to anatomic or in situ interposition graft reconstruction. In
contrast, if the injury is more extensive, is heavily contami-
nated, or is associated with soft-tissue injury, there may not
be viable soft tissue to cover an in situ graft. These more severe
cases may preclude anatomic or in situ reconstruction and
instead require positioning or routing of the conduit in an
alternative or extraanatomic location. Understanding the size
of the injured vessel and the extent of contamination and soft-
tissue injury allow one to make a judgment about the best type
of conduit. Table 18-1 provides a summary of approximate
sizes of vessels that may be affected in the setting of severe
injury.
Thoracic and Abdominal Injuries
The thoracic aorta and its branches are protected by the bone
and muscular structures of the thorax. Blunt injuries that
carry enough force to disrupt these vessels often result in
death. In the civilian setting blunt aortic injury (BAI) is often
manifested as a transection of the proximal descending aorta
at or immediately distal to the ligamentum arteriosum. In this
 18  /  Damage Control: Considerations for Vascular Conduit in the Repair of Vascular Injury 209

scenario a patient will survive based on the integrity of the ography. Penetrating injuries may lead to vessel transection or
periadventitial tissue in the mediastinum. Although this situ- intimal injury due direct or indirect contusion (i.e., concussive
ation is not stable in the long-term, a contained BAI may allow effect). Partial transection of the vessel may prevent retraction
the patient to be transported to a trauma center and treated and vasoconstriction and may lead to more bleeding from the
with an open interposition graft or an endovascular stent- injury. In contrast, complete transection of the elastic arteries
graft. Penetrating injury to the thoracic aorta is often lethal in the upper extremities often results in vessel retraction, vaso-
due to the numerous vital structures in the vicinity. Even low constriction and a relative degree of hemostasis. In the upper
velocity penetrating injuries (i.e., stab wounds) may be lethal extremity, the axillary and brachial arteries are frequently
in this location.27,28 Blunt injury to the abdominal aorta is injured by penetrating mechanisms; and in the lower extrem-
infrequent and accounts for 5% of aortic injuries.29 The ity, the superficial femoral and popliteal arteries are most
majority of abdominal aortic trauma involves the infrarenal affected.31-33 The smaller infrageniculate vessels can also be
segment but its branches may also be injured. Penetrating injured. However, if in isolation, these injuries are associated
injuries to the abdominal aorta and its branches are often with lower rates of mortality and morbidity than the larger,
complicated by injuries to solid or hollow viscus organs more-proximal vessels. If multiple tibial vessels are injured in
leading to bleeding and or enteric contamination.30 the same extremity, the degree of ischemia and even the pro-
pensity for limb loss are likely to be worse.
Extremity Vessels
Blunt arterial extremity injury classically leads to disruption Ideal Conduit for Vascular Trauma
of the intima and flow-limiting defects. The difficulty with The ideal characteristics of conduit include durability (i.e., life
blunt trauma is confirming the diagnosis and specific location of the patient), resistance to infection, ability to incorporate
of vascular injury. As discussed in other chapters of this text, with surrounding tissues, and appropriate diameter for the
this scenario is often delineated with imaging such as duplex, vessel being reconstructed. There is a general consensus that,
contrast computed tomography (CT), or conventional arteri- until artificial biologic conduits are developed, autologous
vein is the favored conduit option. However, given the varied
mechanisms of trauma and the different sizes of injured
vessels, one will need to be familiar with more than just saphe-
Table 18-1 Various Size of Arteries Affected nous vein for vascular conduit. Table 18-2 lists several com-
by Trauma monly used conduits, each with real or perceived advantages
Artery Normal Diameter (mm) and disadvantages.
As noted, the choice of conduit depends on the anatomic
Common carotid 10
region of injury. Since the Vietnam War—and especially
Innominate 12-14
during the wars in Afghanistan and Iraq—the percentage of
Subclavian 10
cervical and extremity vascular injuries has increased.34
Axillary 8-10
Although rare and associated with high mortality, torso inju-
Radial 4-6
ries do occur in the wartime setting. Larger-diameter torso
Thoracic aorta 20-25
injuries often require reconstruction with ePTFE or Dacron.
Abdominal aorta 15-20
These conduits are favored in the torso because of their ready
Common iliac 10-14
availability and their larger diameters. For smaller torso
External iliac 8-10
vessels or in cases of enteric contamination, one may consider
Internal iliac 8-10
autologous vein as conduit. In these cases, depending on the
Common femoral 8-10
extent of injury, one may use the deep femoral or the saphe-
Superficial femoral 6-8
nous vein.
Profunda femoral 6-8
The aorta is most commonly repaired primarily or with a
Popliteal 6-8
prosthetic conduit for reasons already mentioned. The aorta

Table 18-2 Conduit Class: Common Conduits in Trauma

Conduit Resistance to
Type Accessibility Durability Infection Size Matched Miscellaneous Issues
Autologous Easily accessible if there Extremely Good if there is Excellent for the Can lead to pseudoaneurysm
vein (e.g., is not polytrauma (i.e., good adequate tissue upper and lower or blowout if not properly
GSV) bilateral IED injury to coverage extremities covered
the lower extremities)
Prosthetic “Off the shelf” Not the same Good; antibiotic Excellent size for Can lead to pseudoaneurysm
as GSV but impregnation all injuries or thrombosis if placed in
adequate available contaminated field
Cryopreserved Accessible if cold storage Very good Numerous reports Very good for a Requires freezer and time to
allograft available for intraabdominal variety of sizes thaw; not available in
replacement with austere or military settings
good success

GSV, Greater saphenous vein; IED, improvised explosive device.

210 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
may also be reconstructed with a bifurcated graft comprised
of the deep femoral veins sewn side-to-side for 5 cm to create
a large common channel that approximates aortic diameter.
This neoaorta procedure is almost exclusively used in the elec-
tive or the semielective setting following removal of an infected
prosthetic aortic graft and should rarely be used as the primary
procedure for trauma.35 Reconstruction of the iliac artery may
be accomplished with prosthetic or with saphenous or femoral
vein depending on the setting. One strategy to construct a
larger caliber conduit using saphenous vein is referred to as a
“panel graft.” In this case, a long length of the great saphenous
is opened longitudinally and divided into two approximately
equal segments or “panels.” The panels are then sewn side–
to-side and closed over a small or midsized chest tube. Varia-
tions of the panel graft exist, and the strategy can result in an
autologous vein conduit with a caliber that is twice that of the
original saphenous vein diameter.36
Because of the constraints involved with autologous repair
of torso vascular injuries, particularly with regard to the
larger-caliber vessels, repair has traditionally been performed
using prosthetic of collagen impregnated, woven nylon, or
ePTFE. Woven nylon grafts have the disadvantage of stretch-
ing up to 40% over the lifetime of the graft. As such, the
diameter of the woven nylon graft should be relatively under-
sized compared to the diameter of the native artery being
repaired. ePTFE grafts are relatively porous and are prone to
leaching serous fluid through the graft material. This phe-
nomenon also referred to as “sweating” can lead to formation
of seromas in the graft tract. In an effort to mitigate each of
these disadvantages, a multilayered woven nylon and ePTFE
graft is available. The new Triplex prosthetic conduit (Vascu-
tek Terumo, Renfreswshire, Scotland) consists of three layers.
The inner layer is a standard uncoated Dacron graft (DuPont,
Wilmington, DE), and the outer is a standard ePTFE graft.
These two layers are fused together by a central layer of self-
sealing elastomeric membrane.37
Adjunctive maneuvers such as presoaking a woven nylon
graft with rifampin (60 mg/ml) can be performed as a measure
to deliver antibiotic to the field of injury and to reduce the
risk of graft infection. Similarly, ePTFE grafts can be treated
to decrease infections when placed in a contaminated field.
Fisher et al describes a method by which minocycline and
rifampin are bound to ePTFE graft using a unique methylac-
rylate technology to promote controlled antibiotic elution and
to reduce infection risk. In vitro, the antibiotic-bound ePTFE
grafts sustained gradual local release of the antibiotics that
provided resistance from infection by Staphylococcus aureus
and Staphylococcus epidermis for up to 2 weeks.38
The available and best suited conduit for the repair of
upper and lower extremity arterial injury is the greater saphe-
nous vein. It is generally recommended that this autologous
conduit should be harvested from the leg contralateral to any
injury to decrease the risk of any venous congestion resulting
from trauma. This is especially important if the injured lower
extremity has concomitant arterial and venous injuries. In
McCready’s series of patients with extremity trauma, it was
found that 43 of 49 patients with femoral and popliteal artery
injuries reconstructed with saphenous vein experienced an
excellent outcome 33 months after the event.39 Similar out-
comes have been reported in other series although lack of
follow-up with this subset of the population means longer-
term results are not known.40,41 Late thrombosis of saphenous
vein grafts does not necessarily mean catastrophe. In Rich’s
Vietnam experience, 24 of 34 who experienced vein graft
thrombosis required no operative intervention because of
adequate collateral circulation to maintain limb viability. It is
likely that other associated extremities injuries (e.g., bone,
nerve) limited use of the limb and the degree to which mild
to moderate ischemia resulting from graft thrombosis would
result in symptoms such as claudication.42
If saphenous vein is not available as conduit, the upper
extremity veins such as the cephalic and basilic can be used.
The basilic vein has been described for use in bypass and
exclusion of a popliteal artery aneurysm. The basilic vein can
be easily harvested from the arm while simultaneous exposure
of the lower extremity artery is performed by another surgical
team. Tal et al described basilic vein grafts used to bypass and
exclude popliteal artery aneurysm in 5 patients with good
results up to 3 years after the repair.43 In another small series
from Parmar et al, basilic vein was employed for the replace-
ment of infected prosthetic grafts in the iliac and femoral
arterial regions. The basilic vein provided appropriate size
match and was used for in situ replacement.44 Although arm
vein performs favorably with respect to patency and limb
salvage when compared to synthetic conduit, it does require
more-frequent secondary interventions to maintain patency.
In a series of 37 arm vein bypasses, Varcoe et al reported a
30-day primary and secondary patency of 89% and 95%,
respectively, with 95% limb salvage.45
If one is to reconstruct arterial injuries in the distal extrem-
ities (e.g., forearm, leg), the conduit must be small caliber.
Autologous artery or vein is still preferred in these challenging
situations. To obtain an appropriate size match, the distal
greater saphenous vein at the ankle or the lesser saphenous
vein provides relatively familiar options. Rockwell et al,
described use of epigastric artery and dorsal hand vein trans-
position for thumb reimplantation following traumatic
amputation.46 The dorsal hand or foot veins are of good
caliber, but harvesting will leave a significant scar, and there is
potential for injury to the extensor tendons of the hand or
fibrotic scar formation resulting in decreased function. In the
case of hypothenar hammer syndrome, trauma to the hypo-
thenar eminence of the palm causes injury to the ulnar artery
often with formation of a symptomatic aneurysm. Traditional
vein graft repair of a thrombosed ulnar artery using reversed
saphenous vein has been reported.47 However, Temming et al
proposed that an arterial autograft would be superior conduit
(i.e., better size, durability) compared to vein graft in this
scenarios. This group subsequently reported 3 successful cases
of ulnar artery reconstruction using the descending branch of
the lateral circumflex artery. In this novel report, patency of
the reconstruction was confirmed by duplex ultrasound at
periods as long as 28 months after repair.48
Available Conduit in Austere
and Military Settings
Autologous Conduits
Conduit other than greater saphenous vein is usually not
available or feasible in military or civilian scenarios of damage
control surgery. In this context, one must consider the patient’s
overall injury pattern and injury severity (i.e., polytrauma)
when considering harvest of autologous conduit and vascular
 18  /  Damage Control: Considerations for Vascular Conduit in the Repair of Vascular Injury 211
FIGURE 18-2  Short-length interposition saphenous graft in the bra-
chial artery.
reconstruction. The benefits of autologous conduit include its
familiarity and demonstrated effectiveness in scenarios of
elective revascularization for chronic limb ischemia. Addition-
ally numerous retrospective studies have shown the effective-
ness of vein as a conduit in extremity trauma. Nonetheless,
one notable drawback of greater saphenous vein is the time
and expertise required to harvest the conduit. Keen reviewed
the experience with autologous vein repair in extremity injury
(n = 134) in a busy trauma setting and estimated that it
required nearly 10 minutes to harvest and prepare the conduit.
To many, including the editors of this text, the finding of 10
minutes is conservative. In most experiences, harvesting and
preparation of the saphenous vein requires 15 to 30 minutes;
and this can be longer if difficulties are encountered with a
dual saphenous system or if one includes wound closure in
the time estimate. Keen and colleagues reported no graft infec-
tions in their population and attributed this success to liberal
use of rotational muscle flaps and routing the autologous
grafts in an extraanatomic manner out of any contaminated
sites.49
The observations of success-related routing grafts out of or
around the zone of injury and contamination (i.e., extraana-
tomic) should be understood by military surgeons. Several
studies have demonstrated that vein grafts are prone to under-
going transmural necrosis when they are placed in a contami-
nated field without adequate or viable soft-tissue coverage. In
this setting, the conduit can degrade or break down because
of bacterial contaminated with or without desiccation of the
main body of the graft or the anastomotic sites. In general, it
is uncommon to require a long segment of vein for recon-
struction of vascular trauma (Fig. 18-2). In up to 40% of
military extremity vascular injuries, the patient has a con-
comitant orthopedic fracture. In these scenarios, exposing and
controlling the vascular injury with or without the use of a
vascular shunt is accomplished first. Then the contralateral
saphenous vein is harvested while the fracture is reduced and
stabilized. After the orthopedic injury is stabilized, the vascu-
lar injury is reexposed; any vascular shunt is removed; and the
injury is reconstructed with the harvested vein (i.e., graft,
patch angioplasty). If the greater saphenous vein is not avail-
able, the lesser saphenous, the cephalic, or the basilic veins
should be considered. Most of the time, circumstances such
as patient positioning, other injuries, or indwelling intrave-
nous lines exclude exposure and procurement of these alter-
native vein conduits.
Prosthetic Conduits
Prosthetic conduit such as Dacron and ePTFE has been
employed in civilian trauma for a number of years and offers
a wide range of sizes. However, most studies examining the
use of prosthetic grafts in trauma have been in the civilian
setting where the level of soft-tissue injury and contamination
are less than in the military setting. Rich’s experience from
Vietnam demonstrated that the majority of prosthetic grafts
used for reconstruction of vascular trauma were associated
with complications, either infection or thrombosis. These
observations have been corroborated during the wars in
Afghanistan and Iraq, and the use of prosthetic graft material
to reconstruct vascular injuries is generally discouraged in
military patients. Clouse et al reviewed 301 arterial injuries in
Iraq and found that 3% were repaired using prosthetic grafts,
while 57% were managed with autogenous vein repair.50
The severity of lower extremity injury in the wars in
Afghanistan and Iraq, including those sustained as part of the
Dismounted Complex Blast Injury Task Force study, has pre-
sented a particular challenge related to use of autologous vein
conduit. Specifically, in cases where both lower extremities are
mangled or possibly amputated, there is often no saphenous
vein to use as conduit for vascular reconstruction. These
complex scenarios have required military surgeons to inno-
vate either by using temporary vascular shunts for long periods
of time (i.e., extreme shunting) or by using ePTFE as a first
(but likely temporary) interposition graft material. At least
one series has described using ePTFE first as a damage control
option even in the setting of severe contamination and poor
tissue coverage (Fig. 18-3).51 In this setting, the patient and
ePTFE graft are monitored closely for graft disruption; and
the reconstruction is ultimately revised within 5 to 10 days of
the injury (Fig. 18-4). Revising the vascular reconstruction at
even this modest time interval often allows for procurement
of an alternative vein conduit or rerouting of the revision
through an extraanatomic location.51
In the civilian setting, prosthetic grafts such as ePTFE have
been used commonly with satisfactory results. Feliciano and
colleagues reported long-term patency of 70% for arterial
injuries managed with ePTFE grafts. In contrast, this same
group reported poor results with the use of ePTFE for repair
of extremity veins with all reconstructions having thrombosed
during follow-up.52 In the military setting prosthetic grafts
have been observed not to incorporate well with surrounding
soft-tissue coverage. In some cases, this has been because of
primary bacterial contamination, infection, or colonization;
although in others this observation may simply be due to a
noninfected seroma. Even if the original cause is not infec-
tious, the presence of a seroma and nonincorporated graft in
a polytrauma patient is prone to subsequent infection and
anastomotic disruption. As such, ePTFE has been discouraged
in the current military experience and closely monitored if it
is required because of the absence of autologous vein. As
described, ePTFE can be removed or revised in an elective or
more controlled setting if needed in the weeks and months
following injury.53,54
212 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT

A B
FIGURE 18-3 Operative photos of penetrating right common carotid artery injury repaired using an 8-mm ePTFE interposition graft. A, The
patient’s head is turned to the left, and the jugular vein is to the anatomic right of the interposition graft. At the top aspect of the photo, the
intact right facial vein can be observed crossing the more distal common carotid and carotid bifurcation. The small, hand-held, Bookwalter
retractor is at the base of the neck at the sternoclavicular junction. B, The wound is closed over a closed suction drain. The second drain at the
top of this photo is of a negative pressure wound therapy device placed over the débrided entrance wound. ePTEF was chosen as a conduit in
this instance because of its ready, “off-the-shelf” availability and its excellent size match. Of note, in this case there was minimal soft-tissue injury
and no esophageal (i.e., enteric) trauma. (Courtesy Todd Rasmussen.)

Future Considerations properties of native vessels, the implanted vessels should

Artificial Blood Vessels
The limitations associated with the currently available autolo-
gous conduits have led to numerous efforts to create artificial
blood vessels. Teebken outlined the desired characteristics of
an artificial blood vessel as follows: (1) compliance, (2) lack
of thrombogenicity, and (3) resistance to infection.55 Indeed
these traits and availability of a wide range of sizes (akin to
prosthetic grafts) would be ideal for elective and trauma situ-
ations. Kakisis and colleagues reviewed the literature on the
creation of artificial blood vessels and identified the three
basic elements required for construction of a blood vessel as
follows: (1) a structural scaffold, (2) cells, and (3) a nurturing
environment.56 Most scaffolds are created from a collagen
matrix, and in 1986 Weinberg created the first in vitro vessel
based on this matrix.57 The inner surface of the graft was
seeded with bovine endothelial cells, and Dacron mesh was
embedded into the wall. In models created without the mesh
the burst strength was very low compared to those with mesh.
Their model generated further studies based on these tissue-
engineering principles.
One of the issues that influence neovessel strength is the
orientation of the smooth muscle cells on the scaffold. Numer-
ous techniques including the application of pulsatile flow and
magnetic fields have been used to reorient the smooth muscle
cells in a favorable, circumferential axis. Edelman identified
that, although artificial blood vessels may not have the ideal
ideally grow or incorporate to the local environment if they
are composed of viable tissue.58 Kakisis identified constraining
factors in use and development of artificial vessels as the long
period of preparation required to produce bioengineered
products, the risk of infection due to the prolonged duration
of culture, and the need to investigate the use of new biopoly-
mers (as opposed to using the preexisting scaffolds).59 A more
comprehensive discussion of tissue-engineered arteries is
beyond the scope of this chapter, but it is likely that advances
in this field will lead to the development of artificial blood
vessels as technology advances.
Improvements in Storage
It is worth noting that the development of new and efficacious
preservation techniques for human vascular allografts would
also be potentially useful for vascular trauma. Although vas-
cular allografts have many advantages, they currently require
procurement, cryopreservation and storage at −135° C. The
grafts must then be shipped at this temperature and require
approximately 30 to 40 minutes to thaw before use, limiting
significantly their applicability for trauma (military and
civilian).60-62
Conclusion
When conduit is required for the management of vascular
trauma, several options are available. When it is available and
 18  /  Damage Control: Considerations for Vascular Conduit in the Repair of Vascular Injury 213

A B

C
FIGURE 18-4 Operative photo of a mangled right upper extremity and axilla resulting from an explosive mechanism. Limb salvage was pursued
despite a brachial artery injury and massive soft-tissue damage because the median and radial nerves were visualized intact and there was no
injury to the wrist or hand. The right forearm wound is a fasciotomy incision. A, The brachial artery has been reconstructed with a 6-mm ePTFE
graft as a damage control maneuver. This graft was placed at the initial operation with the expectation that it would be temporary and replaced
by an autologous vein graft during subsequent operations if the attempt at limb salvage was continued. B, This photograph was taken 2 weeks
later, after the soft-tissue wound had been stabilized over the course of four operations. The ePTFE graft has been replaced with an autologous
reversed greater saphenous vein interposition graft. In this image, a right latissimus dorsi rotational flap had been accomplished to fill in the
soft-tissue defect and to cover the autologous vascular reconstruction. C, This shows the injury is at the completion of the operation with the
right extremity wound controlled using an extensive negative pressure wound therapy mechanism. (Courtesy Todd Rasmussen.)

of good quality, autologous saphenous vein is the preferred REFERENCES

conduit for extremity injury. Because of its “off–the-shelf ”
availability and range of size, prosthetic conduit, such as
Dacron and ePTFE, is preferable for torso and cervical vascu-
lar trauma. The use of these preferred conduits is at the dis-
cretion of the surgeon and operative team as there are
scenarios where autologous saphenous vein can be used for
torso and cervical injuries and synthetic conduit used for
extremity vascular trauma. The ability to route vascular
conduit out of the zone of contamination and injury is
important, especially in scenarios in which there is a paucity
of viable soft-tissue coverage. Recent wartime experience has
shown that synthetic conduit can be used as an initial damage
control strategy to establish restoration of perfusion even in
heavily contaminated fields. In these complex situations, the
prosthetic functions as a temporary conduit with close obser-
vation and with planned revision at a modest time interval
and in a more-controlled setting. Novel programs are under-
way to engineer new vascular conduits with several having
provided prototypes and products for translational and clini-
cal study.
1. Abbott WM: Presidential address: legend, leadership, legacy. J Vasc Surg
29:1–7, 1999.
2. Menzoian JO, Koshar AL, Rodrigues N: Alexis Carrel, Rene Leriche,
Jean Kunlin, and the history of bypass surgery. J Vasc Surg 54:571–574,
2011.
3. Barker WF: The Society of Vascular Surgery: then and now. J Vasc Surg
23:1035–1042, 1996.
4. DeBakey ME, Simeone FA: Battle injuries of the arteries in World War II:
an analysis of 2471 cases. Ann Surg 123:534–579, 1946.
5. Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam: 1000
cases. J Trauma 10:359–369, 1970.
6. Kelly Gl, Eiseman B: Civilian vascular injuries. J Trauma 15:507–514,
1975.
7. Quan RW, Gillespie DL, Stuart RS, et al: The effect of vein repair on the
risk of venous thromboembolic events: a review of more than 100 trau-
matic military venous injuries. J Vasc Surg 47:571–577, 2008.
8. Khalili IM, Livingston DH: Intravascular shunts in complex lower limb
trauma. J Vasc Surg 4:582–587, 1986.
9. Wengrovitz M, Atnip RG, Gifford RR, et al: Wound complications of
autogenous infrainguinal artery bypass surgery: predisposing factors and
management. J Vasc Surg 11:156–161, 1990.
10. Reifsnyder T, Bandyk D, Seabrook G, et al: Wound complications of
the in situ saphenous vein bypass technique. J Vasc Surg 15:843–848,
1992.
214 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
11. Berceli SA: Autogenous vein grafts. In Cronenwett JL, Johnston KW,
editors: Rutherford’s Vascular Surgery, Chap. 87, copyright 2010, Saun-
ders Elsevier Publishers, p 1321.
12. Suma H, Tanabe H, Takahashi A, et al: Twenty years experience with the
gastroepiploic artery graft for GABG. Circulation 116:188–191, 2007.
13. Klonaris C, Katsargyris A, Papapetrou A, et al: Infected femoral artery
pseudoaneurysm in drug addicts: the beneficial use of the internal iliac
artery for arterial reconstruction. J Vasc Surg 45:498–504, 2007.
14. Rockwell WB, Hurst CA, Morton DA, et al: The deep inferior epigastric
artery: anatomy and applicability as a source of microvascular arterial
grafts. Plast Reconstr Surg 120:209–214, 2007.
15. Bergen JJ, Veith FJ, Bernhard VM, et al: Randomization of autogenous
vein and polytetrafluoroethylene grafts in femoral-distal reconstruction.
Surgery 92:921–930, 1982.
16. Veith FJ, Gupta SK, Ascer E, et al: Six-year prospective multicenter ran-
domized comparison of autologous saphenous vein and expanded
polytetrafluoroethylene grafts in infrainguinal arterial reconstructions.
J Vasc Surg 3:103–114, 1986.
17. Dardik H: A 30-year odyssey with the umbilical vein graft. J Am Coll Surg
203:582–583, 2006.
18. Li WC, Shang HM, Wang PJ, et al: Qualitative analysis if the microstruc-
ture of human umbilical vein for assessing feasibility as vessel substitute.
Ann Vasc Surg 22:417–424, 2008.
19. Neufang A, Espinola-Klien C, Dorweiler B, et al: Femoropopliteal pros-
thetic bypass with glutaraldehyde stabilized human umbilical vein
(HUV). J Vasc Surg 46:280–288, 2007.
20. Walker PJ, Mitchell RS, McFadden PM, et al: Early experience with cryo-
preserved saphenous vein allografts as a conduit for complex limb salvage
procedures. J Vasc Surg 18:561–568, discussion 568–9, 1993.
21. Buckley C, Abernathy S, Lee S, et al: Suggested treatment protocol for
improving patency of femoral-infrapopliteal cryopreserved saphenous
vein allograft. J Vasc 23:731–738, 2000.
22. Vardaian AJ, Chau A, Quinones-Baldrich W, et al: Arterial allograft allows
in-line reconstruction of prosthetic graft infection with low recurrence
and mortality. Am Surg 75:1000–1003, 2009.
23. Chintz JL, Tokoyama T, Bower R, et al: Self-sealing prosthesis for arterio-
venous fistula in man. Trans Am Soc Artif Intern Organs 18:452–457,
1972.
24. Kennealey PT, Elias N, Hertl M, et al: A prospective, randomized com-
parison of bovine carotid artery and expanded polytetrafluoroethylene
for permanent hemodialysis vascular access. J Vasc Surg 53:1640–1648,
2011.
25. Schoenhoff Fs, Loup O, Gahl B, et al: The Contegra bovine jugular vein
graft versus the Shelhigh pulmonic porcine graft for reconstruction of the
right ventricular outflow tract: a comparative study. J Thorac Cardiovasc
Surg 141:654–661, 2011.
26. Fiore AC, Brown JW, Turrentine MW, et al: A bovine jugular vein conduit:
a ten-year bi-institutional experience. Ann Thoracic Surg 92:183–190,
discussion 190–2, 2011.
27. Mattox KL: Thoracic vascular trauma. J Vasc Surg 7:725–729, 1987.
28. Adams JD, Garcia LM, Keith JA: Endovascular repair of the thoracic aorta.
Surg Clin N Am 89:885–912, 2009.
29. Uyeda JW, Anderson SW, Sakai O, et al: CT Angiography in trauma.
Radiol Clin N Am 48:423–438, 2010.
30. Mullins RJ, Huckfeldt R, Trunkey DD: Abdominal vascular injuries. Surg
Clin N Am 76:813–832, 1996.
31. Fitridge RA, Raptis S, Miller JH, et al: Upper extremity arterial injuries:
experience at the Royal Adelaide Hospital, 1969 to 1991. J Vasc Surg 20:
941–946, 1994.
32. Orcutt MB, Levine BA, Gaskill HV, et al: Civilian vascular trauma of the
upper extremity. J Trauma 26:63–67, 1986.
33. Franz RW, Shah KJ, Halaharvi D, et al: A 5-year review of management
of lower extremity arterial injuries at urban Level I trauma center. J Vasc
Surg 53:1604–1610, 2011.
34. Fox CJ, Gillepsie DL, O’Donnell SD, et al: Contemporary management of
wartime vascular trauma. J Vasc Surg 41:638–644, 2005.
35. Claggett GP, Valentine RJ, Hagino RT: Autogenous aortoiliac/femoral
reconstruction from superficial femoral-popliteal veins: feasibility and
durability. J Vasc Surg 25:255–270, 1997.
36. Barbon B, Militello C, De Rossi A, et al: Autologous great saphenous vein
tailored graft to replace an infected prosthetic graft in the groin. Vasc
Endovasc Surg 41:358–361, 2007.
37. De Paulis R, Scaffa R, Maselli D, et al: A third generation of ascending
aorta Dacron graft: preliminary experience. Ann Thorac Surg 85:305–
309, 2008.
38. Fischer PE, Fabian TC, deRiik WG, et al: Prosthetic vascular conduit in
contaminated fields: a new technology to decrease ePTFE infections. Am
Surg 74:524–528, discussion 528–9, 2008.
39. McCready RA, Logan NM, Daugherty ME, et al: Long-term results with
autogenous tissue repair of traumatic extremity vascular injuries. Arch
Surg 206:804–808, 1987.
40. Lau JM, Mattox KL, Beall AC, et al: Use of substitute conduits in trau-
matic vascular injury. Am J Surg 148:229–233, 1984.
41. Shah DM, Leather RP, Corson JD, et al: Polytetrafluoroethylene grafts in
the rapid reconstruction of acute contaminated peripheral vascular inju-
ries. Am J Surg 142:695–698, 1981.
42. Rich NM, Baugh JH, Hughes CW: Significance of complications associ-
ated with vascular repairs in Vietnam. Arch Surg 100:646–651, 1970.
43. Tal R, Rabinovich Y, Zelmanovich L, et al: Preferential use of basilic vein
for surgical repair of popliteal aneurysms via the posterior approach.
J Vasc Surg 51:1043–1045, 2010.
44. Parmar CD, Kumar S, Torella F: Autologous basilic vein for in situ replace-
ment of infected prosthetic vascular grafts: initial experience. J Vasc Surg
17:158–160, 2009.
45. Varcoe RL, Chee W, Subramaniam P, et al: Arm vein as a last autologous
option for infrainguinal bypass surgery: is it worth the effort. Eur J Vasc
Endovasc Surg 33:737–741, 2007.
46. Rockwell WB, Haidenberg J, Foreman KB: Thumb reimplantation using
arterial conduit and dorsal vein transposition. Plast Reconstr Surg 122:
840–843, 2008.
47. Marques E: Ulnar artery thrombosis: hypothenar hammer syndrome.
J Amer Coll Surg 206:188–189, 2008.
48. Temming JF, van Ulchelen JH, Tellier MA: Hypothenar hammer syn-
drome: distal ulnar artery resection with autologous descending branch
of the lateral circumflex femoral artery. Tech Hand Up Extrem Surg
15:24–27, 2011.
49. Keen RR, Meyer JP, Eldrup-Jorgensen J, et al: Autogenous vein graft repair
of injured extremity arteries: early and late results with 134 consecutive
patients. J Vasc Surg 13:664–668, 1991.
50. Clouse WD, Rasmussen TE, Peck MA, et al: In-theater management of
vascular injury: 2 years of the Balad vascular registry. J Am Coll Surg
4:625–632, 2007.
51. Vertrees A, Fox CJ, Quan RW, et al: The use of prosthetic grafts in complex
military vascular trauma: a limb salvage strategy for patients with severely
limited autogenous conduit. J Trauma 66:980–983, 2009.
52. Feliciano DV, Mattox KL, Graham JM, et al: Five-year experience with
PTFE grafts in vascular wounds. J Trauma 25:71–82, 1985.
53. Cheek RC, Cole FH, Smith HF: Comparison of Dacron and aortic auto-
grafts in wounds contaminated with fecal matter. Ann Surg 40:439–442,
1974.
54. Knott LH, Crawford FA, Grogan JB: Comparison of autogenous vein,
Dacron, and Gore-tex in infected wounds. J Surg Res 24:288–293, 1978.
55. Teebken OE, Haverich A: Tissue engineering of small diameter vascular
grafts. Eur J Vasc Endovasc Surg 23:475–485, 2002.
56. Kakisis JD, Liapis CD, Breuer C, et al: Artificial blood vessels: the Holy
Grail of peripheral vascular surgery. J Vasc Surg 41:349–354, 2005.
57. Weinberg CB, Bell E: A blood vessel model constructed from collagen and
cultured vascular cell. Science 231:397–400, 1986.
58. Edelman ER: Vascular tissue engineering: designer arteries. Circ Res
85:1115–1117, 1999.
59. Fahner PJ, Idu MM, van Gulik TM, et al: Systematic review of preserva-
tion methods and clinical outcome of infrainguinal vascular allografts.
J Vasc Surg 44:518–524, 2006.
60. Martinez PG, Rodriguez M, Serrano N, et al: Patency and structural
changes in cryopreserved arterial grafts used as vessel substitutes in the
rat. J Surg Res 124:297–304, 2005.
61. Byrom MJ, Bannon PG, White GH, et al: Animal models for the assess-
ment of novel vascular conduits. J Vasc Surg 52:176–195, 2010.
62. Carrel A: Heterotransplantation of blood vessels preserved in cold storage.
J Exp Med 9:226–228, 1907.
Endovascular Management of
Acute Vascular Injury
SHERENE SHALHUB AND BENJAMIN STARNES
Introduction
Endovascular techniques have become essential for the suc-
cessful management of many elective and emergent vascular
surgical cases. Although diagnostic angiography has always
played a central role in the evaluation and management of
vascular trauma, interventions such as stent-grafting and coil
embolization are being used increasingly as treatment modali-
ties. The use of endovascular interventions increased in fre-
quency during the last decade as improved devices and
experience with catheter-based therapies continued to evolve.
In a review of the National Trauma Data Bank, Reuben et al
found an increase from 2% in 1994 to 8% in 2003 in the use
of endovascular interventions for vascular trauma.1 Com-
pared with traditional surgical repair, endovascular stent-
grafting for the repair of traumatic arterial injury offers the
advantage of decreased morbidity, because a remote access site
may be used, avoiding surgical dissection and lengthy operat-
ing times. Endovascular management of vascular trauma
seems particularly appealing in the setting of the multiply-
injured patient and in cases of injuries to the “watershed”
areas between the trunk and extremities where proximal vas-
cular control can be quite difficult. This chapter reviews
current literature with regard to the endovascular manage-
ment of extracranial carotid injury, blunt thoracic and
abdominal aortic injury, axillosubclavian injuries, and extrem-
ity vascular injury. The topic of use of aortic occlusion bal-
loons in trauma will be discussed as well.
Endovascular Management of
Carotid Arterial Injury
Injuries to the distal internal carotid, to the proximal common
carotid, and to the vertebral arteries are amenable to endovas-
cular adjuncts to arrest hemorrhage, exclude dissections or
pseudoaneurysms, or assist with open repair.2 In patients
with soft signs of a cervical vascular injury and with hemody-
namic stability, there is ample time for further evaluation.
Arteriography may identify an intimal flap, dissection, pseu-
doaneurysm, complete or partial transection, or thrombosis.
Penetrating injuries that require immediate operative inter-
vention are not typically amenable to a purely endovascular
approach, although adjunctive endovascular techniques may
be used to support the standard open repair of these injuries.
Endovascular therapy with bare-metal or covered stents have
been reserved primarily for evolving dissections that are sur­
gically inaccessible, for pseudoaneurysms that persist after
19 
antithrombotic treatment, or for patients with worsening neu-
rologic symptoms.3-6
Neck injuries management has been classically divided
according to three anatomic zones. Zone I injuries occur
below the cricoid cartilage. Those presenting with hard signs
of vascular injury may have an enlarging hematoma at the
thoracic inlet, high chest-tube output, or hemodynamic col-
lapse. These injuries notoriously involve the great vessels.
Immediate control involves a high anterior thoracotomy, a
sternotomy, or a clavicular resection to obtain adequate proxi-
mal control. An endovascular approach to injured neck arter-
ies is appealing in that some of these injuries can be remotely
approached from within the thoracic aorta thus avoiding the
morbidity of extensive surgical exposure. Once the patient is
prepared in the operative theater, an occlusion balloon can be
used from access in the femoral vessels to provide endolumi-
nal proximal control of the great vessels, which allows the
conducting of a surgical exposure in a more controlled fashion
and possibly avoiding sternotomy for proximal exposure.
With an occlusion balloon in place, an arteriogram can locate
the injury and can allow for operative planning. After the
injury is exposed, a vascular clamp can replace the occlusion
balloon; or, if proximal vessel length is not adequate, the
occlusion balloon could remain in place during repair. In cases
of blunt injury with a large mediastinal hematoma (Fig. 19-1),
the unique advantages for an endovascular approach include
avoidance of a general anesthetic and the ability to monitor
neurologic status during the intervention.
Zone II injuries have been classically managed with imme-
diate exploration and direct evaluation of the aerodigestive
tract and the carotid and jugular vessels. Direct examination
and determination of hard signs predict those patients with
significant injuries who might benefit from immediate
exploration.
Zone III injuries above the angle of the mandible at the
base of the skull are often difficult to expose and to control.
Many case reports have demonstrated decreased morbidity
and mortality for endovascular repair of traumatic injury to
large vessels in this region using covered stents or endovascu-
lar coiling of posttraumatic pseudoaneurysms.6-8
While there is not a comparative study of endovascular
repair versus open repair, there are several case series in the
literature reporting success with an endovascular approach.
Initial reports of this application relied on balloon expandable
Palmaz stents for pseudoaneurysms with and without dissec-
tions. Parodi and colleagues reported exclusion of 3 pseudoa-
neurysms with self-expandable covered stents, and 2 were
215
 19  /  Endovascular Management of Acute Vascular Injury 215.e1

ABSTRACT
Once seen as an exotic option, endovascular techniques for
stopping hemorrhage and for restoring perfusion in patients
with vascular trauma are increasingly commonplace in
the specialist setting. The principle methods are catheter-
directed coil embolization and stent-graft deployment;
either may be used in the acute phase or to treat estab-
lished fistulae and pseudoaneurysms. The principle benefits
relate to avoidance of excessive morbidity that may accom-
pany the extensive dissection required to control difficult-
to-reach vascular structures. Stent grafts may be used as
damage control or as definitive measures, with injuries to
the carotid artery, the axillosubclavian axis, and the tho-
racic aorta most amenable to this technique. In particular,
endovascular stent-graft repair appears to have a much
better short- and medium-term safety profile compared to
traditional open repair for blunt injury of the thoracic aorta,
although the life-time durability of stents remains to be
seen. In patients with severe hemorrhagic shock, endovas-
cular deployment of an aortic occlusive balloon avoids
the requirement for thoracotomy and aortic cross-clamp.
Areas for development in endovascular therapy for trauma
include improved stent design and durability suited to a
younger population, better characterization of the indica-
tions for endovascular intervention in different categories
of vessel trauma, the place and duration of antiplatelet
therapy, and improved follow-up of stent recipients.

Key Words:  abdominal aorta,

thoracic aorta,
pseudoaneurysm,
stent-graft,
axillary artery,
subclavian artery,
carotid artery,
vertebral artery,
femoral artery,
transection,
endovascular aortic occlusion balloon
216 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
B C
FIGURE 19-1  Zone I injury of the left common carotid artery in a male crushed between a backhoe and a rock crusher with associated medi-
astinal hematoma and rib fractures. A and B, Representative coronal and axial images showing the injury (white arrows). C, Magnetic resonance
angiography (MRA) performed for brain imaging and demonstration of the injury. D, Angiogram of the common carotid injury. E, Angiogram
post placement of a covered stent.
treated with an autogenous vein-covered Palmaz stent. A vein
graft theoretically reduces platelet aggregation and the poten-
tial for infection in grossly contaminated wounds.9 Covering
the injury site promotes thrombosis of the pseudoaneurysm;
but, if the sac fails to thrombose, one option is to coil-embolize
the sac through the interstices of the bare stent.10
Now that covered stents are commercially available in
smaller diameters, a majority of pseudoaneurysms can be
treated with self-expanding covered stents for both blunt and
penetrating trauma. Du Toit et al examined a series of 19 zone
I and zone III penetrating carotid injuries treated with stent-
grafts over a 10 year period. The technical success rate was
100% with 1 patient experiencing a stroke within 30 days of
the procedure. Of the 14 patients who had a mean follow-up
of 44 months, there were no stent-graft–related strokes or
deaths. Only one asymptomatic occlusion was detected on
follow-up.11 DuBose et al reviewed 31 studies that examined
stent placement for carotid artery injuries between 1994 and
2007. The postprocedural stroke rate for 113 patients was
3.5%, the occlusion rate was 10%, and the leak rate was 5%
for a follow-up period of 2 weeks to 2 years.12 Cox et al treated
10 pseudoaneurysms from military injuries in the carotid and
vertebral arteries with no neurological morbidity; however, 1
of the 2 stent-grafts occluded during follow-up.13 Cothren and
colleagues reported their 3- to 6-month follow-up analysis of
posttraumatic carotid pseudoaneurysms treated with carotid
stents.14 Patients with a persistent pseudoaneurysm 7 to 10
days after injury were considered candidates for stent therapy.
In the analysis, 23 patients were treated with Wallstents
(Boston Scientific, Natick, MA), and 3 of those patients (13%)
D E
experienced ischemic complications: 2 periprocedural and 1
attributed to medication noncompliance. Edwards and associ-
ates placed 22 carotid stents for BCVI: 18 patients had
pseudoaneurysms, and 4 patients were treated for extensive
dissections. There were no periprocedural complications.
Twelve patients in this series were treated with postprocedural
antiplatelet therapy, and eight received anticoagulation. With
a mean angiographic follow-up of 7 months, there were no
occlusions (100% patency).15
Follow-up is imperative in these patients as complications
of concern include thrombosis, clinical embolic events, and
stent fracture, though rarely reported.16-18 In a long-term
follow-up of patients who underwent stenting for carotid
artery dissection treated with uncovered stents, no patient
experienced radiographic thrombosis;, and ischemic symp-
toms did not develop.18 Compliance with medications and
follow-up surveillance should also be considered when plan-
ning appropriate therapy for trauma patients. Based on an
extrapolation of data from carotid artery stenting for athero-
sclerotic disease, a regimen of dual antiplatelet therapy (aspirin
and clopidogrel) appears adequate to prevent stent thrombo-
sis and embolic ischemic events.19
Liu and colleagues treated 7 patients with anticoagulation
for 8 weeks followed by long-term aspirin after stenting for
carotid dissection; and, at 14 months, no thrombosis or neu-
rologic events occurred.18 If antiplatelet therapy is discontin-
ued, stent thrombosis and resultant stroke are inherent risks.3
Duane and colleagues treated a patient with aspirin and clopi-
dogrel after placement of a Wallstent; and, secondary to cost,
the patient refused to comply with clopidogrel therapy. At
 19  /  Endovascular Management of Acute Vascular Injury 217

follow-up, the stent was thrombosed but the patient did not
experience neurologic sequelae.3 Anecdotally, most authors
recommend some form of antiplatelet regimen for at least 6
weeks following stent implantation in a carotid artery based
on carotid artery stenting for atherosclerotic disease.20,21
Additional prospective studies with long-term follow-up are
needed to determine the risks and efficacy of carotid stents
for BCI.

Endovascular Management of
Vertebral Artery Injury
Vertebral artery injury is rare, but the identification of verte-
bral artery injuries has increased owing to the liberal use of
screening tests and improved imaging during trauma workup.
There are no data to support routine stenting for blunt verte-
bral arteries injuries; however, endovascular treatment of the A
vertebral artery with a combination of embolization tech-
niques has been reported. This is usually in the setting of
uncontrollable hemorrhage, arteriovenous fistulas, and pseu-
doaneurysm formation, as well as in cases of symptomatic
patients who cannot tolerate anticoagulation.22,23
Vertebral artery injuries are most commonly due to pene-
trating trauma (Fig. 19-2). In a series of 101 patients with
traumatic vertebral artery injury only 6 patients were the
result of blunt trauma, while the remainder were secondary to
gunshot wounds and stab injuries.24 The series showed that
50% required postoperative angiography and embolization
for clinical arteriovenous fistulas and ongoing bleeding. In
50% of the cases undergoing angiography, the injured verte-
bral artery was thrombosed requiring no treatment, while
the remainder required embolization using a combination of
coils and detachable balloons. Several patients may require
a combined approach involving both open ligation and
B
endovascular embolization. In the cases of intact vessels, the
injury can be crossed from an antegrade approach, allowing FIGURE 19-2  Vertebral artery injury secondary to a stab wound at
embolization of both outflow and inflow (endovascular trap the base of the left neck. A, Aortic arch angiography demonstrates
embolization).22 initial contrast extravasation from the left vertebral artery, which origi-
nates from the aorta, and no flow into the distal vertebral artery.
Endovascular embolization appears to benefit those B, Successful embolization of the vertebral artery.
patients with injuries or low-flow arteriovenous fistulas within
the cervical portion of the vertebral artery. Vertebral artery
injuries within 2 cm of the origin or within a short distance grafts were originally designed for aneurysmal disease and in
of the posterior inferior cerebellar artery are poor endovascu- the early experience they were used in an off-label manner.
lar candidates. High-flow arteriovenous fistulas should also be The three endoprostheses approved by the FDA for the treat-
avoided because of the risk of coil migration beyond the ment of thoracic aortic aneurysms are the Gore Thoracic
lesion. Aortic Graft, approved in March 2005 (Gore & Associates,
Flagstaff, AZ); the Talent Thoracic Stent Graft, approved in
Endovascular Management of Blunt June 2008 (Medtronic, Minneapolis, MN); and the Zenith
TX-2, approved in May 2009 (Cook Inc, Bloomington, IN).
Thoracic Aortic Injury The only device currently approved by the Food and Drug
There has been a recent shift toward endovascular repair of Administration to treat BTAI is the Conformable GORE TAG
blunt descending thoracic aortic injury (BTAI). Multiple series Thoracic Endoprosthesis (Gore & Associates, Flagstaff, AZ),
with short- and midterm follow-up indicate that thoracic which was approved in November 2011.
endovascular aortic repair (TEVAR) is a viable alternative to The pitfalls of TEVAR for BTAI to date have been caused
open repair for traumatic aortic injuries, and several studies by use of devices not designed to address the specific needs of
have demonstrated reduced mortality and paraplegia rates the trauma population which differs from the population with
with endovascular repair of BTAI compared with open aneurysms. The devices fell short in terms of diameter size,
repair.25-29 Thus the most recent clinical practice guidelines compliance, and size of the delivery system, as the trauma
published by the Society for Vascular Surgery suggests that patients are younger with a mean age of 40 years and have
endovascular repair of traumatic thoracic aortic injuries be relatively smaller aortic diameters, have smaller radius of
performed preferentially over open surgical repair or nonop- aortic curvature or so called “Gothic” arches, and have smaller
erative management (Fig. 19-3).30 Available thoracic stent- caliber access vessels.
218 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
D
B C
FIGURE 19-3  Intraoperative arteriogram in LAO projection showing (A) before and (B) after stent-graft placement for a blunt thoracic aortic
injury. C, Three-dimensional (3-D) computed tomography (CT) reconstruction image of a patient who underwent the successful endovascular
repair for blunt aortic injury. D, The inset is an oblique view of the injury as seen on the diagnostic CT before the procedure.
An analysis of the angiographic morphology of 50 trau-
matic aortic disruptions showed that the mean aortic diam-
eter adjacent to the region of injury was approximately
19.3 mm, smaller than the smallest available endoprosthesis,
which measures 22 mm, but falling within the recommended
6% to 19% oversizing criteria. In addition, the mean distance
from the left subclavian artery was 5.8 mm, thus in most cases
the left subclavian artery was covered to achieve a 2-cm seal
zone.31 Due to the size limitations particularly in aortas with
a diameter less than 22 mm, off-label use of extension cuffs
from abdominal aortic endografts (e.g., Gore Excluder Aortic
Extender cuffs [Gore & Associates, Flagstaff, AZ]) and periph-
eral vascular stents (e.g., Zenith AAA iliac leg extensions
[Cook, Inc., Bloomington, IN]) have been used to treat BTAI.
Graft oversizing in the small aortas can lead to device com-
pression as shown in Figure 19-4.32 Graft collapse can also
occur due to lack of apposition of the proximal graft along the
inner curvature of the aortic arch seen in the cases of tight
Gothic arches leads to the “bird-beaking” phenomenon as
shown in Figure 19-5.33,34 The recent release of the Conform-
able GORE TAG Thoracic Endoprosthesis (Gore & Associates,
Flagstaff, AZ) device addresses the aortic size issue and allows
treatment of patients with aortic diameters of 16 mm to
42 mm.
The large and bulky delivery devices ranging between 18
Fr and 25 Fr also pose an access challenge in a younger patient
population with the small caliber iliofemoral vessels placing
them at an increased risk for iatrogenic injury.33 Iliofemoral
vessels that are smaller than 7 mm are associated with increased
risk of iatrogenic complications, and creation of an iliac or
aortic conduit may avoid potential iatrogenic injury.35
Left arm ischemia has been reported following coverage of
the left subclavian by the endograft when proximal landing
zone extension is required. When this complication is encoun-
tered, it can usually be remedied with a carotid subclavian
bypass. A recent study investigating the consequence of left
subclavian artery coverage identified 94 studies incorporating
1704 patients with thoracic aneurysms and demonstrated that
total left subclavian artery coverage without revascularization
increases the prevalence of left arm ischemia (4% versus 0%);
stroke (1.2% versus 0.23%); and the need for an additional
procedure (2.86% versus 0.86%). In contrast, there were no
reported cases of stroke, spinal cord ischemia, endoleak, stent
migration or mortality when the left subclavian artery origin
was only partially covered.36 There are ongoing investigations
regarding the use of fenestrated endografts for preserving left
subclavian artery during TEVAR for BTAI.37
Paraplegia resulting from compromise to the collateral
circulation of the spinal cord is reported in open repair of
traumatic aortic disruptions but has been conspicuously
absent in multiple metaanalyses where TEVAR for BTAI has
been studied.26-28
Repair Versus Observation
Repair is dictated by the type of injury. and the timing of
repair depends on the patient’s associated injuries. Intimal
tears (<10 mm) heal with nonoperative management.38-40 The
University of Washington clinical treatment guidelines for
blunt aortic injury are as follows:39
• All patients with radiographic evidence of blunt aortic
injury (BAI) should undergo antiimpulse therapy with
 19  /  Endovascular Management of Acute Vascular Injury 219
B diameter in the hyperdynamic aorta of the trauma patient
FIGURE 19-4  A and B, Endovascular stent-graft collapse 5 days fol-
lowing successful endovascular repair of a blunt thoracic aortic injury.
The long arrow shows the collapsed stent, and the short arrow shows
the persistent pseudoaneurysm.
b-blockade, if tolerated, coupled with antiplatelet therapy
(81 mg aspirin).
• Observation alone with interval follow-up computed
tomography angiography (CTA) within 30 days is appro-
priate for all intimal tears <10 mm.
• Selective management of large intimal flaps (>10 mm) is
appropriate with repeat imaging within 7 days to assess
for progression. Evidence of progression should be
managed, when possible, with endovascular repair.
• All patients with an aortic external contour abnormality
should be considered for semielective (<1 week) endo-
vascular repair if there is a high likelihood of survival
from other associated injuries. These patients should be
monitored with CT imaging as follows: 1 month, 6
months, 1 year, and every other year thereafter. Patients
with hypotension on presentation and with aortic arch
hematoma >15 mm should be repaired with endovascu-
lar methods on a more urgent basis.
• Intentional left subclavian artery coverage without revas-
cularization is well tolerated in a majority of patients
with BAI.
• Patients with traumatic brain injury and an aortic exter-
nal contour abnormality should be considered for earlier
repair if a deliberate increase in mean arterial pressure is
deemed beneficial for the patient.
A B C
FIGURE 19-5  A and B, Bird-beaking phenomenon results from the
lack of apposition of the proximal graft along the inner curvature of
the aortic arch seen in the case of a young trauma patient who was
treated with a stent-graft. C, This patient subsequently presented with
graft compression and required placement of a giant Palmaz stent
within the previously deployed graft for additional radial force support
and to improve graft apposition.
Intravascular ultrasound use at the time of repair offers a
useful adjunct to characterize the aorta proximal and distal to
the injury site as well as to accurately measure the aortic
(Fig. 19-6).41
The short and medium term results of TEVAR for BTAI are
encouraging, but the impact of aortic growth on graft anatomy
in the long term is not known. It has been shown that the
proximal thoracic aorta dilates minimally after endovascular
repair of BTAIs, with the segment just distal to the left subcla-
vian artery expanding at a slightly greater rate.42 The trauma
population tends to be young and is expected to live decades
following successful repair. The concern for graft migration as
aortic remodeling occurs with growth remains valid, and
adherence to a long-term follow-up protocol is imperative.
Endovascular Management of Blunt
Abdominal Aortic Injury
Blunt injuries to the abdominal aorta are relatively rare and
account for 5% of blunt aortic injuries. Since 1996, there have
been 79 reported cases of blunt abdominal aortic injury. This
injury affects males predominantly and is often seen in high-
speed motor-vehicle collisions, as well as in association with
major blunt intraabdominal injury and thoracolumbar frac-
tures.43 The majority of these injuries occur inferior to the
renal arteries. Abdominal aorta zones of injury are classified
based on possible surgical approaches (Fig. 19-7). The classi-
fication is as follows:
Zone I injuries occur from the diaphragmatic hiatus to the
superior mesenteric artery (SMA).
Zone II injuries include the SMA to the renal arteries.
Zone III injuries are inferior to the renal arteries to the
aortic bifurcation.
The type of blunt abdominal aortic injury can be classified
based on the presence or the absence of external aortic contour
220 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT

Diaphragmatic hiatus

SMA
Celiac artery
Zone I

Zone II

Right renal Left renal artery Zone III

artery
FIGURE 19-6  The use of intravascular ultrasound at the time of blunt IMA
thoracic aortic injury repair allows one to review the intraluminal
anatomy of the aorta and to size the graft appropriately in patients
with hyperdynamic aorta.
Aortic bifurcation

abnormality in similar fashion to the BTAI and is shown in

Figure 19-8.
Management is dependent on initial presentation and type
of aortic injury. In cases of intimal tears, many can be managed
nonoperatively similar to BTAI. On follow-up, most of these
resolve or decrease in size. Endovascular stent-graft placement FIGURE 19-7  Schematic drawing of the abdominal aorta zones of
injury as classified based on possible surgical approaches. IMA, Inferior
has been increasingly reported with over 50% of the reported mesenteric artery.
cases of large intimal flaps and 19% of the pseudoaneurysms
treated in this manner. Zones I and III are amenable to endo-
vascular interventions. These injuries are managed in a
manner similar to blunt injuries of the descending thoracic
aorta with open repair performed only when endovascular
intervention is not an option. Endovascular repair is preferred Aortic contour abnormality
particularly in the setting of the multiply-injured patient, in
cases associated with spillage from intestinal injuries and in No Yes
cases of recent laparotomy (Fig. 19-9).
The long-term durability of aortic endografts for trauma Intimal defect
has not been well described, but data is accumulating rapidly (dissection and/or Contained rupture
in the case of endovascular stenting for blunt thoracic aortic thrombus)
injury. Stent migration, owing to the fact that the initial <10 mm ≥10 mm Yes No
problem is acute trauma and not aneurysmal disease, is a
concern; but it would seem that the risk of progressive Large intimal Pseudoaneurysm Rupture/branch
Intimal tear
flap (LIF) (PSA) vessel avulson
aneurysm neck dilatation or graft migration should be very
low. Clearly long-term follow-up will be required in these FIGURE 19-8  Classification of blunt abdominal aortic injury based
cases. on presence of external aortic contour abnormality.
 19  /  Endovascular Management of Acute Vascular Injury 221
A C
FIGURE 19-9  Large intimal flap in a patient following a motor-vehicle crash. The patient presented with a transected duodenum and acute
limb ischemia of the left lower extremity. A and B, Preoperative CT scan. C, Intraoperative aortogram. D, Three-dimensional (3-D) reconstruc-
tion of the postoperative CT scan.
Endovascular Management of
Axillosubclavian Artery Injury
Injuries to the subclavian and axillary arteries are rare, pri-
marily due to the protective nature of the overlying bony and
muscular structures. When these injuries occur, they can
present with life-threatening hemorrhage, as well as associated
regional injuries and critical limb ischemia. Repair is techni-
cally challenging and associated with significant morbidity
and mortality for a variety of reasons. Exposure to obtain
proximal control requires either a median sternotomy for the
innominate and proximal right subclavian artery or a high
anterolateral thoracotomy with potential clavicular resection
for the proximal left subclavian artery. Endovascular arterial
repair has increased in popularity for the management of
these injuries, obviates the need for dissection at the base of
the neck, and can potentially reduce the potential for iatro-
genic nerve injury in the acute setting. In addition, endovas-
cular repair does not preclude stent explantation with formal
open repair once the injured patient has stabilized.
Multiple case series have described the use of covered stents
in the treatment of subclavian injuries due to iatrogenic,
blunt, and penetrating trauma with technical success rates of
between 94% and 100% and with procedure-related compli-
cation rates of 0% to 22%.44-49 In a retrospective examination
of axillosubclavian injuries, Danetz et al found that a similar
proportion of injuries are appropriate for endovascular tech-
niques. Excluding emergency room (ER) deaths, 17 of 40
(43%) penetrating injuries were potentially treatable. Approx-
imately one-third of the remaining injuries were deemed
D
unsuitable for endovascular management due to hemody-
namic instability, because endovascular interventions were
performed in interventional suites remote from the operating
room (OR).45 Carrick et al identified 15 patients with pene-
trating subclavian artery injuries between 2004 and 2005, of
which 4 of 10 (40%) survivors were managed successfully with
endovascular techniques (covered stents) in an interventional
suite separate from the operating room. In the study, 8 of 10
(80%) patients underwent angiography, and 2 of 10 (20%)
patients were taken directly to the OR secondary to hemody-
namic instability.48
Subclavian artery injuries can be approached from a
transfemoral, a transbrachial, or a combined technique with
a through–and-through brachiofemoral wire.50 Acute throm-
bosis in patients with malperfusion symptoms can be treated
through a retrograde brachial approach; and after flow is
restored, a covered stent can be used to treat the injury. These
are usually self-expanding stents which are oversized by 10%
to 20% of the diameter of the injured vessel to optimize appo-
sition. Most transected vessels can be crossed with a hydro-
philic wire (Fig. 19-10).
Endovascular techniques reduce the morbidity of operative
exposure and potential nerve injury in a blood-stained field.
Xenos and colleagues identified 27 such injuries between 1996
and 2002; 12 of those were deemed suitable for endovascular
treatment. Seven injuries were managed with a variety of
endovascular techniques, and these cases showed a significant
reduction in OR time and estimated blood loss when com-
pared with patients who underwent surgical repair.46 There are
relatively few contraindications to this approach. Some authors
222 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
FIGURE 19-10  Blunt injury of the subclavian artery treated by
covered stent placement via a transbrachial approach.
have advocated that the patient must be hemodynamically
stable while others consider a large supraclavicular hematoma
with brachial plexus compression a relative contraindica-
tion.45,46,48 In our experience we have found that neither is a
contraindication.49
Mobility and compression between the first rib and the
clavicle raise concern about long-term patency in the young
trauma population; it is imperative to follow these patients for
late sequelae. Xenos and colleagues reported 1-year patency
rates similar to open repair: 5 of 5 (100%) open repairs
remained patent; 1 of 7 (14.3%) of the covered stents occluded
with resultant arm claudication; and 2 of 7 (28.6%) (iatro-
genic injuries) died secondary to complications of primary
disease within 8 months.46 In another series by du Toit and
colleagues, 3 early stent thromboses were encountered in 56
patients.51 All 3 were opened with a secondary intervention,
and no patient experienced upper extremity ischemia.
Endovascular Management of
Extremity Vascular Injury
Repair of traumatic lesions using endovascular techniques has
had limited application in the extremities as the acutely
injured patient with hard signs of a peripheral vascular injury
can usually be controlled with direct tamponade or with a
tourniquet. Despite this, the endovascular approach has
A B
FIGURE 19-11  An occlusion balloon used to obtain proximal control
of the distal external iliac artery in a case of an infected femoral artery
pseudoaneurysm due to drug injection. A, Access from the contralat-
eral femoral artery. B, Occlusion balloon inflation in the proximal
common femoral artery.
included diagnostic angiograms, embolization, stent place-
ment, and balloon occlusion for proximal control.
Remote endoluminal occlusion can be advantageous for a
high brachial artery injury or common femoral artery injury
that is associated with an extensive hematoma or an acute
grossly infected cavitary wound. It may also avoid an incision
through a scar that would have potential healing complica-
tions, dissection near the brachial plexus, or dissection in the
groin underneath the inguinal ligament (Fig. 19-11).
In the upper extremity, Lonn and colleagues treated 2 blunt
brachial artery injuries that presented with thrombosis and
signs of distal ischemia. Both patients were found to have
intimal disruptions with thrombosis, and were treated with
angioplasty without stents. Patency was achieved at follow-up
without complications.52 Maynar and colleagues repaired a
single partially transected and separate completely transected
brachial artery with covered stent-grafts in 2 trauma patients.
One patient experienced graft thrombosis in the early periop-
erative period requiring emergent angiographic examination.
The proximal landing zone was treated with angioplasty and
a second covered stent. This patient did not experience adverse
sequelae, and the stent remained patent at follow-up.53 The
utility of endovascular adjuncts for the radial and ulnar
branches of the upper extremity are limited to endovascular
embolization for transections, pseudoaneurysms, or arterio-
venous fistulas.
Traumatic lesions in the femoral artery can be covered with
stents. Marin and colleagues treated a penetrating injury to
the superficial femoral artery with a covered stent which
achieved luminal continuity and exclusion of the associated
pseudoaneurysm.54 Parodi and colleagues successfully utilized
covered stents in the common and superficial femoral artery
for penetrating trauma.55 The use of covered stents in the
popliteal artery have also been reported,56-58 though stents
have been routinely avoided in this location due to the inabil-
ity of a rigid stent to accommodate flexion around the joint.59,60
Newer generations of stent-grafts promise more flexibility and
could potentially serve as a damage control tool.
Iatrogenic injuries secondary to attempted femoral
access account for the majority of pseudoaneurysms and
 19  /  Endovascular Management of Acute Vascular Injury 223
Common
hepatic artery
FIGURE 19-12  Aortic occlusion balloon placed
in the supraceliac aorta of a hemodynamically
unstable patient with blunt abdominal aortic
injury at the level of the renal arteries. SMA, Supe-
rior mesenteric artery.
arteriovenous fistulas that are managed with endovascular
techniques. After ultrasound-guided compression and throm-
bin injection have failed to thrombose pseudoaneurysms,
covered stents can be successfully used to exclude pseudoan-
eurysms from circulation. A case series by Thalhammer and
colleagues describes the use of covered stents to repair iatro-
genic pseudoaneurysms and arteriovenous fistulas in the
superficial femoral and deep femoral arteries. Stent thrombo-
sis was reported to be 17%.61 Iatrogenic vascular injuries sec-
ondary to orthopedic procedures have also been successfully
managed with endovascular techniques.62
Aortic Occlusion Balloons for
Penetrating Trauma and
Blunt Trauma
Remote occlusion of the aorta was first described by Dr. Carl
Hughes, who used a Foley catheter to control traumatic hem-
orrhage during the Korean War.63 The use of transfemoral
intraaortic occlusion balloon (IAOB) for control of massive
hemorrhage has been well described in patients with ruptured
abdominal aortic aneurysms64,65 IAOBs provide relative hemo-
dynamic stability and control hemorrhage before decompres-
sion of the abdomen and cause less trauma to the aortic wall
than the application of an aortic clamp.66 Animal models have
shown this technique to be physiologically similar to aortic
cross-clamping.67
Proximal aortic control in cases of trauma has traditionally
been obtained via anterolateral thoracotomy and aortic cross-
clamping above the diaphragm, though outcomes historically
have been poor.68 Use of a transfemoral IAOB at the level of
Supraceliac aorta
Aortic occlusion balloon
Celiac
trunk
Splenic
a.
Right
renal a. SMA
Left
renal a.
the diaphragm may prove to be helpful in cases of trauma
requiring a resuscitative thoracotomy for aortic cross-clamping
to provide rapid proximal control of hemorrhage and improve
the hemodynamic status before inducing anesthesia or enter-
ing the abdomen (Fig. 19-12). The use of IAOB in trauma has
been described in blunt-trauma cases,69 in cases of pelvic frac-
tures with hemorrhagic shock,70,71 in blunt trauma cases,72,73
in penetrating trauma cases,74,75 and in cases of iliac artery
injuries.76
While further evaluation of this technique is warranted,
IAOB may offer improved outcomes for the severely injured
trauma patients, while simultaneously reducing the morbidity
associated with thoracotomy.77
Long-Term Follow-Up
Follow-up for all trauma patient interventions is notoriously
poor. Most studies are retrospective with short follow-up
periods by traditional surveillance standards. Diligent surveil-
lance, including duplex studies and ensuring continued anti-
platelet therapy for prescribed periods is required to maximize
durability for endovascular interventions in the trauma
population.
REFERENCES
1. Reuben BC, Whitten MG, Sarfati M, et al: Increasing use of endovascular
therapy in acute arterial injuries: analysis of the National Trauma Data
Bank. J Vasc Surg 46:1222–1226, 2007.
2. Moulakakis KG, Mylonas S, Avgerinos E, et al: An update of the role of
endovascular repair in blunt carotid artery trauma. Eur J Vasc Endovasc
Surg 40:312–319, 2010.
3. Duane TM, Parker F, Stokes GK, et al: Endovascular carotid stenting after
trauma. J Trauma 52:149–153, 2002.
224 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
4. Coldwell DM, Novak Z, Ryu RK, et al: Treatment of posttraumatic inter-
nal carotid arterial pseudoaneurysms with endovascular stents. J Trauma
48:470–472, 2000.
5. Ellis PK, Kennedy PT, Barros D’Sa AA: Successful exclusion of a high
internal carotid pseudoaneurysm using the Wallgraft endoprosthesis.
Cardiovasc Intervent Radiol 25:68–69, 2002.
6. Bejjani GK, Monsein LH, Laird JR, et al: Treatment of symptomatic cervi-
cal carotid dissections with endovascular stents. Neurosurgery 44:755–
760, 1999.
7. McNeil JD, Chiou AC, Gunlock MG, et al: Successful endovascular
therapy of a penetrating zone III internal carotid injury. J Vasc Surg 36:
187–190, 2002.
8. Ray MJ, Shaw CJ, Opatowsky MJ, et al: Emergent surgical and endovas-
cular repair of a Level III carotid arterial gunshot injury. Proc (Bayl Univ
Med Cent) 24:101–103, 2011.
9. Parodi JC, Schonholz C, Ferreira LM, et al: Endovascular stent-graft treat-
ment of traumatic arterial lesions. Ann Vasc Surg 13:121–129, 1999.
10. Horowitz MB, Miller G, III, Meyer Y, et al: Use of intravascular stents in
the treatment of internal carotid and extracranial vertebral artery pseu-
doaneurysms. AJNR Am J Neuroradiol 17:693–696, 1996.
11. du Toit DF, Coolen D, Lambrechts A, et al: The endovascular manage-
ment of penetrating carotid artery injuries: long-term follow-up. Eur J
Vasc Endovasc Surg 38:267–272, 2009.
12. DuBose J, Recinos G, Teixeira PG, et al: Endovascular stenting for the
treatment of traumatic internal carotid injuries: expanding experience.
J Trauma 65:1561–1566, 2008.
13. Cox MW, Whittaker DR, Martinez C, et al: Traumatic pseudoaneurysms
of the head and neck: early endovascular intervention. J Vasc Surg 46:
1227–1233, 2007.
14. Cothren CC, Moore EE, Ray CE, Jr, et al: Carotid artery stents for blunt
cerebrovascular injury: risks exceed benefits. Arch Surg 140:480–485,
2005.
15. Edwards NM, Fabian TC, Claridge JA, et al: Antithrombotic therapy and
endovascular stents are effective treatment for blunt carotid injuries:
results from longterm followup. J Am Coll Surg 204:1007–1013, 2007.
16. McCready RA, Divelbiss JL, Bryant MA, et al: Endoluminal repair of
carotid artery pseudoaneurysms: a word of caution. J Vasc Surg 40:1020–
1023, 2004.
17. de Vries JP, Meijer RW, van den Berg JC, et al: Stent fracture after endo-
luminal repair of a carotid artery pseudoaneurysm. J Endovasc Ther 12:
612–615, 2005.
18. Liu AY, Paulsen RD, Marcellus ML, et al: Long-term outcomes after
carotid stent placement treatment of carotid artery dissection. Neurosur-
gery 45:1368–1373, 1999.
19. Bhatt DL, Kapadia SR, Bajzer CT, et al: Dual antiplatelet therapy with
clopidogrel and aspirin after carotid artery stenting. J Invasive Cardiol
13:767–771, 2001.
20. Starnes BW, Arthurs ZM: Endovascular management of vascular trauma.
Perspect Vasc Surg Endovasc Ther 18:114–129, 2006.
21. Bhatt DL, Kapadia SR, Bajzer CT, et al: Dual antiplatelet therapy with
clopidogrel and aspirin after carotid artery stenting. J Invasive Cardiol
13:767–771, 2001.
22. Cohen JE, Rajz G, Itshayek E, et al: Endovascular management of exsan-
guinating vertebral artery transection. Surg Neurol 64:331–334, 2005.
23. Atar E, Griton I, Bachar GN, et al: Embolization of transected vertebral
arteries in unstable trauma patients. Emerg Radiol 11:291–294, 2005.
24. Mwipatayi BP, Jeffery P, Beningfield SJ, et al: Management of extra-cranial
vertebral artery injuries. Eur J Vasc Endovasc Surg 27:157–162, 2004.
25. Demetriades D, Velmahos GC, Scalea TM, et al: Operative repair or endo-
vascular stent graft in blunt traumatic thoracic aortic injuries: results of
an American Association for the Surgery of Trauma Multicenter Study.
J Trauma 64:561–570, 2008.
26. Tang GL, Tehrani HY, Usman A, et al: Reduced mortality, paraplegia, and
stroke with stent graft repair of blunt aortic transections: a modern meta-
analysis. J Vasc Surg 47:671–675, 2008.
27. Takagi H, Kawai N, Umemoto T: A meta-analysis of comparative studies
of endovascular versus open repair for blunt thoracic aortic injury.
J Thorac Cardiovasc Surg 135:1392–1394, 2008.
28. Hoffer EK, Forauer AR, Silas AM, et al: Endovascular stent-graft or open
surgical repair for blunt thoracic aortic trauma: systematic review. J Vasc
Interv Radiol 19:1153–1164, 2008.
29. Hong MS, Feezor RJ, Lee WA, et al: The advent of thoracic endovascular
aortic repair is associated with broadened treatment eligibility and
decreased overall mortality in traumatic thoracic aortic injury. J Vasc Surg
53:36–42, 2011.
30. Lee WA, Matsumura JS, Mitchell RS, et al: Endovascular repair of trau-
matic thoracic aortic injury: clinical practice guidelines of the Society for
Vascular Surgery. J Vasc Surg 53:187–192, 2011.
31. Borsa JJ, Hoffer EK, Karmy-Jones R, et al: Angiographic description of
blunt traumatic injuries to the thoracic aorta with specific relevance to
endograft repair. J Endovasc Ther 9(Suppl 2):II84–II91, 2002.
32. Muhs BE, Balm R, White GH, et al: Anatomic factors associated with
acute endograft collapse after Gore TAG treatment of thoracic aortic dis-
section or traumatic rupture. J Vasc Surg 45:655–661, 2007.
33. Plummer D, Petro K, Akbari C, et al: Endovascular repair of traumatic
thoracic aortic disruption. Perspect Vasc Surg Endovasc Ther 18:132–139,
2006.
34. Annamalai G, Cook R, Martin M: Endograft collapse following endovas-
cular repair of traumatic aortic injury. Diagn Interv Radiol 17:84–87,
2011.
35. Lin PH, Bush RL, Zhou W, et al: Endovascular treatment of traumatic
thoracic aortic injury–should this be the new standard of treatment?
J Vasc Surg 43(Suppl A):22A–29A, 2006.
36. Sepehripour AH, Ahmed K, Vecht JA, et al: Management of the left sub-
clavian artery during endovascular stent grafting for traumatic aortic
injury—a systematic review. Eur J Vasc Endovasc Surg 41:758–769, 2011.
37. Gilani R, Ochoa L, Wall MJ, Jr, et al: Endovascular repair of traumatic
aortic injury using a custom fenestrated endograft to preserve the left
subclavian artery. Vasc Endovascular Surg 45:549–552, 2011.
38. Aladham F, Sundaram B, Williams DM, et al: Traumatic aortic injury:
computerized tomographic findings at presentation and after conserva-
tive therapy. J Comput Assist Tomogr 34:388–394, 2010.
39. Starnes BW, Lundgren RS, Gunn M, et al: A new classification scheme for
treating blunt aortic injury. J Vasc Surg 55:47–54, 2012.
40. Azizzadeh A, Keyhani K, Miller CC, III, et al: Blunt traumatic aortic
injury: initial experience with endovascular repair. J Vasc Surg 49:1403–
1408, 2009.
41. Azizzadeh A, Valdes J, Miller CC, III, et al: The utility of intravascular
ultrasound compared to angiography in the diagnosis of blunt traumatic
aortic injury. J Vasc Surg 53:608–614, 2011.
42. Forbes TL, Harris JR, Lawlor DK, et al: Aortic dilatation after endovascu-
lar repair of blunt traumatic thoracic aortic injuries. J Vasc Surg 52:45–48,
2010.
43. Shalhub S, Starnes BW, Tran NT, et al: A single institution’s experience
with blunt abdominal aortic injury and a contemporary review of the
literature. J Vasc Surg 2012.
44. White R, Krajcer Z, Johnson M, et al: Results of a multicenter trial for the
treatment of traumatic vascular injury with a covered stent. J Trauma
60:1189–1195, 2006.
45. Danetz JS, Cassano AD, Stoner MC, et al: Feasibility of endovascular
repair in penetrating axillosubclavian injuries: a retrospective review.
J Vasc Surg 41:246–254, 2005.
46. Xenos ES, Freeman M, Stevens S, et al: Covered stents for injuries of
subclavian and axillary arteries. J Vasc Surg 38:451–454, 2003.
47. Castelli P, Caronno R, Piffaretti G, et al: Endovascular repair of traumatic
injuries of the subclavian and axillary arteries. Injury 36:778–782, 2005.
48. Carrick MM, Morrison CA, Pham HQ, et al: Modern management of
traumatic subclavian artery injuries: a single institution’s experience in
the evolution of endovascular repair. Am J Surg 2009.
49. Shalhub S, Starnes BW, Hatsukami TS, et al: Repair of blunt thoracic
outlet arterial injuries: an evolution from open to endovascular approach.
J Trauma 71:E114–E121, 2011.
50. Shalhub S, Starnes BW, Tran NT: Endovascular treatment of axillosubcla-
vian arterial transection in patients with blunt traumatic injury. J Vasc
Surg 53:1141–1144, 2011.
51. du Toit DF, Lambrechts AV, Stark H, et al: Long-term results of stent graft
treatment of subclavian artery injuries: management of choice for stable
patients? J Vasc Surg 47:739–743, 2008.
52. Lonn L, Delle M, Karlstrom L, et al: Should blunt arterial trauma to the
extremities be treated with endovascular techniques? J Trauma 59:1224–
1227, 2005.
53. Maynar M, Baro M, Qian Z, et al: Endovascular repair of brachial artery
transection associated with trauma. J Trauma 56:1336–1341, 2004.
54. Marin ML, Veith FJ, Panetta TF, et al: Percutaneous transfemoral inser-
tion of a stented graft to repair a traumatic femoral arteriovenous fistula.
J Vasc Surg 18:299–302, 1993.
55. Parodi JC, Schonholz C, Ferreira LM, et al: Endovascular stent-graft treat-
ment of traumatic arterial lesions. Ann Vasc Surg 13:121–129, 1999.
56. Marin ML, Veith FJ, Panetta TF, et al: Transfemoral endoluminal stented
graft repair of a popliteal artery aneurysm. J Vasc Surg 19:754–757, 1994.
 19  /  Endovascular Management of Acute Vascular Injury 225
57. Parodi JC, Schonholz C, Ferreira LM, et al: Endovascular stent-graft treat-
ment of traumatic arterial lesions. Ann Vasc Surg 13:121–129, 1999.
58. Hussein EA, Al-Kreedees A, Saad A, et al: Endovascular graft bail-out post
reconstruction of popliteal artery injury. First case report. Int Angiol 29:
565–569, 2010.
59. Arena FJ: Arterial kink and damage in normal segments of the superficial
femoral and popliteal arteries abutting nitinol stents—a common cause
of late occlusion and restenosis? A single-center experience. J Invasive
Cardiol 17:482–486, 2005.
60. Hutto JD, Reed AB: Endovascular repair of an acute blunt popliteal artery
injury. J Vasc Surg 45:188–190, 2007.
61. Thalhammer C, Kirchherr AS, Uhlich F, et al: Postcatheterization
pseudoaneurysms and arteriovenous fistulas: repair with percutaneous
implantation of endovascular covered stents. Radiology 214:127–131,
2000.
62. Kickuth R, Anderson S, Kocovic L, et al: Endovascular treatment of arte-
rial injury as an uncommon complication after orthopedic surgery. J Vasc
Interv Radiol 17:791–799, 2006.
63. Hughes CW: Use of an intra-aortic balloon catheter tamponade for con-
trolling intra-abdominal hemorrhage in man. Surgery 36:65–68, 1954.
64. Arthurs ZM, Sohn VY, Starnes BW: Ruptured abdominal aortic aneu-
rysms: remote aortic occlusion for the general surgeon. Surg Clin North
Am 87:1035–1045, viii, 2007.
65. Assar AN, Zarins CK: Endovascular proximal control of ruptured abdom-
inal aortic aneurysms: the internal aortic clamp. J Cardiovasc Surg
(Torino) 50:381–385, 2009.
66. Ozalp B, Canbaz S, Huseyinova G, et al: Histopathological comparison of
vascular wall damage created by external cross-clamp and endoluminal
balloon occlusion techniques. J Cardiovasc Surg (Torino) 50:545–553,
2009.
67. Belczak S, Silva ES, Aun R, et al: Endovascular treatment of peripheral
arterial injury with covered stents: an experimental study in pigs. Clinics
(Sao Paulo) 66:1425–1430, 2011.
68. Karmy-Jones R, Jurkovich GJ: Blunt chest trauma. Curr Probl Surg 41:
211–380, 2004.
69. Soen M, Nishihara I, Fukuda M, et al: Evaluation of 38 cases of employing
aortic occlusion balloon catheter. Masui 54:265–269, 2005.
70. Martinelli T, Thony F, Declety P, et al: Intra-aortic balloon occlusion to
salvage patients with life-threatening hemorrhagic shocks from pelvic
fractures. J Trauma 68:942–948, 2010.
71. Linsenmaier U, Kanz KG, Rieger J, et al: CT-guided aortic balloon occlu-
sion in traumatic abdominal and pelvic bleeding. Rofo 175:1259–1263,
2003.
72. Segol P, Salame E, Auvray S, et al: Major liver injury. Role of preoperative
transcutaneous endoluminal aortic clamping. Presse Med 24:29–30, 1995.
73. Low RB, Longmore W, Rubinstein R, et al: Preliminary report on the use
of the Percluder® occluding aortic balloon in human beings. Ann Emerg
Med 15:1466–1469, 1986.
74. Wolf RK, Berry RE: Transaxillary intra-aortic balloon tamponade in
trauma. J Vasc Surg 4:95–97, 1986.
75. Gupta BK, Khaneja SC, Flores L, et al: The role of intra-aortic balloon
occlusion in penetrating abdominal trauma. J Trauma 29:861–865, 1989.
76. Nam TK, Park SW, Shim HJ, et al: Endovascular treatment for common
iliac artery injury complicating lumbar disc surgery: limited usefulness
of temporary balloon occlusion. J Korean Neurosurg Soc 46:261–264,
2009.
77. Avaro JP, Mardelle V, Roch A, et al: Forty-minute endovascular aortic
occlusion increases survival in an experimental model of uncontrolled
hemorrhagic shock caused by abdominal trauma. J Trauma 71:720–726,
2011.
20  Pediatric Vascular Injury
JEREMY W. CANNON, CAROLE Y. VILLAMARIA, AND MICHAEL A. PECK
Introduction
In the United States, pediatric trauma remains the leading
cause of death among children over 1 year of age; and vascu-
lar injuries constitute a small but important subset of this.
Although injury-prevention measures such as increased use
of seat belts and child-safety seats have effectively reduced the
death rate from unintentional injury in children, modern
series indicate that vascular injuries still occur in 0.6% to 1%
of pediatric trauma patients1,2 which is comparable to the
demographics of this problem decades ago.2,3 Iatrogenic inju-
ries represent a significant proportion of the pediatric vascu-
lar trauma managed in specialty centers across the United
States because of an increase in percutaneous vascular access
procedures in children. Furthermore, current warfare has
resulted in noncombatant injuries, many of which occur in
children.4,5 These injuries frequently have a vascular-injury
component.
The management of these injuries remains largely non-
standardized in the current literature owing to several factors.
First, these patients are cared for by a wide range of subspe-
cialists, including pediatric surgeons, adult vascular surgeons,
trauma surgeons, orthopedic surgeons, and plastic surgeons,
who each bring a unique perspective and management phi-
losophy to the patient’s care. Furthermore, as children age,
their vascular biology evolves significantly, which bears con-
sideration when faced with a pediatric vascular injury (Table
20-1). Neonates and young children have smaller circulating
blood volumes and proportionately smaller arteries that are
highly prone to vasospasm, while the need for future growth
of blood vessels and limbs and the long-term durability of
vascular repairs must be considered. Thus, while older chil-
dren are likely to have the best outcomes when managed simi-
larly to adults with vascular injury, younger patients may
require different approaches; however, defining an appropri-
ate age cutoff and the nature of these differences has proven
elusive. Finally, definitive arterial reconstruction has not
always been viewed as the preferred management approach.
Instead, injured vessels were historically ligated, or the child
was given systemic heparin without repair. This expectant
therapy often resulted in poor limb outcomes with loss of
axial growth from thrombosis, limb overgrowth from arterio-
venous fistula formation, or even amputation from critical
limb ischemia. A more aggressive approach is now advocated
by some surgeons as this approach may result in better
outcomes in the management of extremity vascular injuries.
This lends support to making an early diagnosis and to per-
forming definitive repair as a viable management strategy.1
226
This chapter is structured to address the multiple components
of pediatric vascular injury from iatrogenic, penetrating, and
blunt-traumatic etiologies. Herein, we will examine the scope
of the problem, invasive and noninvasive diagnostic modali-
ties, nonoperative management options, and open and endo-
vascular treatments. We will also address limitations in current
knowledge about these various options.
Demographics and Etiology
Iatrogenic trauma to both the peripheral and central vessels
of children represents a significant proportion of the world-
wide experience with pediatric vascular injuries. Diagnostic
catheterization, cannulation for extracorporeal life support
(ECLS) or cardiopulmonary bypass, placement of arterial
lines (ranging from umbilical arterial catheters to radial arte-
rial lines), arterial puncture for blood gas analysis, and veni-
puncture have all resulted in significant vascular trauma in
children. Multiple centers have reported their individual expe-
rience in the form of small case series6 with only one retro-
spective case-control study on this subject. From these reports,
iatrogenic injuries resulting from diagnostic and therapeutic
catheterization, placement of vascular access catheters, and
indwelling vascular catheters represents from 33%7 to 100%8
of an institution’s experience with pediatric vascular trauma;
and, due to the nature of these procedures, all resulting vas-
cular injuries are penetrating in nature.
Approximately half of pediatric vascular injuries across all
ages are iatrogenic although the proportion of iatrogenic inju-
ries varies inversely with patient age such that neonates have
the highest percentage which then declines in the 2- to 6-year
age range (50% iatrogenic) followed by those over 6 (33%
iatrogenic). Vascular complication rates vary widely from 2%
to 45% depending on the type of catheter-based procedures
considered.9 Catheter-based cardiovascular interventions such
as balloon angioplasty of aortic stenosis or coarctation have
the highest rates of iatrogenic pediatric vascular injury. Even
with heparinization and use of appropriately sized catheters,
the thrombosis rate ranges from 1% to 25%.
The relative incidence of vascular injury due to trauma
increases with the age of the child. Two-thirds of injuries are
noniatrogenic in children over 6 years of age. Of these, between
half and three-fourths are due to a penetrating mechanism—
knives, glass, gunshot wounds and, in wartime settings, im-
provised explosive devices (IED) and high-energy gunshot
wounds.2,3 Blunt vascular injuries (BVI) resulting from long
bone fractures and knee dislocation, as well as great vessel and
aortic injuries from seatbelt and deceleration injuries, are well
 20  /  Pediatric Vascular Injury 226.e1

ABSTRACT
Vascular injuries in children are relatively rare but poten-
tially devastating. Most reported pediatric vascular injuries
are iatrogenic, although larger series of noniatrogenic and
combat-related pediatric vascular trauma have appeared
more recently. The small caliber of the pediatric vascular
tree complicates the diagnosis and management of vascu-
lar injuries in this population. Differentiating a true injury
from vasospasm can be challenging as diagnostic studies
including arteriography carry risks of vascular injury, con-
trast exposure, and radiation exposure. On the other hand,
a delayed or missed diagnosis can result in vascular throm-
bosis leading to limb-length discrepancies or even to
amputation. The biology of pediatric vessels has not been
well studied from a basic science standpoint, and the clini-
cal literature in this area consists almost entirely of case
series that offer the pediatric and adult surgical subspecial-
ists involved in the management of these challenging inju-
ries little insight into their natural history, the appropriate
diagnostic workup, and the optimal management of a par-
ticular injury. Nonetheless, recent advances in medications,
operative techniques, and equipment have increased the
management options for vascular injuries in young patients.
In this chapter, we review both iatrogenic and traumatic
vascular injuries in children and describe the traditional
approaches of observation, ligation, or heparinization
along with the current trend toward surgical exploration
with repair of vascular injuries using open and endovascular
approaches. The need for both basic and clinical research
in this area is also discussed to encourage future multiinsti-
tutional research collaborations aimed at better definition
of the optimal approach to this difficult problem.

Key Words:  pediatric vascular injury,

iatrogenic vascular injury,
vascular trauma,
blunt vascular injury,
blast injury,
fragmentation injury,
interposition graft,
endovascular stent-graft,
limb salvage,
truncal vascular injury

described in pediatric patients but are far less common than
penetrating injuries.
Pediatric truncal vascular trauma is encountered less often
than extremity trauma; however, these injuries are highly
lethal with mortality rates in excess of 50%.10,11 This injury
grouping includes thoracic, abdominal and cervical vascular
wounds due to either a penetrating or blunt mechanism.
Concomitant major injuries are common, particularly with
abdominal vascular injuries, as the wounding mechanism is
frequently of a high-energy nature. The distribution of vascu-
lar injuries in the abdomen is divided among renal, mesen-
teric, iliac, and aortic injuries, which are commonly associated
with other organ injuries. Blunt and penetrating cerebrovas-
cular injuries are also well described in the pediatric popula-
tion. Immediate exploration is indicated for hemodynamically
Table 20-1 Unique Features of Pediatric
Vascular Injury
Special Pediatric Considerations
Etiology More often from iatrogenic injuries
Anatomy/ Small-caliber vessels, which are more prone
Physiology to vasospasm. Supracondylar humeral
fractures can result in brachial artery
injuries.
Diagnosis If pulses are diminished without hard signs
of injury, resuscitate, rewarm, and then
recheck the pulses. Normal IEI/ABI in
children 2 years and younger is 0.88.
Normal IEI/ABI in children over 2 years is 1.
CTA is adequate for large vessels.
Operative Use interrupted, nonabsorbable monofilament
management suture. Spatulate the anastomosis.
ABI, Ankle-brachial index; IEI, injured extremity index.
Head/neck/face
15 (9)
Thoracic
12 (7)
Abdomen/pelvis
28 (17)
FIGURE 20-1  Distribution of 161 pediatric
vascular injuries managed during Operation
Iraqi Freedom (OIF) and Operation Enduring
Freedom (OEF). Numbers are n (%). (Data cour-
tesy Todd E. Rasmussen, San Antonio, TX.)
20  /  Pediatric Vascular Injury 227
unstable patients with penetrating cervical trauma, whereas a
noninvasive workup should be performed in all others. CT
angiography (CTA) is usually adequate for initial evaluation
of the cervical vessels, while catheter angiography is rarely
indicated.10 Outcome, as well as the need for surgical interven-
tion, is largely dependent on the hemodynamic and physio-
logic condition of the patient. The presence of a major venous
injury in the torso (e.g., vena cava, large visceral vein, high-
grade solid organ injury with venous disruption) is associated
with the poorest outcome. This association holds true whether
the torso venous injury is isolated or is part of a constellation
of injuries.
Modern warfare commonly occurs in proximity to civilian
populations, resulting in injuries of the local population
including children.5 Contemporary war studies focus on
adults, and there is a paucity of data reporting on vascular
injuries of pediatric populations. The few series that do exist
on wartime injury of the local pediatric population suggest
that vascular injury in children is a subset encountered,5,12
although more detailed information on the distribution of
these injuries is emerging (Fig. 20-1). When compared to civil-
ian vascular injuries, wartime pediatric vascular injuries are
much more often from a penetrating mechanism. In addition,
wartime vascular injuries have a blast component from impro-
vised explosive devices and high-velocity gunshot wounds.
The blast component further injures blood vessels and sur-
rounding tissue and makes repair complex. Simple suture
repairs and patch angioplasty are replaced by interposition
bypass and complex tissue coverage procedures. Despite the
challenges noted here, in our wartime experience in Iraq and
Afghanistan, the limb-salvage rate in these children is 90%
(Todd E. Rasmussen, San Antonio, TX, personal communica-
tion, Oct. 1, 2011), which is comparable to the limb-salvage
rate reported by U.S. trauma centers in modern series.6
Upper extremity
46 (29)
Lower extremity
60 (37)
228 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
Anatomic and Physiologic
Considerations
Numerous anatomic factors contribute to the high rates of
iatrogenic vascular injury seen in children. Pediatric vascular
access involves cannulation of small vessels in a very compact
anatomic space with relatively large catheters. Ultrasound
studies have shown that as many as 12% of femoral vessels in
children ages 0 to 9 are either partially or completely overlap-
ping.13 Thus, attempts at venous access can easily result in
inadvertent arterial punctures, especially if done without
ultrasound guidance. The use of larger-sized arterial catheters
also predisposes the child to vasospasm, resulting in potential
limb ischemia. Historic studies have suggested that catheters
with a diameter of >50% of the arterial diameter or with a
clearance of less than 1.9 mm around the catheter more often
resulted in femoral arterial spasm.
Physiologic factors in children who sustain vascular injury
from a traumatic or iatrogenic mechanism predispose injured
vessels to occlusion. Pediatric vessels are smaller in caliber and
are observed to be more reactive than adult vessels although
the exact etiology of vasospasm of the developing peripheral
vasculature remains poorly understood. However, seemingly
spontaneous neonatal thrombosis and severe persistent vaso-
spasm (lasting hours) does occur. In addition, polycythemia
and relatively low–intravascular-volume states exist and can
contribute to thrombosis. Lastly, children undergoing invasive
vascular procedures often have poor cardiac function at base-
line with relatively low flow to distal tissue beds, which further
predisposes them to thrombosis from an iatrogenic vascular
injury.
Iatrogenic and traumatic vascular injuries may result in
obstruction of the lumen and subsequent thrombosis or may
cause local vasospasm that may result in thrombosis. When
an injury results in arterial occlusion, the classic physical find-
ings of limb ischemia develop early and progress. Rapid rec-
ognition of the injury and definitive intervention are essential
for limb salvage. When vasospasm is suspected (rather than
thrombosis), removal of any indwelling vascular catheters is
essential as this alone may reverse the process and may allow
improvement in the pulse exam. Adjuncts like administration
of papaverine into the artery to reverse or minimize vaso-
spasm are often utilized.
Limb hypoperfusion can also occur as a result of a trau-
matic arteriovenous (AV) fistula, pseudoaneurysm, or com-
plete vascular transection following an access procedure or a
penetrating vascular injury. AV fistulae may subsequently
result in high output cardiac failure in children especially
when initial cardiac reserve is limited. This is the result of
gradual enlargement of the fistula communication and subse-
quent increase in demand for cardiac output. Such clinical
scenarios can result in limb overgrowth and high-output con-
gestive heart failure necessitating intervention.
Diagnostic Evaluation
Diagnosis of pediatric vascular injuries requires a high index
of clinical suspicion and a careful physical examination. Before
the performance of invasive vascular procedures in children,
establishing a preprocedure baseline pulse examination is
essential for detection of subtle postprocedure blood-flow
deficits after the procedure. As in adults, examination of the
affected and contralateral extremity includes skin color, capil-
lary refill, and pulse examination. In the setting of hemor-
rhagic shock, extremity vasoconstriction can lead to an
abnormal pulse examination even in the absence of a vascular
injury. One series specifically noted a 26% incidence of
peripheral arterial vasospasm at surgical exploration but
found that, in every case, the process ultimately resolved
without a vascular reconstruction.3 Thus, in the multiply-
injured child, life-threatening injuries must be identified,
resuscitation and rewarming must be instituted, and then
peripheral pulses must be reassessed.
In the setting of penetrating trauma, hard signs of vascular
injury such as external bleeding or an expanding hematoma
are reliable indicators of a significant arterial injury that war-
rants surgical intervention. In the absence of such indicators,
the pulse examination and noninvasive testing guide further
management. In such cases, measurement of the injured
extremity index (IEI) using continuous-wave Doppler is a
reliable, noninvasive means of initially assessing for arterial
injuries in children. The IEI is comparable to the ankle-
brachial index (ABI) but is a more general term not confined
to the assessment of lower extremity vascular occlusive disease;
it refers to the Doppler occlusion pressure measured in an
injured extremity relative to that measured in an uninjured
extremity.
The injured extremity index must be performed with
appropriately sized manual blood pressure cuffs. The cuff
should easily encircle the arm and should cover 75% of the
length of the upper arm. A continuous-wave Doppler probe
is used to determine the pressure at which the arterial signal
occludes with cuff inflation. The calculation is taken from the
brachial artery in an uninjured extremity. If both arms are
available, the higher of the two occlusion pressures is used as
the denominator of the ratio equation. For a lower extremity
injury, an appropriately sized cuff is positioned similarly just
proximal to the ankle, and Doppler occlusion pressures are
measured at both the dorsalis pedis and posterior tibial arter-
ies. The highest ankle pressure is used as the numerator to
calculate the IEI ratio. If an injured upper extremity is being
assessed, the cuff is placed distal to the injury and the occlu-
sion pressure measured at the wrist, taking the higher value of
the radial or ulnar artery occlusion pressure. Extrapolating
from expected ABI values in children over 2 years of age, the
IEI should be 1.0 or slightly greater in the absence of a vascular
injury; whereas, in children 2 and under, the normal range is
somewhat lower with a mean of 0.88.14 When a vascular deficit
is suspected by an abnormal pulse or a low IEI (<0.9 in chil-
dren over 2; <0.88 in children 2 and under), it is important to
consider whether poor perfusion is the result of arterial injury,
vasospasm, or limb hypoperfusion from shock as described
above.
If there is concern for a vascular injury with a diminished
pulse and IEI that does not correct with resuscitation and
rewarming, a confirmatory and localizing study can be helpful
if the zone of injury is not clearly delineated. In children,
duplex ultrasound can confirm occlusion and can localize the
site of injury as well as diagnose an AV fistula or pseudoaneu-
rysm.7 This modality can also help differentiate between vaso-
spasm and arterial thrombosis. CTA is now being used more
often for diagnosis of vascular injuries in children and has
been shown to be more reliable for truncal and great vessel
injuries than distal ones (Fig. 20-2).7 If the diagnosis remains

A B
FIGURE 20-2  CTA can be used to evaluate for vascular injuries in
large vessels including the carotid artery (A, black arrow) and the
subclavian artery (B, white arrow). Contrast should be injected con-
tralateral to the suspected injury. In very small children, a hand injec-
tion may be necessary. In both instances, the injuries resulted from a
tiny metal fragment (B, black arrowhead). The carotid pseudoaneu-
rysm (A) was managed with open exploration and repair with an
interposition graft, while the subclavian artery injury was repaired with
a vein patch angioplasty. (A, From Cannon JW, Peck MA: Vascular inju-
ries in the young. Perspect Vasc Surg Endovasc Ther 23:100–110, 2011;
B, courtesy Jerry Pratt.)
A B
FIGURE 20-3  Focal areas of narrowing on arteriography are more
likely to be injuries as opposed to vasospasms, which tend to be more
gradual in contour and longer. A, The arrow indicates a focal filling
defect in the superficial femoral artery. B, The asterisk (*) indicates an
area of vasospasm in the tibioperoneal trunk. (From Cannon JW, Peck
MA: Vascular injuries in the young. Perspect Vasc Surg Endovasc Ther
23:100–110, 2011, Fig 1.)
unclear despite noninvasive testing, conventional angiography
may be considered bearing in mind that the risk of angiogra-
phy increases in younger patients and that it may exacerbate
the problem. In some cases, angiography can be useful in
localizing the site of the injury and in distinguishing an arte-
rial injury from vasospasm (Fig. 20-3). If diagnostic tests are
inconclusive in the presence of an abnormal examination,
surgical exploration is indicated regardless of the age or the
size of the patient. In extreme circumstances, a patient may be
so critically ill that surgical exploration itself would be life-
threatening; and a limb that is hemostatic may not be explored
immediately.
Management of Pediatric
Vascular Injuries
Historically, early exploration for suspected vascular injuries
in children has not been strongly advocated except for exsan-
guinating hemorrhage following vessel avulsion or transec-
20  /  Pediatric Vascular Injury 229
tion. However, poor long-term results from this management
approach are now more widely recognized, including early
tissue loss and long-term limb-length discrepancy. Operative
intervention was avoided in the setting of vasospasm due to
the seemingly poor postoperative results in children under 2
years of age.9 Much of this debate stems from a lack of data
on this subject; however, it seems that the devastating life-long
consequences of a deferred operation far outweighs the risk
of a negative exploration in almost every instance. Further-
more, the idea that there is a relatively short ischemic-threshold
time beyond which limb quality deteriorates rapidly and the
idea that “time is tissue” compel surgeons to intervene early
in order to obtain the best possible results.15 In most instances
of vascular occlusion, thrombectomy of the affected vessel
with patch angioplasty repair of the arteriotomy site can be
achieved, even in children under 2, using either a small Fogarty
embolectomy catheter (Edwards Lifesciences, Irvine, CA) or
an aspiration thrombectomy with an angiocatheter.16 In some
cases of iatrogenic iliac arterial injuries, if the injury is identi-
fied during the index procedure, a covered endovascular
stent can be deployed to repair the injured vessel (Pedro J. del
Nido, Boston, MA, personal communication, Oct. 31, 2010),
although the long-term implications of this management
approach are unknown. Open repair of injured iliac arteries
remains the preferred gold-standard method.
Extremity Injuries
Early repair of vascular injuries in children has been advocated
by some surgeons for decades. However, management did not
always include prompt recognition and repair of injuries; and
unacceptable outcomes in the form of high rates of amputa-
tion and limb-length discrepancy were the result.7 While chil-
dren have greater abilities to develop collaterals than adults,
they suffer as high as 50% amputation rates after major vas-
cular disruption with delayed or nonoperative management.
With femoral artery disruption, long-term outcomes indicate
extremely high rates of limb-length discrepancy which can
take several years to become evident yet may respond to
delayed vascular reconstruction with catchup growth.9
Based on these observations, as indicated above, the man-
agement strategy for most pediatric vascular injuries should
parallel the tenants of vascular-trauma care in adults (Fig.
20-4). These include early definitive arterial reconstruction,
repair of venous injuries, use of temporary vascular shunts,
systemic and regional heparin administration, balloon cath-
eter thrombectomy, and the liberal use of fasciotomies. The
pediatric-specific technical considerations include the man-
agement challenges associated with vasospasm, as well as
the need to allow for subsequent vascular growth by creating
a spatulated anastomosis and by using interrupted sutures.
Following surgical reconstruction, extremely long-term follow-
up should be performed to track patency and to detect any
aneurysmal degeneration of the repair or any limb-length
discrepancy.
When an iatrogenic vascular injury results in an incom-
plete vessel occlusion such as a small intimal flap or partial
dissection, it may be possible to delay or avoid definitive surgi-
cal intervention if the limb remains viable. Systemic heparin-
ization should be employed if not contraindicated to prevent
propagation of any thrombosis stemming from the site of
injury. Small flaps and dissections often respond favorably to
catheter-directed balloon angioplasty, particularly if they are
230 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT

A B C
FIGURE 20-4  A, Isolated penetrating injury to the right leg of an 8-year-old boy, resulting in a pulseless leg with absent Doppler signals.
B, The wound was hemostatic; so heparin (75 units/kg) was bolused in the emergency department (ED); and the patient was taken for opera-
tive exploration. Through a medial approach, the below-knee popliteal artery was found to be injured. C, Greater saphenous vein that was
harvested from the contralateral leg was used for the reconstruction. A below-knee popliteal–to-posterior tibial bypass graft was performed with
interrupted sutures. Note the spatulated saphenous vein, which had been prepared for the distal anastomosis.

in the direction of antegrade arterial flow. Serial monitoring
of the circulatory status should continue thereafter, and open
operative intervention should follow if the examination
deteriorates.
One of the largest recent experiences in pediatric vascular
trauma comes from the vascular registry of combat injuries
managed in Iraq and Afghanistan (Fig. 20-5).12 High-energy
penetrating blast wounds from improvised explosive devices
and gunshot wounds result in extensive tissue damage often
with an associated vascular injury component. All such adult
and pediatric extremity trauma cases were managed similarly
with the use of heparin, with thrombectomy, with extensive
soft-tissue débridement, with fasciotomy, with repair of
venous injuries, and with interposition reversed saphenous
vein reconstruction of arteries. Pediatric arterial anastomoses
were performed using an interrupted suture technique with
nonabsorbable polypropylene suture.12 The care of these
patients from initial reconstruction to final wound closure or
skin grafting was conducted by a multidisciplinary team of
medical and surgical specialists led by the operative vascular
surgeon. These favorable results lend significant support to the
philosophy of early diagnosis and operative management of
vascular injuries in children.
Several commonly accepted methods of artery reconstruc-
tion exist, including primary repair, vein patch angioplasty,
and interposition repair using reversed greater saphenous vein
(GSV), other autologous vein, or synthetic grafts (expanded
polytetrafluoroethylene [ePTFE] or Dacron). Minimal inju-
ries can be reconstructed, primarily when there has been a
clean transection of the vessel, or repaired with a patch angio-
plasty where there is moderate loss of wall circumference but
vessel continuity is preserved. However, primary repair is not
possible when the injury is more extensive, when injury
involves loss of surrounding tissue, or when there has been
direct destruction of the vessel. For these more complex
reconstructions, GSV is preferred because it is the most
size-appropriate and most-available arterial replacement
conduit.3,17 The ipsilateral GSV should be avoided to avoid
compromising venous outflow of an injured extremity. Lesser
saphenous and upper extremity veins may be used for recon-
struction provided they are size appropriate. Synthetic conduit
is generally avoided due to infection and patency concerns.
Furthermore, injured arteries are frequently too small for
commonly available synthetic grafts (6-mm diameter and
larger), and patency using smaller synthetic grafts (3-mm to
5-mm diameter) is unknown. In addition, these grafts also do
not enlarge over time as the child’s artery grows.
The technique for constructing a vascular anastomosis in
children with small, growing vessels warrants further discus-
sion. Numerous classic studies have supported the recom-
mendation of performing an interrupted suture technique for
arterial anastomoses in growing vessels.18 There are now
more-recent animal research models that have compared
various repair methods and materials. Titanium clip, running
dissolvable suture, and interrupted permanent suture anasto-
moses have been evaluated in an effort to determine the best
method to connect growing vessels. In these studies, no one
method has proven to be superior. However, a running-type
anastomosis using permanent suture tended to inhibit vessel
growth.19 Anastomosis methods have not been directly com-
pared in pediatric patients, and long-term follow-up is poor.
It is therefore not possible to know with certainty the advan-
tages and limitations of the various methods. While a running-
type anastomosis with dissolvable suture may be considered,
this material has been shown experimentally to be more
thrombogenic than permanent monofilament suture. Thus,
an interrupted suture technique using nondissolvable poly-
propylene suture should protect against narrowing and will be
less thrombogenic.3,19 When performing arterial anastomoses
in growing vessels, one additional technique to protect against
narrowing is to create a spatulation. This bevel-shaped con-
nection between the vein graft and the native artery creates a
functionally enlarged communication that allows for some
vessel growth without stricturing.
Patch angioplasty and primary repair were used exclusively
in one pediatric series, avoiding interposition bypass entirely.
This is a perfectly acceptable strategy in low-velocity penetrat-
ing injuries and in some blunt injuries because it avoids
luminal growth issues at anastomosis sites.2 However, this
approach is not likely to succeed in the setting of high-energy
trauma, such as fragmentary wounds seen in wartime and
complex civilian trauma. Reconstruction in these situations
requires vessel débridement, and interposition repair is much
more likely to be necessary to allow a tension-free repair. In
 20  /  Pediatric Vascular Injury 231

A B

C D

FIGURE 20-5  A, Penetrating wound to the right thigh of a 5-year-

old girl. B and C, The right foot had a weakly palpable pulse. There
was a Doppler signal, but the IEI was diminished at 0.35. The right
foot and great toe manifested a noticeable pallor when compared
to the uninjured left extremity. D, (Arrow) The wound was hemo-
static; so heparin (75 units/kg) was bolused in the emergency
department. The right leg was explored, and the injured superficial
femoral artery (SFA) was exposed. The injured segment was 4 cm
distal to the takeoff of the deep femoral artery. E, (Arrows) A
reversed greater saphenous vein interposition graft was used to
replace the injured segment of the SFA. Interrupted 6.0 monofila-
E ment expanded polytetrafluoroethylene (ePTFE) sutures were used
for both the proximal and distal anastomosis.

these cases, there are often concomitant fractures, soft-tissue
defects, nerve injuries, and vein injuries to contend with as
well. These complex injury patterns are best managed with a
team approach, often with a vascular shunt being placed to
temporize while other injuries are managed first.12
Injured deep veins of the proximal extremities, namely the
femoral, popliteal, and axillary veins, should undergo repair
whenever possible. Larger more proximal veins and central
veins transport large amounts of blood and have few collateral
options when acutely injured. Injury without repair of these
vessels leads to significant edema and possibly phlegmasia.
Primary repair, lateral venorrhaphy, nonreversed vein interpo-
sition, and synthetic interposition bypasses have all been
described. Early patency of all types of vein reconstruction is
excellent. Vein repair is important for alleviation of limb
edema, for improvement of patency of arterial repairs, and for
overall improved limb function.
Supracondylar Humerus Fractures  
and Brachial Artery Injuries
A particular subset of pediatric extremity vascular injuries is
the pink pulseless hands associated with supracondylar
humerus fractures. This is the most common upper extremity
fracture pattern in younger children, and the vascular-injury
rate is as high as 10%. Lateral displacement of this thin portion
of the humerus puts the brachial artery and median nerves
232 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
at risk. Stretch injuries, which can disrupt the vessel intima
or impingement, are the usual mechanisms of injury. If reduc-
tion of the fracture does not return a normal pulse to the wrist
and maintain normal hand perfusion, surgical exploration is
indicated. Likewise, if there is initially profound ischemia,
immediate brachial exploration is indicated. The preferred
conduit is greater saphenous vein with the proximal thigh
vessel having the best size match for the brachial artery. Pos-
terior elbow dislocations can also lead to a similar vascular-
injury pattern.20
Fasciotomy
The liberal use of lower extremity four-compartment fasci-
otomy incisions in the setting of prolonged arterial ischemia
and extensive tissue injury is well documented. This practice
is almost universal in wartime extremity injuries and is also
well described in the civilian pediatric literature with fasci-
otomy rates ranging from 12% to 46%.3 This approach likely
plays a significant role in improving the quality of limb
salvage.
Truncal Vascular Injuries
The management of these major central and cervical injuries
in the pediatric population is largely similar to the adult popu-
lation, inasmuch as there is usually major life-threatening
hemorrhage or ischemia that demands immediate surgical
attention. In the pediatric population, there is a limited role
for endovascular management. Temporary balloon occlusion
of a major inflow vessel (such as the subclavian artery or
descending aorta) is feasible and may minimize hemorrhage,
while open surgical control is obtained. Therapeutic endovas-
cular interventions should not be largely considered in the
youngest of patients due to small vessel size, vasospasm, and
future growth. In contrast, there may be a role for thoracic
stent-grafts in adolescent and adult-sized patients in the man-
agement of descending aortic injuries.
Most cases of pediatric thoracic aortic injuries and great
vessel trauma are managed with open surgery. Aortic injuries
are treated with the clamp-and-sew technique, utilizing a syn-
thetic interposition graft.10,11 Although complete thoracic dis-
ruption is rarely survivable, outcomes of patients reaching the
hospital alive and hemodynamically stable are near 80% with
very low rates of paraplegia. Most deaths are due to head
trauma or other associated injuries. Delayed repair with early
initiation of beta-blocker therapy has shown a survival benefit
to patients.21
Management of abdominal vascular injuries is driven by
the hemodynamic stability of the patient and severity of asso-
ciated injuries. Methods of repair include aortic replacement
with a synthetic graft, use of GSV or hypogastric artery for
other arterial injuries and lateral venorrhaphy or interposition
repair for the inferior vena cava.
Management of injuries to the cervical vessels depends on
the mechanism of injury and the injury location. For surgi-
cally accessible injuries to the carotid artery, primary repair,
patch angioplasty, and interposition grafting with vein or
ePTFE are accepted methods of repair. Ligation of distal inter-
nal carotid artery injuries may be required when the injury is
too distal for repair. Distal extracranial (zone III) carotid pseu-
doaneurysms may be excluded with a percutaneously placed
graft for injuries that extend up to the skull base. Proximal
carotid artery injuries (zone I) may be reached via a median
sternotomy with extension of the incision to the affected side
of the neck. These injuries may also be treated with endovas-
cular stenting via percutaneous femoral access or with open
exposure of the ipsilateral cervical carotid artery and retro-
grade stenting. Blunt carotid artery injuries rarely benefit from
surgical intervention, and treatment consists of anticoagula-
tion or antiplatelet therapy in most cases, with repeat nonin-
vasive imaging in the future. Patients with penetrating carotid
injuries have a better functional recovery than those sustain-
ing blunt injury.2 Internal jugular vein injuries can be primar-
ily repaired, patched or ligated depending on the extent of the
injury.
Right innominate artery injuries require a median ster-
notomy. The proximal right subclavian artery may also be
reached via this approach. Supraclavicular incisions are
required for more distal subclavian artery injuries bilaterally.
The origin of the left subclavian artery is accessed via a high
left anterior lateral thoracotomy. Combination incisions, such
as a trapdoor incision, may be necessary for extensive injuries
to the left-sided great vessels.
Endovascular Applications
Endovascular interventions for all forms of traumatic vascular
injuries have steadily increased over the past decade.21 Tho-
racic stent-grafting in particular has seen an exponential rise
in use over this time in adult trauma patients. Early outcomes
are not inferior to the standard of open surgery with regard
to early survival, stroke, and paraplegia rates. Extrapolation of
this technology to pediatric patients is limited by several
factors. Notably, existing stent-grafts are generally too large for
the pediatric aorta while the delivery system is typically either
too large for femoral vessels or too short and an iliac conduit
is required for more proximal delivery. Also, expected vessel
growth in younger children may lead to future graft migration
or restricted vessel growth. Thoracic aortic stent-grafts have
been placed in a small number of adolescent patients with
good early results. These patients had achieved near-adult size,
and further aortic growth was likely to be minimal.22 Despite
the available and emerging stent-graft technology, the current
standard of care for pediatric thoracic aortic injury remains
open repair.
Other applications for endovascular therapy in children
with vascular trauma include angioplasty for minor intimal
injuries or dissection flaps in the setting of blunt extremity
injury. Injuries to the iliac vessels during catheterization pro-
cedures have also been managed with endovascular stent-
grafts although the long-term outcomes of such interventions
have not been described. Lastly, as described above, endovas-
cular therapies may be employed for the management of sur-
gically inaccessible injuries to the cervical vessels in the setting
of either blunt or penetrating vascular trauma.
Nonoperative Management
Nonoperative approaches including anticoagulation alone
have not been proven to be superior to other management
strategies in the setting of iatrogenic or traumatic vascular
injuries and should be utilized with extreme caution. One
consideration is in the setting of a contraindication to surgical
exploration such as extreme critical illness. Occasionally a
blunt injury to the vertebral artery or intracranial carotid
artery may be managed with anticoagulation alone. For
extremity injuries, if intervention is delayed beyond the

critical tissue ischemia time but perfusion via collaterals main-
tains limb viability, interval surgical reconstruction can be
performed as this approach has been reported to restore some
limb length.9,23 However, in all surgically accessible locations,
early intervention is still greatly preferable to this approach if
at all possible.
ECLS Cannulation
ECLS cannulation has also been associated with pediatric vas-
cular injury; however, even without direct vascular injury, the
relative occlusion of the right carotid artery during VA ECLS
has been implicated in both cognitive and motor neurologic
deficits. Such evidence, comparable to the long-term limb-
length discrepancies previously described, has led some centers
to perform routine carotid reconstruction following decan-
nulation. This approach has resulted in favorable patency rates
and favorable neurologic outcomes relative to controls.24
Adjuncts to the Management of
Vascular Injuries in Children
Temporary Vascular Shunts
Temporary vascular shunts, described in depth in Chapter 17
of this text, are devices designed to allow early or expedited
restoration of perfusion across in an injured or disrupted
vessel. A temporary vascular shunt typically remains in place
while other procedures such vein harvest or extremity fracture
reduction are performed. Early or expedited restoration of
perfusion with a temporary shunt is felt to preserve tissue
viability until a definitive vascular repair can be performed.
The use of temporary vascular shunts has gained increased
attention in the context of damage control resuscitation by
military surgeons in the wars in Afghanistan and Iraq.25 Both
military and civilian experience indicates that proximal
extremity arterial shunts remain patent in between 85% and
95% of cases and do not negatively impact limb-salvage rates
when used in proximal vessels such as the brachial or femoral
artery.25 Shunts in smaller more-distal vessels have lower
patency rates and have not been shown to improve limb-
salvage attempts.
Given the experience with vascular shunts in adult vascular
trauma, a similar approach is recommended for pediatric
patients with vascular injury. As with adults, vascular shunts
may be most useful in young patients with mangled extremi-
ties, including concomitant vascular and orthopedic injuries.
In this setting, the shunt may be used to restore perfusion
across the injured or disrupted vessel while resuscitation is
accomplished and while orthopedic injuries are reduced and
stabilized. It is important to note that balloon-catheter throm-
bectomy should be performed before placement and after
removal of a shunt. Heparinized saline should also be infused
into the distal ischemic arterial segment before and after shunt
removal. An appropriately sized shunt should be selected to
balance between maintaining patency and preventing an
unwanted intimal injury. The use of a temporary vascular
shunt reduces overall ischemia time and can serve as a bridge
to definitive repair. The reduction in ischemia time may result
in lower rates of compartment syndrome, nerve injury, and
muscle loss, which may improve the overall quality of limb
salvage and in turn prevent late amputation due to poor limb
function.
20  /  Pediatric Vascular Injury 233
Role of Heparin
Heparin reduces platelet aggregation and prevents clot forma-
tion and propagation. As a stand-alone therapy, it prevents
further thrombus accumulation while normal fibrinolytic
mechanisms promote recanalization of occluded vessels.
Heparin may also prevent thrombus accumulation during
periods of transient vasospasm. Although the use of heparin
as a stand-alone therapy for vascular injury has fallen out of
favor, its systemic or regional use is an important adjunct in
reconstruction of pediatric vascular injury. As in adults,
heparin is often contraindicated in cases of polytrauma where
the risk of unwanted bleeding is high. In these cases, the use
of local (i.e., flushing the open vessel surfaces) or regional (i.e.,
infused into the proximal and distal segments to be recon-
structed) heparin is important. If the vascular injury is iso-
lated and the risk of unwanted bleeding is low, then systemic
heparin should be initiated once the diagnosis is suspected or
made. Systemic heparin should be dosed and maintained at
therapeutic levels until any vascular reconstruction is com-
plete and normal perfusion reestablished. Continuation of
heparin for 24 to 48 hours may have a role following repair of
small arteries or in those where the reconstruction had to be
revised. Temporary use of systemic heparin may also be used
in cases of pediatric vascular injury where vasospasm has been
a complicating factor, reducing distal outflow. Antiplatelet
therapy, namely, low-dose aspirin, may be considered in the
young, following arterial reconstruction to decrease platelet
aggregation at repair sites. Like heparin, the risk of aspirin-
related complications (i.e., Reye syndrome) must be balanced
with any benefit to be achieved with its use.
Lytic Therapy
Generally, thrombolytic therapy in arterial trauma has a
limited role as concurrent injuries often contraindicate their
use. The greatest utility may be when there has been a delay
in diagnosis following blunt or iatrogenic injury, resulting in
vascular thrombosis that extends into the tibial vessels. It may
also have a role in the management of iatrogenic vascular
injuries, although the indications for this approach compared
to operative intervention have not been defined. Lytic therapy
is often able to resolve acute thrombotic occlusions as a stand-
alone therapy, or it may reveal an injury more specifically to
better direct repair. Catheter-directed intraarterial adminis-
tration beginning just proximal to the thrombosis and through
its extent is the preferred method of drug delivery. Tissue
plasminogen activator (tPA) is currently the only available
agent at a dose of 0.25 to 1.5 mg/hr. Fibrinogen levels are
trended to ensure lysis of the thrombus with discontinuation
of the infusion once systemic fibrinogen levels fall (suggesting
complete dissolution of the clot). Heparin infusion is used
concurrently and is continued after thrombolysis to prevent
clot extension. Follow-up angiography is then performed
through the existing catheter to identify residual luminal
defects that need additional management such as angioplasty,
open thrombectomy, or surgical reconstruction. Bleeding is
the greatest risk of this treatment modality.
Postoperative Management
Antiplatelet therapy is commonly used following vascular
reconstructions in adults—for both traumatic and chronic
234 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
indications. It is presumed that the injured vessel and the
newly constructed anastomosis are devoid of epithelium and
prone to platelet deposition. New epithelium generally reforms
within several days at a vascular anastomosis. Consequently,
although there is no proven benefit in terms of graft outcome
or limb salvage, the theoretical benefit of an antiplatelet agent
will be realized with a very short course of therapy (e.g.,
30 days or less) while a longer course offers no additional
advantage.
Postoperative surveillance is best performed using a com-
bination of clinical assessment, IEI, and duplex ultrasound at
regular intervals. This combination can detect a failing recon-
struction with good reliability.2 Studies that require intrave-
nous contrast including CTA and angiography are rarely
necessary; thus, radiation exposure can be minimized in these
pediatric patients. Unfortunately, follow-up is not universal in
pediatric trauma patients making long-term outcomes largely
unknown. Surveillance immediately after repair and at the
initial postoperative visit can detect technical imperfections
that could lead to early graft failure. Long-term surveillance is
designed to screen for aneurysmal dilation of grafts and to
detect anastomotic stenosis, which can lead to late bypass
failure or limb growth disturbance.
Outcomes Following Pediatric
Vascular Injuries
Little is known of the outcomes following pediatric vascular
trauma due to the small number of studies in this area. One
case series of iatrogenic femoral injuries found that a palpable
pulse was restored after surgical intervention in 6 of 14 patients
(age 6 months to 9 years) with acute lower limb ischemia, with
4 more regaining a palpable pulse in follow-up for an overall
rate of 71%.9 In this group, 2 patients died of cardiopulmo-
nary complications. Of 7 patients (age 3 to 9 years) with
chronic ischemia, 4 children presented with claudication and
3 presented with leg-length discrepancy and gait disturbance.
All underwent surgical intervention (iliofemoral bypass graft
in 5; femoral–femoral bypass graft in 1; patch angioplasty in
1). Also, 6 of 7 had a palpable pulse postoperatively; and, on
long-term follow (mean 3.3 years), claudication improved in
4 of 4; and leg length discrepancy improved in 1 of 3.
Similarly, long-term follow-up of extremity and other arte-
rial reconstructions following noniatrogenic pediatric vascu-
lar trauma has historically been poor, making the fate of
bypass grafts uncertain. Enlargement of GSV interposition
bypasses is theoretically likely to occur over time; but, despite
reports of vein bypasses for renal artery reconstruction having
a high aneurysmal degeneration rate, no such reports exist for
the extremities. Regular (annual) surveillance of graft func-
tion should be performed if at all possible. Duplex studies
would allow for detection of graft degeneration or failure and
would allow timely reintervention and improved assisted
primary patency rates.3,17
In reports of traumatic vascular injuries, unadjusted mor-
tality ranges from 9.7% in a series of 103 patients at a single
institution2 to 13.2% in 1138 patients under 16 years old from
the National Trauma Databank.1 The cause of death is rarely
related directly to the vascular injury, and the adjusted mortal-
ity in children with vascular injuries is significantly lower than
in adults (odds ratio 0.60; 95% confidence interval 0.45 to
0.79; p < 0.001).1 Limb loss occurred in 11 of 58 patients with
extremity arterial injuries; and on long-term follow-up of 65
of 103 patients, 2 leg-length discrepancies were identified.2
Future Directions
The vast majority of the recommendations included in this
chapter are based on evidence from animal studies, case series,
and expert opinion. Given the relatively small numbers of
these cases in any given institution, multiinstitution collabora-
tion is imperative to move beyond this low level of evidence.
The basic demographics of pediatric vascular trauma are now
tracked in the National Trauma Data Bank (NTDB) as reported
in the annual pediatric report and have been studied by at least
one group,1 although outcomes specifically related to manage-
ment of the vascular injury are not tracked. Future collabora-
tive efforts should focus on evaluating the translation of
management techniques refined during our current combat
experience to the civilian pediatric population. Furthermore,
the effort to systematically study the short- and long-term
outcomes of neonatal vascular injuries should be a high prior-
ity because these injuries have the greatest associated costs in
terms of disability and loss of quality of life. Finally, the use
of modern technology for injury prevention, such as ultra-
sound guidance and new generation endovascular techniques,
warrants careful evaluation in the pediatric population.
Conclusions
Pediatric vascular trauma resulting from blunt and penetrat-
ing mechanisms is managed by a range of surgical specialists.
Although historic approaches to these injuries have empha-
sized nonoperative measures, modern reports indicate that
operative intervention is feasible, safe, and necessary in many
scenarios. Results from vascular trauma management in
combat suggest that a comprehensive approach that includes
damage control resuscitation with vascular shunting as
required, use of an interposition graft for reconstruction with
interrupted sutures, use of perioperative anticoagulation, and
liberal use of fasciotomy in the setting of extremity injuries
results in good short-term outcomes in pediatric patients.
Future research efforts should focus on developing a more
thorough understanding of the vascular biology of the devel-
oping vascular system and its response to injury even as mul-
tiinstitutional clinical collaborations are established to study
the optimal clinical approach to the management of pediatric
vascular trauma.
REFERENCES
1. Barmparas G, Inaba K, Talving P, et al: Pediatric vs adult vascular trauma:
a National Trauma Databank review. J Pediatr Surg 45:1404, 2010.
2. Klinkner DB, Arca MJ, Lewis BD, et al: Pediatric vascular injuries: pat-
terns of injury, morbidity, and mortality. J Pediatr Surg 42:178, 2007.
3. Myers SI, Reed MK, Black CT, et al: Noniatrogenic pediatric vascular
trauma. J Vasc Surg 10:258, 1989.
4. McGuigan R, Spinella PC, Beekley A, et al: Pediatric trauma: experience
of a combat support hospital in Iraq. J Pediatr Surg 42:207, 2007.
5. Coppola CP, Leininger BE, Rasmussen TE, et al: Children treated at an
expeditionary military hospital in Iraq. Arch Pediatr Adolesc Med 160:
972, 2006.
6. Corneille MG, Gallup TM, Villa C, et al: Pediatric vascular injuries: acute
management and early outcomes. J Trauma 70:823, 2011.
7. Dalsing MC, Cikrit DF, Sawchuk AP: Open surgical repair of children less
than 13 years old with lower extremity vascular injury. J Vasc Surg 41:983,
2005.

8. Flanigan DP, Keifer TJ, Schuler JJ, et al: Experience with iatrogenic pedi-
atric vascular injuries. Incidence, etiology, management, and results. Ann
Surg 198:430, 1983.
9. Lin PH, Dodson TF, Bush RL, et al: Surgical intervention for complica-
tions caused by femoral artery catheterization in pediatric patients. J Vasc
Surg 34:1071, 2001.
10. Allison ND, Anderson CM, Shah SK, et al: Outcomes of truncal vascular
injuries in children. J Pediatr Surg 44:1958, 2009.
11. Cox CS, Jr, Black CT, Duke JH, et al: Operative treatment of truncal
vascular injuries in children and adolescents. J Pediatr Surg 33:462, 1998.
12. Peck MA, Clouse WD, Cox MW, et al: 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 45:1197, 2007.
13. Warkentine FH, Clyde Pierce M, Lorenz D, et al: The anatomic relation-
ship of femoral vein to femoral artery in euvolemic pediatric patients by
ultrasonography: implications for pediatric femoral central venous
access. Acad Emerg Med 15:426, 2008.
14. Katz S, Globerman A, Avitzour M, et al: The ankle-brachial index in
normal neonates and infants is significantly lower than in older children
and adults. J Pediatr Surg 32:269, 1997.
15. Burkhardt GE, Gifford SM, Propper B, et al: The impact of ischemic
intervals on neuromuscular recovery in a porcine (Sus scrofa) survival
model of extremity vascular injury. J Vasc Surg 53:165, 2011.
16. Aspalter M, Domenig CM, Haumer M, et al: Management of iatrogenic
common femoral artery injuries in pediatric patients using primary vein
patch angioplasty. J Pediatr Surg 42:2007, 1898.
20  /  Pediatric Vascular Injury 235
17. Cardneau JD, Henke PK, Upchurch GR, Jr, et al: Efficacy and durability
of autogenous saphenous vein conduits for lower extremity arterial
reconstructions in preadolescent children. J Vasc Surg 34:34, 2001.
18. Steen S, Andersson L, Lowenhielm P, et al: Comparison between absorb-
able and nonabsorbable monofilament sutures for end-to-end arterial
anastomoses in growing pigs. Surgery 95:202, 1984.
19. Calles-Vazquez MC, Crisostomo V, Sun F, et al: Angiographic, ultrasono-
graphic, and macroscopic assessment of aortic growth after VCS clips,
interrupted polypropylene, or running polyglycolic acid anastomosis.
J Pediatr Surg 42:2007, 1695.
20. Brahmamdam P, Plummer M, Modrall JG, et al: Hand ischemia associ-
ated with elbow trauma in children. J Vasc Surg 54:773, 2011.
21. Karmy-Jones R, Hoffer E, Meissner M, et al: Management of traumatic
rupture of the thoracic aorta in pediatric patients. Ann Thorac Surg
75:2003, 1513.
22. Milas ZL, Milner R, Chaikoff E, et al: Endograft stenting in the adolescent
population for traumatic aortic injuries. J Pediatr Surg 41:e27, 2006.
23. Klein MD, Coran AG, Whitehouse WM, Jr, et al: Management of iatro-
genic arterial injuries in infants and children. J Pediatr Surg 17:933, 1982.
24. Desai SA, Stanley C, Gringlas M, et al: Five-year follow-up of neonates
with reconstructed right common carotid arteries after extracorporeal
membrane oxygenation. J Pediatr 134:428, 1999.
25. Rasmussen TE, Clouse WD, Jenkins DH, et al: The use of temporary
vascular shunts as a damage control adjunct in the management of
wartime vascular injury. J Trauma 61:8, 2006.
21  Inferior Vena Cava Filters
CHIRAG M. PATEL, DINESH G. RANATUNGA, AND IAN RENFREW
Filters and Terminology
A variety of inferior vena cava (IVC) filters are available on
the market today and these are summarized in Table 21-1; the
more commonly used devices are shown in Figure 21-1. Vena
cava filters may be divided in to two groups: those that are
permanent and those that are potentially retrievable, the latter
being the most frequently utilized in clinical practice today. In
addition, filters may be inserted for either “therapeutic” or
“prophylactic” indications based on the presence or absence
of pulmonary embolism (PE) and/or deep venous thrombosis
(DVT). In this context, the term “therapeutic” is somewhat of
a misnomer as the filter itself does not treat the thrombus or
thromboembolism (i.e., it does not decrease the amount of
thrombus). However, as the filter is placed to treat the natural
history of the condition, the term “therapeutic” is common-
place. Therapeutic filters are those that are placed in patients
with a confirmed clinical event (i.e., diagnoses of DVT and/
or PE) to prevent subsequent thromboembolic sequelae. In
contrast, prophylactic filters are those that are placed without
the diagnosis of a clinical event (i.e., DVT or venous throm-
boembolism [VTE]). In the case of prophylactic filters, the
device is most commonly used in patients who are deemed to
be at a high risk for future VTE4 and/or those who are not
suitable for anticoagulation (prophylactic or therapeutic).
Prophylactic filter placement has seen the largest growth in
filter use.5
Indications
There has been an exponential increase in the use of IVC filters
over the last 2 decades, driven by their increasing availability,
relative ease of insertion, good safety profile, and use for pro-
phylactic indications. Despite their popularity, there is a sur-
prising paucity of robust clinical evidence supporting their
efficacy with only two randomized controlled trials (RCTs)
being conducted and examining their outcomes.6,7 Indications
for IVC filter insertion may be broadly divided into the fol-
lowing two subgroups: recommended use (based on evidence-
based guidelines) and expanded use (referring to indications
beyond those specified in evidence-based guidelines).8 These
indications are summarized in Box 21-1.
Recommended Indications
IVC filter placement is recommended in those patients with
proven VTE and with one or more of the following: (1) a
contraindication to anticoagulation, (2) a current or previous
complication from anticoagulation, or (3) a recurrent VTE
236
despite full or adequate anticoagulation.8-10 In patients in
whom a filter was inserted as an alternative to anticoagulation,
conventional pharmacological anticoagulation should be
started once bleeding risk resolves; and the filter should be
removed thereafter.
Expanded Indications
IVC filters may be used for a range of indications beyond those
specified in evidence-based guidelines. Typically, the use of a
filter in this category involves a high-risk clinical scenario,
including patients with hypercoagulable conditions for which
limited evidence exists to guide the practice. Examples include
patients with cancer, those who are pregnant with an estab-
lished DVT, high-risk surgical or trauma patients, and patients
with chronic thromboembolic disease or cardiorespiratory
frailty in the presence of DVT.8,11-13 The use of filters as a pro-
phylactic measure in the high-risk trauma patient has been
the subject of interest in the literature recently. The lack of
randomized data to support the use of IVC filters in this group
of patients must again be reiterated. However, it is up to indi-
vidual institutions and clinicians to decide on best practice for
their patients in this category on a case-by-case basis.
Trauma
Complex trauma patients have the highest incidence of VTE
of all hospitalized patients, with PE attributed to the third
most-common cause of death in these patients who survive
the first 24 hours from their injuries.9,14 VTE risk is exacer-
bated by factors influencing coagulopathy such as immobility,
fluid depletion, inflammatory mediators, and iatrogenic
factors including treatment with blood products. Pharma­
cological (low molecular weight heparin) and mechanical
thromboprophylaxis (intermittent pneumatic compression
[IPC)]) and graduated compression stockings are advocated
as first-line therapies in those without significant-bleeding
risk.9 There remains debate about optimal VTE prophylaxis in
those considered to be at high risk of VTE with associated
significant-bleeding risk.
Several groups have advocated the use of prophylactic IVC
filters in the prevention of PE in high-risk trauma patients.
Guidelines published by The Eastern Association of the
Surgery in Trauma in 2002 suggested consideration of prophy-
lactic IVC interruption for select high-risk patients.15 EAST
developed a risk-stratification tool—the Risk Assessment
Profile (RAP)—to allow stratification of trauma patients
according to VTE risk. The RAP score (Box 21-2) takes into
account various other scoring systems such as the Glasgow
Coma Scale (GCS) and the abbreviated injury score (AIS),
 21  /  Inferior Vena Cava Filters 236.e1

ABSTRACT
Venous thromboembolism (VTE) encompasses a range
of clinical presentations, with pulmonary embolism (PE)
being the most significant due to its potential to cause fatal
cardiopulmonary compromise. An estimated 25,000 to
200,000 fatalities per year are attributable to PE with rates
of nonfatal PE thought to reach 630,000 cases per year.1-3
Although systemic anticoagulation remains the gold-
standard therapy for all forms of VTE, inferior vena cava
(IVC) interruption with an implantable filter is advocated in
a small subgroup of patients in whom anticoagulation is
contraindicated or ineffective. This chapter provides an
overview on the use of IVC filters in select patient groups
(including those utilized in trauma patients), highlighting
different filter types, indications, techniques, and potential
associated complications.

Key Words:  venous thromboembolism,

prophylaxis,
filter,
indications,
complications
 21  /  Inferior Vena Cava Filters 237

Table 21-1 An Example of the Variety of IVC

Filters Currently Available on the
Market
Insertion Site
Size of (Jugular/ MRI
Device Introducer Femoral) Compatibility
Permanent Filters
Bird’s Nest 14 Fr Either (separate No
kits)
Greenfield 14 Fr Either (separate No
(stainless kits)
steel)
Simon 9 Fr Either (separate Yes
Nitinol kits) A B
TrapEase 8 Fr Either (1 kit for Yes
both)
VenaTech 14.6 Fr Either (one kit) Yes
Retrievable Filters
Gunther 12 Fr Either (separate Yes
Tulip kits)
OptEase 8 Fr Either Yes
Recovery 9 Fr Femoral Yes
Filter

C D
Box 21-1 Use of Inferior Vena Cava Filters
FIGURE 21-1  Commonly utilized retrievable IVC filters. A, Cook
Recommended use (based on evidence-based guidelines) Günther Tulip. B, Cook Celect. C, Cordis OPTEASE permanent IVC
• Proven VTE with contraindication for anticoagulation filter. D, Bard G2.
• Proven VTE with complications of anticoagulation treatment
• Recurrent VTE despite anticoagulation treatment (failure of
anticoagulation)
Expanded use (indications beyond those specified in Box 21-2 Risk Assessment Profile (RAP) Score
evidence-based guidelines)
• Recurrent PE complicated by pulmonary hypertension Age Weight
• Patients with DVT and limited cardiopulmonary reserve or   >40 but <60 2
chronic obstructive pulmonary disease (COPD)   >60 but <75 3
• Patients with large, free-floating iliofemoral thrombus   >75 4
• Following and during thrombectomy, embolectomy, or Injury-related factors Weight
thrombolysis of DVT   AIS >2 for the chest 2
• Trauma patients with a high risk of DVT (head and spinal cord   AIS >2 for the abdomen 2
injury, pelvic or lower extremity fractures) with a   Spinal fractures 2
contraindication for anticoagulation   AIS >2 for the head 3
• High-risk surgical patients with a contraindication for   Coma (GCS score <8 for >4 hr) 3
anticoagulation   Complex lower extremity fracture 4
  Pelvic fracture 4
• Patients with DVT who have cancer, who have burns, or who
  Spinal cord injury with paraplegia/quadriplegia 4
are pregnant
Contraindications for filter placement Iatrogenic factors Weight
  Central femoral line >24 hr 2
• Uncorrectable coagulopathy
  4 or more transfusions during first 24 hr 2
• Chronically thrombosed IVC   Surgical procedures >24 hr 2
• Sepsis or bacteremia   Repair or ligation of major venous injury 3
• Mega IVC (3.5 cm) Underlying conditions Weight
 Obese (>120% Metropolitan Life Table) 2
Adapted from Crowther MA: Inferior vena cava filters in the   Malignancy 2
management of venous thromboembolism. Am J Med 120:   Abnormal coagulation factors at admission 2
S13–S17, 2007.   History of thromboembolism 3

Adapted from Rogers FB, Cipolle MD, Velmahos G, et al:

Practice management guidelines for the prevention of venous
thromboembolism in trauma patients: the EAST practice
management guidelines work group. J Trauma 53:142–164, 2002.
AIS, Abbreviated injury score; GCS, Glasgow Coma Scale.
238 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT

together with 16 other patient factors.16 A RAP score greater

than 5 signifies increased a threefold increased risk of VTE.
Contrary to this, however, the American College of Chest
Physicians (ACCP) 2008 guidelines recommend against the
use of IVC filters as primary thromboprophylaxis in patients
with major trauma or spinal cord injuries (Grade 1C evi-
dence). These guidelines recommend that high-risk trauma
patients who are contraindicated to low molecular weight
heparin due to bleeding risk should receive mechanical pro-
phylaxis with IPS or GCS alone (Grade 1B evidence).9 Much
variation in practice exists among national and international
trauma centers; and, without any randomized controlled trials
addressing the efficacy of IVC filters for trauma, this trend is
likely to continue.17

Contraindications
Contraindications to placement of an IVC filter are uncom-
mon; but, nonetheless, it is important to recognize them. Con-
traindications include severe uncorrectable coagulopathy,
complete vena cava thrombosis and evidence of bacteremia /
sepsis and mega IVC (>3.5 cm diameter).

Techniques
Filter insertion and retrieval (in the case of nonpermanent
filters) requires appropriate prior fluoroscopic venographic
imaging in order to characterize the venous anatomy and to
diagnose the presence of caval thrombus. Filters may be placed
either via a femoral, jugular, or brachial approach, the jugular
being the most commonly employed especially in trauma
patients.
Insertion
Filters are approved for placement within the infrarenal
portion of the IVC. In certain circumstances, filters may be
placed safely within the suprarenal IVC (Fig. 21-2); a list of
indications for suprarenal IVC deployment is given in Box
21-3.18 Venous access is gained using ultrasound (US)-guided
puncture of the internal jugular or common femoral vein
(usually accessed on the right side), and a catheter is placed to
the level of the iliac veins, allowing subsequent venography. A
high-flow, high-pressure venogram (i.e., a cavogram) through
a flush angiographic catheter allows for assessment of anatomy
(i.e., the IVC and the renal veins). This maneuver also allows
for assessment of the IVC caliber, and it aids in excluding the
presence of IVC thrombus and other anomalies that may pre-
clude filter deployment (e.g., duplicated IVC) (Fig. 21-3). A
catheter can then be exchanged over a wire for the filter intro-
ducer sheath and the filter subsequently placed below the renal
veins (Fig. 21-4). A completion venogram is then performed
to ensure adequate positioning, orientation, and vena cava
integrity. It is important to ensure that a patient in whom a
potentially retrievable filter is placed is scheduled for the
appropriate follow-up.
Retrieval
Use of retrievable filters for short-term caval interruption has
increased in frequency.19,20 Although it is true that all retriev-
able filters may also be used as permanent filters, the vast
majority of IVC filters are placed for a transient need rather
than permanent need for VTE protection. Kaufman et al
FIGURE 21-2  Suprarenal IVC filter in a patient with compression of
the infrarenal IVC due to a pelvic mass. Renal veins are opacified on
the postinsertion venogram (arrows).
Box 21-3 Indications for Suprarenal Filter
Placements
The presence of IVC thrombus precluding placement of a filter
in the infrarenal IVC
Filter placement during pregnancy. Suprarenal placement is also
appropriate in women of childbearing age.
A thrombus extending above a previously placed infrarenal filter
A gonadal vein thrombosis
Anatomic variants (duplication of the IVC; low insertion of renal
veins)
Significant extrinsic compression of the infrarenal IVC
Intrinsic narrowing of the infrarenal IVC
Patients with an intraabdominal or pelvic mass who will undergo
surgery and in whom operative IVC mobilization is
contemplated
recommended that retrievable filters be considered in patients
with short-term risks for VTE and/or PE, with short-term
contraindication to anticoagulant therapy, with a life expec-
tancy greater than 6 months, and where compliance with
medications and follow-up appointments is assured.21
Filters are successfully retrieved in 82% of cases, via a
jugular approach, although some may be extracted through
the femoral route.22 A venogram should be performed prior
to retrieval to check for filter position (in relation to the IVC),
embolization, perforation, IVC thrombus, and intra- or supra-
filter thrombus (Fig. 21-5). Once these have been excluded,
the filter is retrieved using a snare to capture a hook at its apex
and then is collapsed to its predeployment shape or orienta-
tion by pushing the sheath over its expanded extent. A veno-
gram should then be performed to ensure IVC integrity. An
example of filter retrieval is shown in Figure 21-6.

FIGURE 21-3  Duplicated IVC in a preoperative patient with DVT.
FIGURE 21-4  Infrarenal IVC filter. A renal vein flow void is demon-
strated on the venograms (arrows).
Complications
Complications may be classified as short- or long-term and
are summarized in Box 21-4. Complications related to filter
insertion occur in approximately 4% to 11% of patients.
Although there is variability in reported complication rates for
21  /  Inferior Vena Cava Filters 239
FIGURE 21-5  A clot within the filter on the preremoval venogram is
seen as a filling defect within the filter (arrow).
filters overall, fatal complications are rare (less than 0.2%).23,24
In experienced hands, the process of IVC filter insertion is
associated with a low rate of complications; and, with proper
selection of filter indications and with appropriate manage-
ment, the risk of long-term complications is also low.
Short-Term Complications
Acute periprocedural or immediate postprocedure-related
complications include arterial puncture and pneumothorax
(these two potential complications being avoidable with
U.S. guidance), hematoma formation, and filter malposition.
Complications may be related to contrast agents, sites of
access, wire- and catheter-induced complications, and direct
filter-related issues. Misplacement or early deployment of the
filter must be recognized to allow retrieval and repositioning,
if possible. Filter tilting, angulation, or incomplete opening
may be seen secondary to sheath-device malposition or strut
deployment into a vessel orifice. Some have suggested that
filter tilt greater than 15 degrees from the midline is related
to a reduction in filter efficacy.23 Migration of the filter
could be problematic in trauma patients if there is antici-
pated manipulation of the IVC during subsequent operative
procedures.
Long-Term Complications
The role of long-term or permanent filter placement has come
under scrutiny due to the risk of long-term adverse events.
The reported incidence of DVT following insertion of IVC
filter is in the range of 6% to 36%.24,25 Importantly, IVC
thrombosis and PE post–IVC filter insertion have been
reported to be as high as 28% and 9%, respectively.26 The use
of retrievable filters is advantageous in this respect, if removed
after short intervals. Unfortunately, filters are infrequently
240 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
FIGURE 21-6  Removal of an IVC filter with a snare and resheathing the filter (i.e., not pulling the filter into the sheath, but pushing the sheath
over the filter to collapse it). Post IVC–filter removal venograms show no contrast extravasation or tear.
Box 21-4 Complications
SHORT-TERM COMPLICATIONS
• Contrast reaction
• Arrhythmia
• Air embolism (especially with jugular insertion)
• Pneumothorax/hemothorax
• Extravascular penetration of guidewire
• Premature opening—iliac vein
• SVC, heart, proximal IVC
• Incomplete opening
• Tilting/angulation
• Misplacement—iliac vein, renal vein Proximal to renal veins
when this was not planned
• Often requires placement of a second filter
• Guidewire entrapment
• Filter migration (3% to 69%)
• Embolization of the filter (2% to 5%)—to heart, pulmonary
artery
• Filter fracture
• Insertion site bleeding/hematoma. This will interfere with
subsequent anticoagulation.
• Infection at insertion site
• Contrast-induced renal dysfunction
• Arteriovenous fistula
PA, Pulmonary artery; SVC, superior vena cava.
removed despite initial placement of a retrievable system, with
retrieval rates quoted to be as low as 22%. Such low filter rate
retrieval is most commonly attributable to lack of patient
follow-up.27 Significantly, increased risk of DVT and IVC
thrombosis remain serious long-term concerns due to the
increased tendency to postthrombotic syndrome.28,29
Filter migration and mechanical failure were thought to be
infrequent events.19,30 However, a recent study by Nicholson
et al demonstrated significantly higher rates of filter fracture
and embolization—up to 25%—some of which resulted in
serious clinical sequelae.31 As of 2014, there remains a lack of
sound evidence base for the long-term safety and efficacy of
retrievable filters.
• Failure or delay in anticoagulation, which may lead to
progressive DVT, phlegmasia cerulea dolens, or venous
gangrene
• Insertion site thrombosis (2% to 35%) appears to be greater
with femoral route.
• Recurrent PE (0.5% to 6%)
• Fatal PE—rare (<1%)
• Death—very rare (3/2557)
LONG-TERM COMPLICATIONS
• Increased risk of subsequent DVT
• Physician assumption of long-term protection with failure to
prophylax
• Migration: proximal or distal
• Penetration of the vein wall/perforation: retroperitoneal, aorta,
ureter, bowel
• Common, generally no adverse consequences
• Filter fracture
• IVC occlusion (2% to 28%) with resultant chronic leg edema,
hyperpigmentation and ulceration
• Vena caval syndrome
• Risks associated with subsequent right heart/PA catheterization
from femoral vein including temporary pacemakers
• Lumbar pain from nerve impingement
• Pyophlebitis (very rare)
Summary
Inferior vena cava filters, whether permanent or potentially
retrievable, are indicated in the prevention of venous throm-
boembolism in those select patients in whom anticoagulation
is contraindicated. The increasing availability, the good safety
profile, and the ease of placement and removal of retrievable
filters have seen a dramatic rise in the number of filters
deployed recently. The efficacy of IVC filters has been well
documented when used for this recommended application;
however, robust evidence of its use in expanded clinical indi-
cations is currently lacking. Further prospective research is
required to assess long-term efficacy and safety data.
 21  /  Inferior Vena Cava Filters 241

REFERENCES 16. Welle MK: Inferior vena cava filter use as pulmonary embolism prophy-
laxis in trauma. Orthop Nurs 30:98–114, quiz 115–116, 2011.
1. Development NC: Prevention of venous thrombosis and pulmonary
17. Rajasekhar A, Lottenberg R, Lottenberg L, et al: Pulmonary embolism
embolism. JAMA 256:744–749, 1986.
prophylaxis with inferior vena cava filters in trauma patients: a systematic
2. Clagett GP: Basic data related to venous thromboembolism. Ann Vasc
review using the meta-analysis of observational studies in epidemiology
Surg 2:402–405, 1988.
(MOOSE) guidelines. J Thromb Thrombolysis 32:40–46, 2011.
3. Committee HoCH: The prevention of venous thromboembolism in hos-
18. Kalva SP, Chlapoutaki C, Wicky S, et al: Suprarenal inferior vena cava
pitalised patients. Second report of session 2004-5, London, 2007, DOH.
filters: a 20-year single-center experience. J Vasc Interv Radiol 19:1041–
4. Greenfield LJ, Proctor MC, Michaels AJ, et al: Prophylactic vena caval
1047, 2008.
filters in trauma: the rest of the story. J Vasc Surg 32:490–495, discussion
19. Hann CL, Streiff MB: The role of vena caval filters in the management of
496–497, 2000.
venous thromboembolism. Blood Rev 19:179–202, 2005.
5. Stein PD, Kayali F, Olson RE: Twenty-one-year trends in the use of infe-
20. Rutherford RB: Prophylactic indications for vena cava filters: critical
rior vena cava filters. Arch Intern Med 164:1541–1545, 2004.
appraisal. Semin Vasc Surg 18:158–165, 2005.
6. Decousus H, Leizorovicz A, Parent F, et al: A clinical trial of vena caval
21. Kaufman JA, Kinney TB, Streiff MB, et al: Guidelines for the use of
filters in the prevention of pulmonary embolism in patients with proxi-
retrievable and convertible vena cava filters: report from the Society of
mal deep-vein thrombosis. Prevention du Risque d’Embolie Pulmonaire
Interventional Radiology Multidisciplinary Consensus Conference. J Vasc
par Interruption Cave Study Group. N Engl J Med 338:409–415, 1998.
Interv Radiol 17:449–459, 2006.
7. Usoh F, Hingorani A, Ascher E, et al: Prospective randomized study com-
22. Uberoi R, Chalmers N, Walton P, et al: N. Inferior vena cava filter registry
paring the clinical outcomes between inferior vena cava Greenfield and
report. British Society of Interventional Radiology 2011.
TrapEase filters. J Vasc Surg 52:394–399, 2010.
23. Stawicki SP, Sims CA, Sharma R, et al: Vena cava filters: a synopsis of
8. Crowther MA: Inferior vena cava filters in the management of venous
complications and related topics. J Vasc Access 9:102–110, 2008.
thromboembolism. Am J Med 120:S13–S17, 2007.
24. Miyahara T, Miyata T, Shigematsu K, et al: Clinical outcome and compli-
9. Geerts WH, Bergqvist D, Pineo GF, et al: Prevention of venous thrombo-
cations of temporary inferior vena cava filter placement. J Vasc Surg
embolism: American College of Chest Physicians Evidence-Based Clinical
44:620–624, 2006.
Practice Guidelines (8th Edition). Chest 133:381S–453S, 2008.
25. Kinney TB: Update on inferior vena cava filters. J Vasc Interv Radiol
10. Kearon C, Kahn SR, Agnelli G, et al: Antithrombotic therapy for venous
14:425–440, 2003.
thromboembolic disease: American College of Chest Physicians Evidence-
26. Patel SH, Patel R: Inferior vena cava filters for recurrent thrombosis:
Based Clinical Practice Guidelines (8th Edition). Chest 133:454S–545S,
current evidence. Tex Heart Inst J 34:187–194, 2007.
2008.
27. Karmy-Jones R, Jurkovich GJ, Velmahos GC, et al: Practice patterns and
11. Cherry RA, Nichols PA, Snavely TM, et al: Prophylactic inferior vena cava
outcomes of retrievable vena cava filters in trauma patients: an AAST
filters: do they make a difference in trauma patients? J Trauma 65:544–
multicenter study. J Trauma 62:17–24, discussion 24–25, 2007.
548, 2008.
28. Crochet DP, Stora O, Ferry D, et al: Vena Tech-LGM filter: long-term
12. Bates SM, Greer IA, Pabinger I, et al: Venous thromboembolism, throm-
results of a prospective study. Radiology 188:857–860, 1993.
bophilia, antithrombotic therapy, and pregnancy: American College
29. Tardy B, Mismetti P, Page Y, et al: Symptomatic inferior vena cava filter
of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th
thrombosis: clinical study of 30 consecutive cases. Eur Respir J 9:2012–
Edition). Chest 133:844S–886S, 2008.
2016, 1996.
13. Girard TD, Philbrick JT, Fritz Angle J, et al: Prophylactic vena cava filters
30. Athanasoulis CA, Kaufman JA, Halpern EF, et al: Inferior vena caval
for trauma patients: a systematic review of the literature. Thromb Res
filters: review of a 26-year single-center clinical experience. Radiology
112:261–267, 2003.
216:54–66, 2000.
14. Knudson MM, Ikossi DG: Venous thromboembolism after trauma. Curr
31. Nicholson W, Nicholson WJ, Tolerico P, et al: Prevalence of fracture and
Opin Crit Care 10:539–548, 2004.
fragment embolization of Bard retrievable vena cava filters and clinical
15. Rogers FB, Cipolle MD, Velmahos G, et al: Practice management guide-
implications including cardiac perforation and tamponade. Arch Intern
lines for the prevention of venous thromboembolism in trauma patients:
Med 170:1827–1831, 2010.
the EAST practice management guidelines work group. J Trauma 53:142–
164, 2002.
 Soft-Tissue and Skeletal
Wound Management in the
22  Setting of Vascular Injury
SHEHAN HETTIARATCHY AND JON CLASPER
Introduction
Extremity injuries involving significant trauma to bone, soft
tissue, and major vessels are relatively uncommon outside of
the wartime setting. This constellation of injuries may also be
referred to as the mangled extremity. Much of the difficulty
encountered in managing patients with a mangled extremity
is due to the fact that few surgeons gain much experience in
dealing with this challenging injury pattern. In order to meet
this challenge, such injuries are best dealt with by a multidis-
ciplinary team that combines the subject-matter expertise of
vascular, plastic, and orthopedic specialists. The purpose of
this chapter is to consider the nature of the extravascular
component of severe limb trauma, the priorities in recon-
struction, and the sequencing of interventions in order to
furnish the vascular surgeon with the key imperatives of soft-
tissue and skeletal management as understood by their ortho-
pedic and plastic surgical colleagues.
Epidemiological Factors
The likelihood of fracture-associated extremity vascular
trauma depends on the nature of the associated orthopedic
injury; in a recent review the overall incidence was estimated
to be less than 1%.1 However, certain orthopedic injury pat-
terns, such as posterior knee dislocation, mandate a higher
index of suspicion. Vascular injuries may be more commonly
associated with fractures in the high-energy ballistic and blast
environments of military trauma. From a database of 679
patients with military extremity trauma, Brown et al identi-
fied 34 patients and 37 limbs with vascular injury.2 In only 9
of these limbs was the vascular trauma not associated with a
corresponding fracture. The authors of this study noted that
outcome was worse in patients with combined orthopedic and
vascular injury, and this was attributed to the unfavorable
soft-tissue sequelae of energy transfers sufficiently large to
cause bone fracture. This finding is also consistent with exam-
ples of high-energy extremity wounds reported in the civilian
literature.3 In an Israeli report of 35 casualties, both military
and civilian, Romanoff revealed that of 35 combined ortho-
pedic and vascular injuries, 14 (40%) involved the femoral
vessels, 9 (26%) compromised the popliteal vessels, and 8
(23%) involved the brachial artery.4 Upper limb injury com-
plexes were often related to gunshot wounds compared to
lower limb injuries. In Brown’s series (reporting experience
from the British military), 11 injuries (30.5% of all cases)
involved the upper limb, with 7 involving the brachial artery,
and 4 involving the radial and/or ulnar arteries.
242
The orthopedic injury most commonly associated with a
vascular injury is dislocation of the knee, particularly when
the dislocation is posterior in nature. The orthopedic injury
is of relatively low priority in the initial management of the
patient as the knee will usually be easy to reduce and, in some
cases, may have been reduced before the vascular injury is
appreciated. In general, the majority of these will be closed
injuries. In a literature review totaling 245 knee dislocations
with a 32% incidence of vascular injuries, time to revascular-
ization was the most important factor in determining outcome.
The authors described a salvage rate of 89% when this was
carried out in less than 8 hours, compared to an amputation
rate of 86% when the delay was greater than 8 hours.5 A more-
recent prospective report, undertaken as part of a multicenter
study depicting the outcome of severe lower limb injuries
described 18 patients, of whom 4 (22%) required amputation
(a figure that is relatively consistent in the literature). Despite
successful salvage, patients still had a moderate to high level
of disability 2 years after the injury; the knees were stiffer and
weaker; and only 2 were stable in all directions.6
Grading of Orthopedic Fractures
Open fractures represent a heterogeneous group of injuries,
but the relationship between extent of tissue damage and like-
lihood of limb salvage and functional recovery has been rec-
ognized for decades. As such, a formal system for grading the
severity of open fractures was introduced by Gustilo and
Anderson in 1976 (Table 22-1). 7 This remains a universally
accepted classification of the wound associated with an open
fracture, relating especially well to the risk of infection. For
Gustilo type I fractures, an infection rate of 1% or less can be
expected; and for type II fractures, a rate of approximately 3%
has been reported.8 Since the original description, it has been
recognized that those with type III fractures are a large and
heterogeneous group; and, to reflect this, a modification to the
original grading was made with subdivision of type III frac-
tures as follows:
• Type IIIA—Adequate soft-tissue cover of the bone
despite extensive laceration
• Type IIIB—Extensive soft-tissue loss, with periosteal
stripping and exposed bone. Usually associated with
massive contamination
• Type IIIC—Open fracture with vascular injury that
needs repair
For type IIIA fractures, an infection rate of 17% has been
reported, and for type IIIB 26%. Type IIIC fractures have a
variable infection rate, depending on the soft-tissue injury and
 22  /  Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 242.e1

ABSTRACT
An injury to a limb that compromises the soft tissues, vas-
culature, and skeleton has the potential to lead to limb loss,
either immediately or delayed, or to result in a limb with
significant dysfunction. The only way to avoid these out-
comes is to treat each element of the injury thoroughly in
a simultaneous manner. It is important to realize that any
one component of this triad of injury can be the deciding
factor between a salvageable, functional limb and one that
either functions poorly or requires amputation. These inju-
ries should be dealt with by a team that includes experts
in these areas (vascular, plastic, and orthopedic surgeons)
so that the correct decisions can be made at the correct
times. The overall aim should not be limb salvage but
functional limb salvage. In order to achieve this concept of
having the right team to make the right decision, the
definitive management of these complex injuries should be
performed in specialist centers that have the appropriate
experience and the right personnel to deal with all aspects
of the injury. Finally, it should be remembered that the key
decision is whether to attempt salvage or not. A lower limb
amputation can be a very functional option. Getting this
decision right is vital if the patient is to make a good and
holistic recovery from the limb injury.

Key Words:  amputation,

lower limb scoring systems,
débridement,
limb salvage,
revascularization,
soft-tissue reconstruction,
outcome,
rehabilitation
 22  /  Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 243
Table 22-1 Gustilo-Anderson Classification of
Open Tibial Fractures
Type I An open fracture with a wound less than 1-cm long
and clean
Type II An open fracture with a laceration more than 1-cm
long without extensive soft-tissue damage, flaps,
or avulsions
Type III An open segmental fracture, an open fracture with
extensive soft-tissue damage, or a traumatic
amputation
the time to revascularization. A proportion of IIIC injuries
require amputation due to lack of reconstructive options, and
late infection is of less relevance as an outcome measure in
this group. In a report of 546 tibial fractures, 7 of 9 IIIC inju-
ries required amputation.9 The relative rarity of these injuries,
combined with their heterogeneous nature means that mean-
ingful comparison of outcomes (either between different
papers or even between patients reported in the same paper)
is difficult, if not impossible.
Salvage Versus Amputation
In essence only the following three decisions are available to
the surgeon managing an extremity injury where limb isch-
emia is present: perform primary amputation, defer primary
amputation to a later date, or attempt surgical intervention
with a view to limb salvage. The latter may involve a lengthy
or complex revascularization procedure, definitive fracture
fixation, and soft-tissue coverage extending to microvascular
tissue transfer. There are inherent risks of attempted limb
salvage as the procedures may be costly in terms of patient
reserve and risk of mortality, need for multiple operative pro-
cedures, and prolonged rehabilitation.
“Successful limb salvage” is a subjective phrase; outcomes
can be variably defined according to patient factors such as
pain, function, return to work, and satisfaction. Expectation
of recovery varies according to the individual. Younger patients
tend to have higher levels of preinjury activity, and rehabilita-
tion will be concordantly longer in order to ensure recovery
to previous functional capability. In contrast, the older, less-
mobile population may have lower expectations. Expectation
management forms a key part of the duty of the multidisci-
plinary team in cases of limb salvage or amputation, with
regular and consistent counseling of the patient and their rela-
tives in order to allow realistic but positive interpretations of
recovery potential.
Studies have reported the long-term outcomes and quality
of life in limb-salvage patients with open tibial shaft fractures
and severe soft-tissue loss compared to amputees.10 Limb-
salvage patients took longer to achieve full weight-bearing
status, were less willing or able to work, and had a significant
loss in range of movement at the ankle. Fairhurst et al dem-
onstrated that early amputees had higher functional scores,
fewer operations and returned to work and sporting activities
within 6 months. They concluded that early amputation was
better when confronted with a borderline salvageable tibial
injury.11 However, recent reports from a prospective multi-
center trial of 556 patients (the Lower Extremity Assessment
Project [LEAP]), reported no difference in functional out-
comes between patients who either underwent limb-salvage
surgery or early amputation at 2-year and 7-year follow-up
points.12 The level of amputation was a further predictor of
outcome. Further analysis of the difference in cost analysis of
limb salvage, and amputation has shown that the latter is
significantly more expensive if the ongoing maintenance and
replacement costs of the prostheses are included.
Several scoring systems have been developed to help guide
the decision as to whether or not to amputate after severe
lower limb trauma, and they have been designed to augment
subjective clinical impression with objective assessment based
on specific criteria. In their retrospective review of 58 severely
injured limbs, Bonanni et al showed low sensitivities of Man-
gled Extremity Severity Score (MESS) (22%), limb-salvage
index (61%), and predictive salvage index (33%).13 The LEAP
study assessed MESS, predictive salvage index, limb-salvage
index, nerve injury; ischemia/soft tissue contamination; skel-
etal; shock; age (NISSA), and Hannover Fracture Scale (HFS)-
97. The authors reported a high specificity but much lower
sensitivities for the scores than those reported by the develop-
ing authors. The performance decreased further when imme-
diate amputations were excluded.12 A further study from the
same group suggested that lower limb extremity scores do not
predict the short- or longer-term functional outcome.
Strategies in Managing the Severely
Injured Limb
Sequencing of Interventions
Considerable debate has centered on the sequencing of opera-
tive steps in the management of the mangled extremity. The
following elements of treatment are necessary for most limbs
that exhibit an open fracture associated with major vascular
injury:
• The extent of soft-tissue damage, vascular compromise,
and skeletal instability must be systematically assessed.
• The wound should be débrided so that all unviable tissue
is removed.
• Vascular repair/reconstruction should be performed.
• Skeletal stabilization must be performed.
• Mitigation of complications—such as infection or com-
partment syndrome—must be undertaken proactively.
Determining the optimal sequence of reperfusion versus
stabilization of the limb may be difficult because the following
two competing imperatives have to be reconciled: the period
of warm ischemia must be as limited as possible (and should
never extend beyond 6 hours from time of injury), yet skeletal
stability must be achieved in a timely fashion without com-
promising any vascular repair. Deciding on the best sequence
has attracted much debate over the past 4 decades. A meta-
analysis of the data concluded that amputation rates are not
affected by the sequencing of revascularization, whether
undertaken before or after fracture stabilization.14 The authors
acknowledged the retrospective nature of the cohort studies
analyzed, and outcomes other than amputation were not con-
sidered in their review.
McHenry in 2002 retrospectively studied a cohort of 27
limbs with orthovascular injury secondary to gunshot wounds
and concluded that revascularization (whether definitive or
via a shunt) should be carried out before skeletal stabilization,
on the basis of a nonsignificant trend toward higher fasciot-
omy rates in 5 cases where stabilization was prioritized.15 The
244 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
cohort included brachial, femoral, and popliteal injuries; but
the authors did not include patients with crural vessel injury.
Furthermore, 13 of the 14 internal fixations were carried out
in the group that had initial revascularization, suggesting pos-
sible selection bias.15 Initial revascularization followed by skel-
etal fixation was not associated with damage of the vascular
repair, contradicting an often-quoted rationale that orthope-
dic manipulation and fracture fixation in the setting of a
freshly repaired vessel carries a major risk of disruption.
The debate around sequencing has been blunted by the
development of temporary vascular shunting as a means of
ensuring early restoration of flow and facilitation of a window
of opportunity for orthopedic intervention. Extensive experi-
ence with the use of vascular shunts during the wars in
Afghanistan and Iraq includes clinical data suggesting that this
damage control adjunct extends the window of limb salvage
in the most severely injured extremities.16,17 Translational large
animal data, also stemming from investigation during the
wars, has shown improved extremity neuromuscular recovery
and function with shorter ischemic times (less than 3 hours).18
Whichever strategy is chosen, it is worth reiterating that these
injuries are infrequently seen and often require individualized
solutions. Some cases merit early stabilization, others shunt-
ing, and some early definitive vascular repair.
Major Limb Amputation for Trauma
Amputations undertaken for the acutely injured and unsal-
vageable extremity offer a set of challenges that differ from
those regularly encountered by vascular surgeons managing
patients with unreconstructible peripheral vascular disease. In
particular, patients with limbs that have been rendered unsal-
vageable by blast have very specific requirements. In such cir-
cumstances, guidelines developed by UK Defence Medical
Services may prove helpful (and are applicable to the patient
with non–blast-mangled extremity) as set out in Box 22-1.
In assessing the viability of the distal soft-tissue envelope
(which will define the level of amputation), medial and lateral
Box 22-1 UK Defence Medical Services Guidelines
Concerning Trauma Amputation
1. The examination findings, together with the indications to
amputate the limb, should be documented.
2. Existing limb salvage scores should NOT be used to
determine the need for amputation.
3. Whenever possible, the decision to amputate a limb should
be confirmed by a second surgeon.
4. All wounds should be photographed.
5. Radiographs should be obtained before amputation.
6. Neurological dysfunction (particularly numbness of the sole
of the foot) should NOT be part of the criteria used to
decide amputation.
7. The site of amputation should be at the lowest level possible.
8. Guillotine amputations should not be performed.
9. There should be no fashioning of flaps at initial
débridement.
10. Bone should be cut at the most distal soft-tissue levels.
11. Amputation should not to be carried out at the level of any
fracture unless this is the appropriate skin/soft-tissue level.
12. No part of the wound is to be closed at initial surgery.
13. No attempt is to be made to prevent skin retraction.
14. Through-knee amputation is acceptable if appropriate.
longitudinal incisions should be used to extend the wounds
in order to allow adequate exposure if the preexisting wounds
do not afford this assessment. At initial débridement, all
viable tissue should be preserved even if bone length appears
excessive or if excess soft tissue is present. This is to avoid
compromising definitive closure, particularly if further skin
or soft-tissue necrosis occurs. Definitive flaps should not be
performed at the initial débridement. This may result in the
excision of viable tissue, which could be required for definitive
wound closure, particularly if further excision is required or
if nonstandard flaps are necessary. Definitive flaps are created
at the time of wound closure, usually 2 to 5 days later.
Essentially a trauma amputation should be considered an
extension of débridement, rather than a definitive procedure
in its own right. By adopting this attitude, the limb is removed
as part of the débridement of nonviable tissue, the tissues are
excised at the most distal point possible, and the temptation
to fashion formal flaps is avoided.
Assessment of the Injured Extremity
The patient with a severely injured or mangled extremity
should be managed within trauma protocols based around
Advanced Trauma Life Support guidelines or their equivalent.
The limb injury, no matter how severe, should not detract
from or delay any lifesaving interventions that need to be
undertaken to ensure that major hemorrhage is controlled
and that the airway is secured. Bleeding from the limb should
be controlled; direct pressure applied through sterile dress-
ings, combined with elevation, is appropriate. If unsuccessful,
the application of a tourniquet is indicated. Ideally this should
be a pneumatic tourniquet but a military-style combat appli-
cation mechanical tourniquet with a windlass mechanism will
suffice.
Each tissue type, skin, muscle, and nerve should be consid-
ered and assessed separately. The zone of injury (i.e., the part
of the limb that has received the energy transference from the
wounding mechanism) should be determined. This zone can
vary in size depending on how the injury was induced; but,
irrespective of size, all tissues within the injury zone will have
been affected to a lesser or greater extent. Certain tissues, such
as skin, are more robust and can tolerate a degree of injury,
whereas others (fat, muscle) are more likely to suffer irrepa-
rable damage.
For extremities, it is important to determine whether a
degloving component is present. This is when the skin has
been sheared off the deep fascia, leading to thrombosis or
avulsion of the skin perforating vessels and subsequent skin
death. Degloving occurs in traction or shearing injuries and
is often observed if a limb has been run over by a vehicle.
Degloving also occurs in blast injuries, where the blast mecha-
nism strips the skin away from the underlying tissues. Detect-
ing the presence of a degloving injury can be difficult; but it
should always be considered given a suspicious mechanism of
injury. Soft-tissue appraisal should occur in conjunction with
the orthopedic assessment. This should include an assessment
of limb-length discrepancy, abnormal bony contour, joint
function, and axial stability according to the usual “look/feel/
move” paradigm.
A full neurovascular examination should be performed,
although a depressed level of consciousness will not permit
a full assessment of motor and sensory functions. The
 22  /  Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 245

Table 22-2 Functional Motor and Sensory Assessment of the Extremities

Nerves
Upper Limb
Musculocutaneous nerve
Median nerve
Ulnar nerve
Radial nerve
Lower Limb
Saphenous nerve (terminal
branch of femoral nerve)
Tibial nerve (sensory medial
and lateral plantar nerves)
Sural nerve (branch of
common peroneal nerve)
Common peroneal nerve
Superficial branch peroneal
nerve
Deep branch peroneal
nerve
Motor
Elbow flexion
Wrist flexion, abduction of thumb.
(Thumb can be brought out at
90° from palm.)
Abduction of fingers
Extension of elbow, wrist, and fingers
at metacarpophalangeal joints
Plantarflexion of the foot
Ankle eversion (lateral compartment)
Dorsiflexion of the foot
Sensory Significance
Radial border Injury in axilla/upper arm; risk of axillary/
of forearm brachial artery injury
Thumb Consider flexor compartment syndrome.
Little finger May also have ulnar artery injury
First web Consider extensor compartment syndrome.
Medial border Thigh injury or anterior thigh compartment
of foot syndrome. Femoral artery/vein may be
injured.
Sole of foot Posterior compartment of leg injury or
compartment syndrome. Posterior tibial
artery may also be injured.
Lateral border Popliteal fossa injury
of foot
Indicates injury before division into deep and
superficial branches (sensory loss in both
superficial and deep branches). Lateral
compartment injury or compartment
syndrome
Dorsum of foot Lateral compartment injury or compartment
syndrome
First web space Anterior compartment injury or
compartment syndrome. Anterior tibial
artery may also be injured.

peripheral nerves of the extremity should be examined (Table
22-2). In the foot, these are saphenous nerve (instep) medial
and lateral plantar nerves (sole), sural nerve (outer border),
superficial peroneal nerve (dorsum), and deep peroneal nerve
(first web-space dorsum). In the hand, these are the median
nerve (index finger), the ulnar nerve (little finger), and the
superficial branch of the radial nerve (first web space).
Motor examination may be limited by pain from the injury
or mechanical disruption of the muscles being tested. In the
lower extremity the tibial nerve (ankle plantar flexion) and
deep branch of the peroneal nerve (ankle dorsiflexion) are
examined. In the upper extremity, the following nerves should
be tested: the median nerve (thumb abduction); the ulnar
nerve (finger abduction); the radial nerve (elbow/wrist/finger
at metacarpophalangeal joint extension); and the musculocu-
taneous nerve (elbow flexion). Detailed examination of the
individual muscle groups may also be performed.
The vascular examination should be performed before and
after any reduction of fractures or joint dislocations. Com-
partment syndrome should be searched for and should be
actively excluded. The wounds are then inspected via careful
removal of overlying dressings. At this stage, only visual
inspection may be possible, so the assessment will not be as
informative as the exploration or definitive assessment per-
formed in the operating theater. The location and size of the
wounds should be documented. Tire marks or abrasions on
the skin may seem innocuous but may be the result of a shear-
ing force and hence important indicators of degloving. The
exposure of any fractures or joints should be documented.
Large, loose particles of gross contamination should be
removed, but formal irrigation of wounds within the emer-
gency department (ED) is not required as this is best under-
taken in the operating theater. ED irrigation risks flushing
contaminants deeper into the wound, worsening of patient
hypothermia, and delaying definitive surgery. Similarly, there
is no indication for wound exploration in the ED as this can
be achieved in a far more comprehensive and controlled
fashion in the operating room. Once the soft-tissues have been
assessed, the wounds should be photographed and then
dressed with a saline-moistened gauze covered by an occlusive
dressing. The limb should then be splinted as close to the
anatomical position as is possible.
All patients should receive tetanus prophylaxis if there is
doubt about native immunity. A stat dose of antibiotics should
be administered intravenously (e.g., Co-amoxiclav 1.2 g or
cefuroxime 1.5 g). (If the patient has a documented penicillin
allergy, clindamycin 600 mg IV can be used instead.)
If there is doubt about vascular integrity (e.g., if pulses are
not restored following an early attempt at traction and splint-
ing), further investigation may be merited as discussed in
Chapters 5 and 6. However, it should be appreciated that
routine preoperative angiography is not indicated in single-
level injuries. In this scenario, the vascular injury is invariably
at the same level as the soft-tissue and bony injuries. Glass et al
found that angiography had no impact on limb-salvage rates,
regardless of the time interval to revascularization (intervals
less than 6 hours: 85% and 90% limb-salvage rates with and
without angiography, respectively; intervals greater than 6
hours: 61% and 67% limb-salvage rates with and without
angiography, respectively).19 We advocate judicious use of
angiography and only in the scenario of multilevel soft-tissue
or skeletal injury where the site of vascular injury is not clear.
246 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
Much of the debate regarding the value of routine angiog-
raphy in patients with open fractures has been made nugatory
by the ubiquity of multidetector computed tomography (CT).
CT angiography (CTA)—performed as part of the CT series
assessing other aspects of the limb injury (e.g., the positions
of bony fragments) or other injuries to other bodily areas
(head, axial skeleton, torso)—may be utilized to avoid the
need for formal digital subtraction angiography. However, if
CTA has not been performed but angiography is still indi-
cated, an on-table study may be the most expeditious way of
obtaining the necessary information.
Initial Surgical Management
The first steps in the surgical management of the poly trau-
matized extremity are as follows:
1. Prescrubbing of the limb
While the patient is in the anesthetic room, the limb
should be prescrubbed with a soap solution and a surgi-
cal scrub brush. This is termed a “social clean” and does
not involve scrubbing the wound itself. A pneumatic
tourniquet should be placed on the proximal limb if the
wound permits. The decision to inflate will be influ-
enced by the degree of control of hemorrhage at the
start, with further appraisal of the hemorrhage once
surgical exploration of the wound has begun. The
bloodless field afforded by a tourniquet allows easier
identification of important structures, but the aggregate
tourniquet time must be monitored carefully with the
goal of minimizing the ischemic insult to vulnerable
tissues. The limb should be prepped and draped in the
standard fashion.
2. Reestablishment of circulation via a shunt and
reassessment
The first step is to rapidly identify the injured vascu-
lar axis, to apply local control measures, and then to
judiciously shunt arterial and venous structures. The
selection and use of temporary vascular shunts as
damage control adjuncts in this setting are reviewed in
detail in Chapter 17. Once perfusion has been reestab-
lished with temporary vascular shunt(s), further assess-
ment of options for limb salvage should be made by
swift examination of the wounded tissues. This may
involve the use of a “trial of débridement” using a com-
bination of limited débridement and surgical exposure
of deeper tissues lying within and bordering on the
injury zone to gain more information on the extent of
disruption and the likelihood of functional recovery.
3. Surgical débridement of injured tissues
Definitive débridement should be systematic and
meticulous but should not be so radical as to resect
frankly uninjured and uncontaminated tissue bordering
the wound. Where the degree of functional recovery
may hinge on preservation of tissue volume, an overly
aggressive approach is not correct.
The normal sequence is to work superficial–to-deep
and peripheral–to-central. Where there has been signifi-
cant anatomical disruption, it can be prudent to identify
the main neurovascular structures first to avoid inadver-
tent injury during débridement. The skin edge of the
traumatic wound should be excised. The wounds usually
need to be extended to allow access to all damaged
tissues. In the lower limb, extensions are performed
along fasciotomy lines to limit the additional damage of
débridement. All overtly devitalized and contaminated
tissue should be débrided. The layers and tissues should
be worked through systematically. Assessing the viability
of different tissues can be difficult and requires experi-
ence. For skin, the best assessment is bleeding from a
cut edge. Fat can appear discolored if devascularized.
Muscle is assessed by the “four Cs”: contractility (muscle
twitches when lightly gripped with forceps); consistency
(does not tear when gently handled); color (red-pink
color; not a dusky purple); and capacity to bleed. Bone
may be difficult to assess, but a combination of intact
periosteum and bleeding from the bone ends suggests
viability. All nerves should be preserved. Note that
absence of bleeding is unreliable as a marker of unviabil-
ity if the patient is hypotensive or hypothermic or if a
tourniquet is being used. If there is a suggestion that
tissue may be viable but underperfused, it should be
left for subsequent review when perfusion has been
optimized.
As discussed previously, degloving injury occurs
when tissue, particularly skin, is sheared away from its
underlying structures. This leads to damage of the per-
forating vessels and subsequent tissue death, although
this may only manifest itself after 3 to 5 days. Making
an assessment of the viability of degloved tissue is dif-
ficult, and incisions close to an area of degloving may
lead to further compromise of perfusion and may pre-
cipitate the death of tissue that may have otherwise sur-
vived. Degloved skin is more fragile than normal skin,
must be handled delicately, is intolerant of tension when
used to close wounds, and should be used with caution
when fashioning amputation flaps.
Multiplanar degloving occurs when muscles and
neurovascular structures are sheared in different tissue
planes (Fig. 22-1). This signifies a more severe injury
and a poorer chance of limb salvage. When assessing
and documenting the extent of degloving injury it can
be useful to apply the Arnez classification (Box 22-2).
FIGURE 22-1  Multiplanar degloving of a lower limb following being
run over by a truck. Looking into the popliteal fossa, the posterior
aspect of the leg is visible. The vessels were intact, but the severity of
the bony and soft-tissue injury were not compatible with salvage.
 22  /  Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 247
Box 22-2 Arnez Classification of Degloving Injury
1. Localized degloving
2. Noncircumferential single-plane degloving
3. Single-plane circumferential degloving
4. Circumferential and multiplanar degloving
Once the soft-tissue débridement has been com-
pleted, bony débridement is begun. The bone ends
should be delivered and again assessed for viability and
contamination. All grit and debris should be removed
by scrubbing, by bone excision, or with a burr. Any
loose bony fragments that do not have soft-tissue
attachment should be removed. Larger fragments, par-
ticularly if they comprise the articular surface of a joint
may be preserved, although they risk becoming seques-
tra if vascularity is poor. Once the soft-tissue and bony
débridement has been completed, the wound should be
irrigated and washed with low-pressure saline lavage of
between 3 and 6 L depending on wound size. There is
little evidence to support the use of additional antimi-
crobial agents.20 Hydrogen peroxide does not confer any
benefit but acts solely to damage tissues. It should not
be used.
At any stage in this process of concurrent débride-
ment and wound assessment, it may become apparent
that tissue loss is catastrophic and that there is no rea-
sonable hope of limb salvage. Depending on the nature
and the degree of injury, as well as the experience of the
operator, this position may be reached within minutes
of surgical exposure and débridement; or it may become
apparent only after a more thorough and prolonged
assessment of deeper structures within the wound. In
these circumstances, the decision to amputate a limb
depends on multiple factors; but patient physiology is a
consistent variable. In the poly-traumatized and criti-
cally ill individual, there is nothing to be gained from
delaying limb ablation. However, where physiology
permits—and unless the situation demands urgent sep-
aration of the limb from the body—a decision concern-
ing amputation should be explored with the patient and
consent obtained as appropriate. It is often wise to defer
amputation until a later second-look opportunity, 24 to
48 hours after the initial surgery, in order to counsel the
patient and to set expectations accordingly.
4. Stabilization of the fracture site
Operative stabilization eliminates fracture move-
ment, protects the vascular repair, and reduces the risk
of infection.7 In one of the earliest reports, Rich et al
reviewed the results of open fractures that required a
vascular repair during the war in Vietnam, and reported
that 50% of all intramedullary nails required removal
for complications directly related to the implant.21 The
most common complication was infection; and the
authors concluded that, in the military environment,
external splints with the use of transfixion pins was a
safer option for the stabilization of fractures associated
with vascular injury. In his 1979 series, Romanoff
reported on patients of whom the majority had internal
fixation with screws or plates.4 Internal fixation was
associated with a lower rate of amputation (30%) than
external fixation (45.3%), but the authors acknowl-
edged that this was likely to be related to injury factors
rather than the chosen technique. However, the authors
concluded that infection rates were directly influenced
by the method of fixation, with higher rates associated
with internal fixation (45% versus 27.2%).
Plate fixation of open fractures of the lower limb fell
out of favor in the 1980s. Bach and Hansen reported a
prospective trial of plate versus external fixator for
severe open tibial fractures in 1989. Of 26 fractures
treated by plate fixation, 9 (35%) developed wound
infections and 5 (19%) developed chronic osteomyelitis.
Of the 30 fractures treated by external fixation, 4 (13%)
developed wound infections and only 1 (3%) developed
chronic osteomyelitis. At final follow-up, all tibial frac-
tures had healed; but the conclusion of the authors was
that plate fixation had little role in the stabilization of
severe open tibial fractures.22 Most contemporary
sources agree that plate stabilization of open femoral
fractures is rarely indicated and that IM nails have been
more commonly used. A recent review has also con-
cluded that IM nailing is the treatment of choice,
although the authors admit that there are few prospec-
tive studies of open femoral fracture.23 IM nails were
associated with a deep infection rate of 3.3%, compared
with 13.3% with definitive external fixation; the latter
was also associated with a malunion rate of 23.3% and
a reoperation rate of 17% (outcomes poorer than
reported with traction).
Despite the apparent superiority of IM nailing for
internal fixation, it should be noted that few of the
patients included in these studies had sustained a vas-
cular injury. In such cases—where timely limb reper­
fusion is a prerequisite to successful outcome—the
advantage of definitive IM fixation is often outweighed
by the expediency of external fixation. The latter facili-
tates concurrent activity such as vein harvest, and
requires less specialist equipment and, arguably, less
technical expertise. Furthermore, external fixators can
be used to span a disrupted joint and to maintain stabil-
ity of fractures involving the articular surfaces. In effect,
external fixation can be effectively used as a damage
control technique before definitive vascular repair and,
from there, IM fixation and soft-tissue cover. Complica-
tions such as pin-site infection must be guarded against
through rigorous care of the fixator–skin interface and
minimization of delay to definitive IM fixation in order
to prevent long-term infective sequela.
5. Definitive vascular repair with autologous graft
Definitive vascular repair establishing adequate per-
fusion to the mangled extremity is a key tenet of man-
agement. As is discussed in Chapters 14, 15, 18, and 23,
the use of autologous vein (e.g., great saphenous) as a
vascular conduit is preferred in nearly all cases of
mangled extremity. Because this aspect of management
is reviewed thoroughly elsewhere in this book, this
chapter will not elaborate on its conduct.
6. Coverage of repair with soft tissue
The vascular repair will be threatened if the extent of
injury means that soft-tissue cover is not possible. Nega-
tive pressure wound therapy (NPWT) dressings are
commonly used to seal open fractures associated with a
248 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
A B
soft-tissue defect, but they may contribute to anasto-
motic breakdown if they are placed directly in contact
with exposed vessels. In short, viable soft tissue must be
placed over the repair: and, if this is not possible through
local apposition, local flaps must be mobilized (Fig.
22-2). Sartorius, if available, is a good option for cover-
ing the common femoral vessels. Other types of flap
coverage are discussed later in this chapter.
7. Performance of fasciotomies
Fasciotomies of the calf should be two-incision fas-
ciotomies (to enable full access to all four compart-
ments). The most critical aspect of performing calf
fasciotomies is accurate placement of the incisions.
Medially, there are three perforating vessels that arise
from the posterior tibial vessels at 5 cm, 10 cm, and
15 cm above the medial joint line of the ankle and reach
the skin 1.5 cm to 2 cm posterior to the medial subcu-
taneous border of the tibia. These perforators are
important in open fractures because they provide the
blood supply for the distally based local fasciocutaneous
flaps that can be used to cover open fractures. Preserva-
tion is assured by making the medial incision 1.5 cm
posterior to the medial subcutaneous border of the
tibia. This distance should be measured and marked
before making the incision. By following this method,
all potential reconstructive options are preserved. If
there has been extensive vascular disruption and these
perforators are no longer intact, the placing of the inci-
sion is less critical; but it is important not to expose the
subcutaneous border of the tibia. The lateral incision is
placed 2 cm lateral to the lateral subcutaneous border
of the tibia. The anterior compartment is opened, and
the intermuscular septum between it and the lateral/
peroneal compartment is identified and released. When
extending the incision proximally care should be taken
to protect the common peroneal nerve.
FIGURE 22-2  A, A reversed vein
graft to manage a brachial artery
defect following a high-velocity
gunshot wound to the antecubital
fossa. There are few local cover
options for the graft. B, A proxi-
mally based adipofascial flap
raised from the forearm and cov-
ering the vessel.
Reconstruction
Orthopedic interventions should be planned and then exe-
cuted at the same time as definitive soft-tissue reconstruction.
When it is not possible to approximate soft tissue over the
defect, appropriate reconstructive options must be considered.
It should be remembered that adequate and timely débride-
ment must be performed before reconstruction; it is the
quality of this initial débridement that sets the foundation for
success.
Fix and Flap
The “fix and flap” approach consists of near simultaneous
skeletal fixation and soft-tissue coverage with a flap. This tech-
nique is predicated on the evidence that early wound closure
decreases the risk of deep infection.24 Godina et al’s 1986
series of 532 patients treated with microsurgical reconstruc-
tion for extremity trauma revealed a postoperative infection
rate of 1.5% for patients treated within 72 hours of injury,
compared to 17.5% in those who received delayed opera-
tions.25 Byrd and Spicer (1985) also found that reconstruc-
tions performed within 5 days had a lower incidence of
osteomyelitis (5%) than those covered later (40%).26 Delay
leads to technical difficulty (the tissues are more friable and
planes often fibrosed) and is associated with higher flap failure
rate and predisposition to long-term infection.26,27 Further-
more, extremity fractures covered by free flaps—fully trans-
posed blocks of vascularized tissue that are grafted onto a local
vascular axis in order to remain viable—heal faster when the
flap is performed within 15 days.28 Achieving early fix and flap
may be difficult if the patient is unstable secondary to their
polytrauma or if institutional factors make timely work-up
very difficult. Naique et al reported a deep infection rate of
8.5% for an average coverage time of 6.8 days, which suggests
that a threshold of 7 days to fix and flap is a clinically appro-
priate time frame.27
 22  /  Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 249
Choice and Type of Reconstruction
The nature of the tissue defect is the principle factor that
determines the choice of reconstructive technique. Bare bone
and joint tissue does not tend to granulate; and thus split skin
grafts will not suffice in such cases; and, where there are large
complex defects with substantial loss of volume or where the
tissues overlying bone are thin (as is the case with the tibia),
a flap is often required. Where possible, and in low-energy
transfer wounds, a local flap may be possible assuming the
local vascular supply (as mediated by perforating vessels) is
robust. Formal intraarterial angiography—obtained post vas-
cular reconstruction—may help in this determination.
Flap Reconstruction
For lower limb trauma, the choice of local flaps—that is, flaps
raised from tissue beds bordering the injury zone—is contin-
gent on the site of the injury:
• Upper-third tibia/knee
The upper third of the tibia can be covered using a
gastrocnemius muscle flap. The medial and/or lateral
heads are mobilized and pedicled on their feeding
vessel—the sural artery. The muscle can be completely
detached and can be used to cover defects as high as the
suprapatellar region. The flap relies on the sural artery
being intact, and extensive vascular disruption around
the knee may preclude this option. Alternately, a proxi-
mally based saphenous artery fasciocutaneous flap can
be utilized for upper-third defects. This vessel, a branch
of the descending genicular artery, should be intact
unless the vascular injury is midthigh.
• Middle-third tibia
Distal fasciocutaneous flaps based on the medial per-
forators from the posterior tibial artery are best suited to
cover defects here. The perforators tend to arise 5 cm,
10 cm, and 15 cm above the medial joint line of the
ankle. A vascular injury to the posterior tibial vessels or
a medial fasciotomy incision placed too posteriorly may
compromise these perforators and preclude use.
• Distal-third tibia/ankle
Few local fasciocutaneous flap options are available
for use in this zone. A fasciocutaneous flap based on the
posterior tibial perforators may be raised and then
rotated through 180° around the axis of the perforator to
bring the flap into the defect. Such flaps have a tenuous
venous drainage and a concordantly higher complication
rate. Other local options include a flap based on the sural
neurovascular bundle that allows tissue from the poste-
rior aspect of the calf to be pedicled in a reversed fashion
to cover defects around the ankle. Such flaps tend to have
a higher complication rate with partial flap loss, though
Parrett et al suggest that the evidence is skewed by
comorbidity and that sural flaps are reliable in fit healthy
patients.29
Free Flaps
Distal defects are frequently treated with free tissue transfer
flaps because these contour well to the ankle region and are
perceived to have lower complication rates. Furthermore, free
flaps can be used when the zone of injury is too large for local
flaps or when local vascular compromise militates against the
potential viability of a local flap. After the free flap is raised,
its native blood supply is disconnected and the flap is moved
to the distal leg, with reanastomosis of the flap vascular pedicle
to local vessels using microsurgical technique. Thus free tissue
transfer relies on the presence of patent vessels outside of the
injury zone in order to secure both flap perfusion and venous
outflow. Vessel segments chosen as targets for flap inflow
should lie proximal to the vascular injury; if the length of the
pedicle at hand is not sufficient to reach the identified segment,
it is permissible to use a vein loop to supply the flap. A less-
optimal solution is to achieve inflow by utilizing the segment
of in-situ reversed vein graft (used to restore vascular integrity
to the limb), anastomosing the flap pedicle in end-to-side
fashion to the vein graft. Free tissue transfer in the face of
vascular reconstruction always requires careful evaluation of
the best inflow/outflow vessel option.
When free flap extremity surgery is being considered, there
must be no question of patient stability, as procedures may be
10 hours or more in duration. Late amputation should be
considered if it is anticipated that the patient will be unable
to tolerate the process of free tissue transfer and where the act
of leaving an open fracture uncovered for a prolonged period
carries a very high risk of deep infection.
Muscle Versus Fasciocutaneous Flaps
Mathes et al popularized the concept that muscle flaps were
beneficial in reducing the consequences of infection as a result
of his experimental work conducted in a canine model.30
Gopal et al advocated muscle as being instrumental in achiev-
ing the low infection and nonunion rates reported in their
series of 84 open tibial fractures.24 Direct comparison of flaps
based on muscle versus fasciocutaneous tissues is difficult
because much of the data on fasciocutaneous flaps relates to
local as opposed to free flaps. (Local flaps may have less vas-
cularity when compared to free flaps.) Hallock showed that
fasciocutaneous flaps could be used to treat previously infected
fractures with reasonable success.31 Harry et al designed an
experimental mouse model and found that, while the vascu-
larity at the fracture site was greater with fasciocutaneous
flaps, bone healing was faster and stronger when muscle was
used. The authors concluded that muscle maybe preferable for
diaphyseal (shaft) fractures.32
Using muscle flaps carries a risk of inducing functional
deficit and weakness in the bodily region used to raise the flap.
Muscle flaps are less esthetic and have a less stable surface
when compared to fasciocutaneous flaps, a drawback that can
be nullified by using a chimeric flap that has both muscular
and fasciocutaneous elements (Fig. 22-3).
Commonly Used Flaps for Lower  
Limb Wounds
• Fasciocutaneous flaps
The anterolateral thigh (ALT) flap (Fig. 22-4) is a very
popular flap for lower limb reconstruction for several
reasons. It is based on an area of skin and fascia on
the anterolateral aspect of the thigh supplied by perfora-
tors of the descending branch of the lateral circumflex
femoral artery. This provides a very large flap (15 cm ×
35 cm) with a long pedicle (up to 12 cm) providing a
coverage solution for most defects of the lower limb. The
ALT flap can be raised from the contralateral leg without
any intraoperative repositioning and can be taken as a
thin flap (or thinned after being raised) to provide a
250 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
low-profile solution to tissue defects around the foot and
ankle. Other commonly used fasciocutaneous free flaps
include the radial forearm (for smaller defects), the scap-
ular flaps, and the parascapular flaps (raised around
vessels close to the axilla). The latter are commonly used
around the ankle but can be bulky due to the thickness
of the dermis.
• Muscle flaps
The latissimus dorsi (LD) flap is used when a large
area of cover (up to 20 cm × 40 cm) is required because
it is based on the largest muscle in the body. It has a long
pedicle (6 cm to 16 cm; average 9 cm) and can be quick
to raise. LD flaps are raised with the patient in the lateral
position, which requires an intraoperative change in
patient position, and are associated with postoperative
shoulder dysfunction. The latter may retard rehabilita-
tion, the ability to transfer from wheelchair to bed, and/
or the proper use of crutches. Alternative flaps include
FIGURE 22-3  An anterolateral thigh flap with a block of vascularized
muscle (chimeric flap) to cover a lower limb open fracture. There is
experimental evidence that the muscle may be beneficial for faster
fracture union.
A B
FIGURE 22-4  A, Anterolateral thigh flap being raised on the right thigh. B, Flap raised to show the feeding vessel, perforators from the
descending branch of the lateral circumflex femoral artery.
serratus anterior muscle flap and gracilis muscle flap (the
latter suitable for long, narrow defects).
Commonly Used Flaps for Upper  
Limb Wounds
Options include radial forearm flaps for smaller defects or
ALT flaps for larger defects. Local flaps include reversed radial
forearm, posterior interosseous artery, and lateral arm flaps.
All of these can be pedicled on their supplying vessels to cover
various defects from the elbow downward. As with lower limb
local flaps, a vascular injury and repair will compromise the
choice of vessel used, and a formal angiogram is often required
to confirm the local options.
Where necessary, the upper limb can be moved to the area
of a potential flap raised from the groin or abdomen—a
maneuver not permissible for the lower limb. Such flaps can
be raised and left connected to the native blood supply and
from there grafted onto the limb defect. After 3 weeks, the
blood supply of the flap integrates with that of the upper limb;
and the connection to the donor site is surgically divided to
leave an island of torso tissue covering the upper limb defect.
No microsurgical vascular anastomosis is required, and there
is no need to formally evaluate or utilize the axial vessels of
the upper limb—unlike free-flap or local fasciocutaneous
techniques.
Outcomes of Limb Salvage
Saddawi-Konnefka and colleagues reviewed 28 observational
studies concerning the treatment of tibial fractures and
observed that the most common complications after limb
salvage were the following: osteomyelitis (17.9%) and fracture
nonunion (15.5%) with secondary (late) amputation in
7.9%.33 The authors were able to compare the secondary
amputation rate between those without vascular injuries
(5.1%) and those with vascular injury (28.7%). Taking the
groups together, 63.5% of salvage patients returned to work,
compared to 73% of amputees.
In 1997 Lin et al reported on 36 lower extremity revascu-
larizations performed on 34 patients. After the revasculariza-
tion, 7 (19.4%) patients with IIIC fractures underwent
 22  /  Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury 251
secondary amputation within 1 week. At the 2-year follow-up,
the overall secondary amputation rate had risen to 25% (9 of
36). Of 29 salvaged limbs among their 27 patients, 23 limbs
(79.3%) required secondary coverage procedures that included
12 free flap transfers (41.4%). All 27 patients required further
surgery to improve functional outcome.34
Outcome seems to improve when temporary vascular
shunts are used,19 although the protective nature of shunting
may be of far less benefit in more-distal and higher-grade
fractures such as Gustilo IIIC injuries.3
Wartime injuries are typically characterized by high-energy
transfer, gross contamination, and delay in definitive treat-
ment. In Brown et al’s series of 35 combat-injured and devas-
cularized limbs, 29 had an associated fracture and 6 did not.
Of the patients who had an associated fracture, 15 (52%)
underwent primary amputation, 13 of which were damage
control procedures in critically ill patients. In the remaining 2
patients (both of whom had experienced a time interval from
point of injury to surgery of greater than 6 hours), the injured
limbs were deemed anatomically unsalvageable. Fourteen
limbs had vascular repairs undertaken, with a much higher
incidence of postoperative complications in patients with an
associated fracture.
Summary
The management of a devascularized extremity with a signifi-
cant bone and soft-tissue injury is challenging. The complex-
ity of these cases requires a team approach in order to ensure
that unfeasible options are rejected and that the optimal route
to maximal functional recovery is selected. It can be appreci-
ated that there are numerous reconstructive options and that
the eventual choice will depend on the patient, the nature of
the defect, and the surgical preference. Finally, it should be
remembered that amputation of the mangled extremity may
be the best reconstructive option for the patient in some
cases.
REFERENCES
1. Miranda F, Dennis J, Veldenz H, et al: Confirmation of the safety and
accuracy of the physical examination in the evaluation of knee disloca-
tions for injury of the popliteal artery: a prospective study. J Trauma
52:247–252, 2002.
2. Brown K, Ramasamy A, Tai N, et al: Complications of extremity vascular
injuries in conflict. J Trauma 66:S145–S149, 2009.
3. Subramanian A, Vercruysse G, Dente C, et al: A decades experience with
temporary vascular shunts at a Level 1 trauma centre. J Trauma 65:316–
326, 2008.
4. Romanoff H, Goldberger S: Combined severe vascular and skeletal
trauma. J Cardiovasc Surg 20:493–498, 1979.
5. Green N, Allen B: Vascular injuries associated with dislocation of the
knee. J Bone Joint Surg Am 59-A:236–239, 1977.
6. Patterson B, Agel J, Swiontkowski M, et al: Knee dislocations with vascular
injury: outcomes in the Lower Extremity Assessment Project (LEAP)
study. J Trauma 63:855–858, 2007.
7. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one
thousand and twenty-five open fractures of long bones. J Bone Joint Surg
Am 58-A:453–458, 1976.
8. Templeman DC, Gulli B, Tsukayama DT, et al: Update on the manage-
ment of open fractures of the tibial shaft. Clin Orthop 350:18–25, 1998.
9. Caudle R, Stern P: Severe open fractures of the tibia. J Bone Joint Surg
Am 69-A:801–807, 1987.
10. Georgiadis GM, Behrens FF, Joyce MJ, et al: Open tibial fractures with
severe soft-tissue loss. Limb salvage compared with below-the-knee
amputation. J Bone Joint Surg Am 75:1431–1441, 1993.
11. Fairhurst MJ: The function of below-knee amputee versus the patient
with salvaged grade III tibial fracture. Clin Orthop Relat Res 301:227–232,
1994.
12. MacKenzie EJ, Bosse MJ, Pollak A, et al: Long-term persistence of
disability following severe lower-limb trauma. J Bone Joint Surg Am
87-A:1801–1809, 2005.
13. Bonanni F, Rhodes M, Lucke JF: The futility of predictive scoring of
mangled lower extremities. J Trauma 34:99–104, 1993.
14. Fowler J, MacIntyre N, Rehman S, et al: The importance of surgical
sequence in the treatment of lower extremity injuries with concomitant
vascular injury: a meta-analysis. Injury 40:72–76, 2009.
15. McHenry T, Holcomb J, Aoki N, et al: Fractures with major vascular
injuries from gunshot wounds: implications of surgical sequence.
J Trauma 53:717–721, 2002.
16. Rasmussen TE, Clouse WD, Jenkins DH, et al: The use of temporary
vascular shunts as a damage control adjunct in the management of
wartime vascular injury. J Trauma 61(1):15–21, 2006.
17. Gifford SM, Aidinian G, Clouse WD, et al: Effect of temporary vascular
shunting on extremity vascular injury: an outcome analysis from the
GWOT vascular initiative. J Vasc Surg 50(3):549–555, 2009.
18. Hancock HM, Stannard A, Burkhardt GE, et al: Hemorrhagic shock
worsens neuromuscular recovery in a porcine model of hind limb vascu-
lar injury and ischemia/ reperfusion. J Vasc Surg 53(4):1052–1062, 2011.
19. Glass G, Pearse M, Nanchahal J: Improving lower limb salvage following
fractures with vascular injury: a systematic review and management algo-
rithm. J Plast Reconstr Aesthet Surg 62:571–579, 2009.
20. Anglen JO: Comparison of soap and antibiotic solutions for irrigation of
lower-limb open fractures: an experimental study. J Orthop Trauma
19:591–596, 2005.
21. Rich NM, Metz CW, Hutton JE, et al: Internal versus external fixation
of fractures with concomitant vascular injuries in Vietnam. J Trauma
11:463–473, 1971.
22. Bach AW, Hansen ST: Plates versus external fixation in severe open tibial
shaft fractures. Clin Orthop 241:89–94, 1989.
23. Giannoudis PV, Papakostidis C, Roberts C: A review of the management
of open fractures of the femur and tibia. J Bone Joint Surg Br 88-B:281–
289, 2006.
24. Gopal S, Majumdar S, Batchelor A, et al: Fix and flap: the radical ortho-
paedic and plastic treatment of severe open fractures of the tibia. J Bone
Joint Surg Br 82:959–966, 2000.
25. Godina M: Early microsurgical reconstruction of complex trauma of the
extremities. Plast Reconstr Surg 78:285–292, 1986.
26. Byrd HS, Spicer TE, Cierney G 3rd: Management of open tibial fractures.
Plast Reconstr Surg 76:719–730, 1985.
27. Naique SB, Pearse M, Nanachahal J: Management of severe open tibial
fractures: the need for combined orthopaedic and plastic surgical treat-
ment in specialist centres. J Bone Joint Surg Br 88:351–357, 2006.
28. Francel TJ, Vander Kolk CA, Hoopes JE, et al: Microvascular soft-tissue
transplantation for reconstruction of acute open tibial fractures: timing
of coverage and long-term functional results. Plast Reconstr Surg 98:478–
487, 1992.
29. Parrett BM, Pribaz JJ, Matros E, et al: Risk analysis for the reverse sural
fasciocutaneous flap in distal leg reconstruction. Plast Reconstr Surg
123:1499–1504, 2009.
30. Mathes SJ, Alpert BS, Chang N: Use of the muscle flap in chronic osteo-
myelitis: experimental and clinical correlation. Plast Reconstr Surg
69:815–829, 1982.
31. Hallock GG: Utility of both muscle and fascia flaps in severe lower
extremity trauma. J Trauma 48:913–917, 2000.
32. Harry LE, Sandison A, Pearse MF, et al: Comparison of the vascularity of
fasciocutaneous tissue and muscle for coverage of open tibial fractures.
Plast Reconstr Surg 124:1211–1219, 2009.
33. Saddawi-Konnefka D, Kim H, Chung K: A systematic review of outcomes
and complications of reconstruction and amputation for type IIIB and
IIIC fractures of the tibia. Plast Reconstr Surg 122:1796–1805, 2008.
34. Lin C, Wei F, Levin S, et al: The functional outcomes of lower-extremity
fractures with vascular injury. J Trauma 43:480–485, 1997.
BIBLIOGRAPHY
Howard PW, Makin GS: Lower limb fractures with associated vascular injury.
J Bone Joint Surg Br 72:116–120, 1990.
Nanchahal J, Nayagam S, Khan U, et al: Standards for the management of
open fractures of the lower limb, London, 2009, RSM Press Ltd.
 Vascular Surgery in the
23  Austere Environment
DAVID M. NOTT
Introduction
Vascular surgery is normally conducted in a highly technical
environment with a full complement of specialized equipment
including noninvasive ultrasound technology, state-of-the-art
computed tomography (CT), modern fluoroscopy, specialized
instruments for open surgery, and postoperative intensive care
units and wards staffed with experienced vascular nurses and
junior doctors. Performing vascular surgery in an austere
environment is the antithesis to this. Faced with major vascu-
lar injury, the surgeon will find few tasks more demanding of
his or her wisdom, especially with regard to decision making.
The primary principles are always control of life-threatening
hemorrhage and prevention of end-organ ischemia. However,
time, resources, and the patient’s physiology are pressing
factors that require constant consideration. The diagnosis and
management of arterial and venous injury are performed by
careful clinical examination supplemented with a continuous-
wave Doppler probe. In the austere setting, there are rarely
other, more-elaborate diagnostic modalities. Correct clinical
decisions are paramount with limited equipment, inexperi-
enced intensive care staff, and a limited means to transfer
patients to a higher level of care.
It is vitally important to begin the task with the right
mindset and to approach all vascular injuries in damage
control mode. Blood loss alone will have altered the patient’s
physiology, and the overriding necessities are to stop bleeding,
to reestablish blood flow using shunts combined with fasci-
otomy or to ligate; and, if necessary, to perform amputation.
One must also be prepared to make quick decisions. This is
not the environment in which to spend a long time perform-
ing extensive and difficult vascular reconstructions. In general,
one should not entertain the idea of performing a complex
vascular anastomosis at the first operation. If the decision is
to shunt the injured vessel, one must make sure all the bleed-
ing has stopped and bring the patient back the following day
for a more definitive operation. That strategy will allow time
for the patient to warm up, will allow for adequate resuscita-
tion to take place, and will allow time to source blood donors
if blood is still required.
The single surgeon working in a relief or humanitarian aid
scenario requires a multiplicity of skills. Apart from knowl-
edge pertaining to vascular anatomy and surgical techniques,
including extraanatomic bypass, it is also necessary to be able
to perform nerve and tendon repairs, to undertake orthopedic
trauma management (reduction of fractures, external fixa-
tion), and to be able to perform elements of plastic surgery
(which entails knowledge of the blood supply to muscles and
skin necessary to cover vascular repairs). The aim of this
252
chapter is to review the management of the patient with vas-
cular and associated injuries from the perspective of marked
resource constraint and to highlight areas of differences and
commonality with trauma surgery as it is practiced in replete,
developed-world settings.
Fundamentals
Figure 23-1 demonstrates much of the basic equipment that
should be taken on austere missions in which extensive injury
management is anticipated. A handheld Doppler machine,
magnifying loops, an operating headlight with batteries, 20 or
so umbilical vein catheters (size 4 and size 6), and 4 boxes of
5-0 Prolene. Most nongovernmental organization (NGO)
operating theaters are well provisioned, but lighting is usually
a limitation, and the instruments tend to be fairly large and
cumbersome.
In general, clinical evidence of an arterial injury is mani-
fested in one of the following four ways: external bleeding,
end-organ or extremity ischemia, pulsatile hematoma, or
internal bleeding accompanied by signs of shock. Patients
present very early, early, late, or very late. Those who present
late are a self-selected group, often hemodynamically normal
but with mummified limbs (if in hot, dry climates). In this
scenario, there is no role for revascularization; and amputa-
tion is the necessary option (Fig. 23-2).
Sometimes the patient may not understand the conse-
quences of an arterial injury, therefore, making the rational
argument for the amputation in order to save the patient’s life
can be extremely challenging. The patient in Figure 23-3 did
not appreciate that his leg was beyond salvage. When he did
agree to an amputation 4 days later, he consented only to a
below-knee amputation (though the whole of the below-knee
compartment was necrotic). It took another week of intense
discussion before the patient agreed to the definitive proce-
dure, and by that time sepsis was present. In these instances,
even if the patient understands that a limb is not viable,
culture and religion sometimes decree that a person must die
with his/her body in toto or intact. In such difficult circum-
stances, the surgeon must rely on his or her understanding
and empathy for the patient’s personal and religious beliefs.
The patient in South Sudan in Figure 23-4 was otherwise very
fit and well, but he chose to return to his village with a wooden
splint and died 2 weeks later.
As highlighted in Chapter 5, the decision to operate on
vascular trauma is based on hard and soft signs of injury. Hard
signs of vascular injury include the absence of distal pulses,
active external hemorrhage, signs of ischemia, expanding or
pulsatile hematoma, and a bruit or thrill (in the case of an
 23  /  Vascular Surgery in the Austere Environment 252.e1

ABSTRACT
In many instances, managing vascular trauma takes place
in a resource-constrained environment, which invokes par-
ticular challenges concerning both technique and decision
making. Based on personal experiences of the author
gained over 2 decades of military and nongovernmental
organization (NGO) missions, this chapter reviews the
management of vascular trauma in the context of the
austere setting. The chapter makes particular emphasis on
the principles of the damage control surgery and how this
approach is fundamental in such challenging circum-
stances. Equipment, vascular techniques, soft-tissue cover-
age, and crew resource management (CRM) issues are also
explored in this chapter.

Key Words:  vascular trauma,

austere setting,
resources,
logistics,
military,
nongovernmental,
team

FIGURE 23-1  Important tools for the austere vascular surgeon.
FIGURE 23-2  A 14-year-old girl who fell off a tree while picking
mangos in Chad and presented to the hospital 2 weeks later.
arteriovenous fistula). Soft signs of vascular injury consist of
a stable hematoma, diminished distal pulses, injury in the
proximity of a major vessel, or neurological deficit. The most
common arterial injury associated with hard signs is either a
partial laceration or a complete vessel transection. In general,
complete transection leads to retraction and thrombosis of
the proximal and distal ends of the vessel with subsequent
ischemia. In contrast, partial laceration causes persistent
bleeding or pseudoaneurysm formation. In the austere envi-
ronment, only those patients with hard signs undergo treat-
ment. The diagnostic equipment is generally not available to
accurately diagnose vascular injury presenting only with soft
signs. Repeat examinations or serial clinical monitoring and
pressure measurements (i.e., injured extremity index [IEI])
with the handheld Doppler will often reveal a trend in patients
who initially present with soft signs and then go on to develop
hard signs.1
Neck Injuries
Carotid Injuries
In austere environments, the only indication for surgery in the
neck is penetrating trauma with hard signs. Blunt carotid
23  /  Vascular Surgery in the Austere Environment 253
FIGURE 23-3  Discussions pertinent to the level of amputation.
FIGURE 23-4  This patient had absent distal Doppler pulses due to a
gunshot wound to the leg and refused treatment on religious grounds.
injuries resulting in intimal disruption with subsequent dis-
section or thrombosis may present with catastrophic neuro-
logical symptoms that develop sometime after the injury was
sustained. Such patients do not normally present to the
surgeon. In cases of penetrating trauma, the method of expo-
sure and treatment of injuries to the vascular structures of the
neck is determined in large part by the precise location of the
injury and the anatomy of blood vessels and surrounding
structures. The neck has been classically been divided into
three zones (Fig. 23-5). Zone I is from below the cricoid car-
tridge to the superior border of the clavicle; zone II lies
between the cricoid cartilage and the angle of the jaw; zone
III extends above the angle of the jaw to the base of the skull.
Hard signs include external or intraoral bleeding, an expand-
ing (arterial) or stable (venous) hematoma, stridor and air
bubbling from the wound, and a palpable thrill or audible
bruit. In the absence of hard signs, assessment of the neck is
by careful clinical examination, which must be repeated seri-
ally. Without clinical signs of a vascular- or aerodigestive
injury (such as pain on swallowing, subcutaneous emphy-
sema, or soft tissue air on a lateral neck radiograph), nonop-
erative management should be followed.2-4 If facilities for a
barium/Gastrografin swallow are available, that should be
performed. Nonoperative management does not equate with
254 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
III
ne
Zo
II
ne
Zo
I ligated if it is found to be the cause of the bleeding. In this
ne
Zo
FIGURE 23-5  Zones of the neck. (Redrawn from Penetrating neck
injuries. Oral Maxillofacial Surg Clin N Am 20:393–414, 2008.)
conservative management, and these patients should be regu-
larly reviewed. Any change in status may mean a change in the
management plan is needed. There has been considerable
debate in the literature regarding whether it is mandatory to
explore any wound in the neck that has penetrated the pla-
tysma. This author’s policy is to not explore the neck in the
absence of hard signs.5-7
If bleeding is coming from the external carotid artery or its
branches, ligation is the preferred option. An injury to the
common carotid artery below the bulb, if deemed unrecon-
structible, can be managed with ligation. In these challenging
cases, one must accept that perfusion of the brain on the
injured side will occur via retrograde flow from the posterior
circulation and the contralateral side. Other injuries of the
bulb and internal carotid artery can be reconstructed with a
vein patch and segmental defects managed with an interposi-
tion vein graft. In all cases, the long saphenous vein should be
harvested from the groin because there are reports of carotid
patch disruption if the vein is taken from the ankle.8,9 Resec-
tion of the internal carotid with external-to-internal carotid
artery transposition is a good option when treating proximal
internal carotid artery (ICA) injuries in children.10 Injuries
involving the jugular veins can be ligated with impunity, and
this is the preferred option over reconstruction in the austere
setting.11
There has been debate about the use of a cervical collar in
penetrating neck injuries. In the author’s opinion most
patients with penetrating neck injuries will not survive if they
have cervical spine trauma because they are already tetraplegic
or have associated major head injury. Those with no neuro-
logical signs rarely have a spinal injury, so using a collar may
potentially obstruct the airway and mask other injuries.12
The patient with a hard sign or signs of cervical vascular
trauma should be taken urgently to the operating theater,
because rapid expansion of a hematoma may occur, resulting
in deviation of the trachea and elevation of the floor of the
mouth. In this circumstance, one must be prepared to perform
an emergency tracheostomy or cricothyroidotomy if the anes-
thetist is having any difficulty with intubation. One must also
be sure to prep the neck and chest, in case of the requirement
for proximal control, and to prep the proximal thigh for vein
harvesting (Fig. 23-6). If needed, suction drains can easily be
made by creating a vacuum in a 50-mL syringe and then using
plungers from 20-mL syringes to maintain the plunger in the
suction position (Fig. 23-7).
Preoperatively, it is very important to assess the neurologi-
cal status of the patient using the Glasgow Coma Scale (GCS).
An adverse outcome is more likely to occur in a patient with
a GCS of less than 8, and in this situation the ICA should be
scenario, no attempt at carotid repair should be made, even if
there is antegrade flow, due to the risks of causing propagation
of thrombus and, on restoration of perfusion, converting an
ischemic infarct into a hemorrhagic one.13,14 Those not in
coma or with only a mild neurological deficit should be con-
sidered for carotid repair using a vein patch or reversed vein.
Because only 35% of patients have an intact circle of Willis,
there is a risk of significant neurological insult if the ICA is
ligated.15
Carotid—jugular fistulae are rare. In 1994, during this
author’s mission to Sarajevo, a 13-year-old girl with a frag-
ment wound to the neck presented for care. The penetrating
wound had become swollen, and there was a readily palpable
thrill over the enlarged neck mass. Unlike arteriovenous fistu-
lae in the limbs, carotid–jugular fistulae are particularly prone
to complications such as intractable high-output cardiac
failure, atrial fibrillation, and embolization.16 In the case of the
13-year-old girl, the common carotid artery was clamped; and
perfusion of the internal carotid relied on flow from the exter-
nal carotid. Having isolated the fistula, both the internal
jugular vein and the common carotid artery were repaired
with 5-0 Prolene.
It is recognized that internal carotid artery stump pressures
are highly variable; but, on the whole, the ICA back pressure
may be augmented by 10 mm Hg to 15 mm Hg if the external
carotid artery is maintained in continuity. If this can be main-
tained, it may augment internal carotid artery stump pressures
to the degree that repair of some carotid injuries may not be
necessary.17 Although some surgeons advocate using a shunt
in isolated common carotid artery injuries, this author has not
used one in this situation; and there are no studies to support
its role in this setting.18
Associated Neck Injuries
In the setting of penetrating neck wounds with a vascular
component, one should always look for injuries to the esopha-
gus and the laryngotrachea. If preoperative radiology is not
possible, one can ask the anesthetist to pass a nasogastric tube
to allow easier identification of the esophagus. Repair of local
damage to the esophagus may be undertaken with a two-
layered 3-0 absorbable suture, using the sternomastoid muscle
to buttress the suture line and to reduce the risk of leakage.
This muscle takes its blood supply from the occipital artery
and the superior thyroid artery branches of the thyrocervical

FIGURE 23-6  Tetraplegic pa-
tient with a low-velocity
gunshot wound to the side
of the face, causing external
carotid artery and internal
jugular vein disruption. Both
the artery and the vein were B C
ligated.
FIGURE 23-7 Syringe suction bottle.
trunk and thus can be mobilized from the clavicle by dividing
the sternal and clavicular heads. Tracheal injuries can be
repaired primarily with an absorbable suture and similarly
buttressed with the sternomastoid muscle. If the tracheal
defect is large, it should be converted into a tracheostomy.19
Operative Management of Zone III Injuries
Various techniques for gaining access to the inherently
difficult-to-expose distal internal carotid artery have been
reported. However, methods involving subluxation of the
temporomandibular joint and vertical ramus osteotomy are
23  /  Vascular Surgery in the Austere Environment 255
often not achievable in the austere environment.20,21 A useful
technique is to divide the digastric muscle and to partially
sublux the mandibular condyle. This is accomplished by force-
ful opening of the mouth, kept open by careful positioning of
a self-retaining retractor with swabs over the molars and a
Langenbeck retractor placed under the angle of the jaw to lift
it forward.22 This was the technique used in one such case that
is depicted in Figure 23-8.
Operative Management of Zone I Injuries
The classic teaching for zone I injuries of the neck is that
proximal control of the innominate, the subclavian, and the
carotid arteries should be enabled via a median sternotomy,
followed by cervical extension into either side of the neck (Fig.
23-9). In the austere environment, this approach has to be
tempered with the available resources for preoperative and
postoperative care. In some circumstances, appropriate facili-
ties are available, and in these cases a median sternotomy is
the best option. If the necessary equipment is available, this
exposure is not difficult to perform and provides an excellent
working view of zone I vascular structures.
If conditions are not suitable to perform a median ster-
notomy, one should consider taking the clavicle out in order
to gain access to the root of the neck. This is performed by
making a supraclavicular incision extending from the midline,
coursing over the midpoint of the clavicle, and continuing
below the clavicle to the deltopectoral groove. The sternal and
clavicular heads of the sternomastoid muscle are divided, and
a periosteal elevator is used to separate the structures over the
clavicle. It is easier to divide the clavicle with bone cutters than
to dislocate it from the acromioclavicular and sternoclavicular
joints. Following separation from the underlying subclavius
muscle, divide the scalenus anterior while preserving the
phrenic nerve. This gives excellent access to the whole of the
256 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
A made from the deltopectoral groove to the lateral two-thirds
B patch or an interposition graft using autologous long saphe-
FIGURE 23-8  Zone III injury of the carotid, with the defect repaired
with a vein patch.
first part of the subclavian artery, the proximal common
carotid, and the axillary vessels. Contrary to opinion, the
shoulder is not destabilized by its removal, provided the
muscles attached to it are reconstituted.23,24
The left side may be more difficult to expose because the
subclavian artery arises posteriorly from the aortic arch, but
gentle traction on the first part with a Satinsky clamp often
yields an additional centimeter of length. This must be per-
formed with care as the subclavian artery is thin and nonmus-
cular, and it tears easily. If the subclavian artery is torn during
access maneuvers, the first task should be to ligate the vessel
rather than to try to repair it. In most cases, upper limb cir-
culation is maintained via the rich collateral circulation
around the shoulder girdle (Fig. 23-10).25
An alternative to full sternotomy is limited sternotomy,
which can be performed using bone cutters to divide the
manubrium to the level of the sternomanubrial joint giving
access to the upper mediastinum. In this author’s view, one
should avoid the trapdoor incision and exposure (which
includes an anterior left thoracotomy and median sternotomy
through the third or fourth interspace), because this is associ-
ated with the following: significant bleeding (resulting from
the division of thick muscles); severe postoperative pain (due
to iatrogenic rib fractures); and a high incidence of respiratory
complications. If it is not possible to perform a limited ster-
notomy, one should consider an anterolateral thoracotomy
with extension to the other chest (i.e., a clamshell incision),
which provides excellent exposure. Postoperative ventilation
may be promoted through aggressive analgesia, including
intercostal nerve blocks, and early physiotherapy.
Upper Limb Vascular Injuries
Because of the close anatomical relationship of the neurovas-
cular structures, the brachial plexus is injured in about one-
third of patients with subclavian or axillary vascular trauma.
In this situation it is necessary to perform a nerve repair, pri-
marily by dissecting the nerve and suturing the epineural layer
with 5-0 Prolene during the first exploration.26 Access to the
axillary artery is achieved by using an infraclavicular incision
of the clavicle. This exposure requires splitting the fibers of
the pectoralis major muscle and dividing the pectoralis minor
muscle as it attaches to the coracoid process. Straightforward
and quick to perform, this is the method of choice in nearly
all cases of penetrating arm injuries to gain proximal control
before isolating the damaged vessels (Fig. 23-11). Further
exposure of the axillary artery can be performed very rapidly
by dividing the origins of the pectoralis major and pectoralis
minor muscles (Fig. 23-12). Pectoralis major can be divided
about 2 cm from its attachment to the humerus and retracted
inferomedially. The underlying pectoralis minor muscle is
then divided near its insertion on the coracoid process and is
retracted. This allows exposure of the whole of the axillary
artery up to the lower border of the teres major.
Because the axillary vessels are usually soft, lateral repair
will narrow the vessel; and better results are obtained if a vein
nous vein is employed. However, if repair is not possible, the
extensive collateral circulation around the axillary artery
means that ligation is an option (with an acceptance of a risk
of ischemic sequelae of 25% to 30%). Primary ligation of a
vein in the upper limb is usually well tolerated because of
lower hydrostatic pressure within the superior vena cava asso-
ciated with erect posture, smaller minute volume blood flow,
and extensive collaterals (Fig. 23-13, Fig. 23-14).27 A fasciot-
omy is always performed when managing extremity vascular
trauma in the austere domain. The forearm contains the fol-
lowing three compartments: the volar compartment, dorsal
compartment, and mobile wad containing the brachioradialis;
the extensor carpi radialis brevis; and the extensor carpi radia-
lis longus. The carpal tunnel should be opened or released
during upper extremity fasciotomy in most cases.
Brachial and Forearm Vessels
In contrast to the axillosubclavian arterial segment, ligation of
the brachial artery results in amputation in nearly half of
cases; and therefore flow should be reestablished (particularly
if the injury lies in the proximal vessel above the origin of the
profunda brachii).28 Direct suture repair should never be per-
formed in the brachial artery, because of the potential to
narrow the vessel. Instead, short-section resection and primary
end-to-end anastomosis, vein patch angioplasty, or applica-
tion of reversed saphenous vein interposition graft is prefer-
able. The use of shunts is often warranted. Though thrombosis
may occur, limb-threatening sequelae are not always apparent.
 23  /  Vascular Surgery in the Austere Environment 257

FIGURE 23-9  Pulsatile swelling in zone

I and zone II of the neck due to a gunshot
wound with median sternotomy to gain B C
proximal control of the carotid artery.

A B
FIGURE 23-10 Gunshot to zone I of the neck with removal of the clavicle and ligation of the subclavian artery.

FIGURE 23-11 Exposure of the

infraclavicular axillary artery for A B
proximal control.
258 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
FIGURE 23-12 Complete exposure of the axillary artery.
FIGURE 23-13  Arteriogram performed 2 weeks after a gunshot
wound to the axillary artery causing thrombosis.
This author has had two cases, both transferred from field
hospitals deep in hostile territory, where the non–vascular-
trained surgeon had elected to place shunts into the brachial
artery. Both cases had a long transfer time of 4 to 5 days. When
explored, the shunts were occluded although the arms and
were well perfused with good radial and ulnar Doppler signals.
The shunts were removed and the brachial artery ligated in
each patient, with no troublesome consequences. One possi-
bility is that occlusion over a period of days may have allowed
collaterals to open with no loss of end perfusion, although this
explanation remains to be proven.
It is this author’s preference to place a temporary vascular
shunt when managing an extremity with a combined ortho-
pedic and vascular injury. This strategy is employed to reduce
the warm ischemic time before application of an external
fixator. Any sort of sterile plastic tubing can be used, and dif-
ferent sizes of nasogastric tube or intravenous fluid sets will
FIGURE 23-14  This child had a gunshot wound to the axilla and
necessitated the ligation of the axillary artery just above the border
with teres major muscle; no vascular sequelae followed.
FIGURE 23-15 Slings made out of surgical gloves and shunts form
nasogastric tubes.
suffice to ensure diameter match is consistent with the vessel
concerned. For upper extremity injuries, slings can be manu-
factured or improvised using a wristband in a surgical glove
(Fig. 23-15). When fashioning a shunt, one should ensure that
it is slightly smaller than the artery and should cut carefully
so that it is unlikely to damage the intima. The shunt should
be secured in the intravascular position with a double silk
suture tied on the outside of the vessel. Having shunted the
vessel (and following application of the external fixator) the
long saphenous vein can be harvested and prepared as a
reversed vein interposition graft. The vascular shunt may then
be removed and the vein interposed grafted accomplished.
Umbilical vein catheters are a vital piece of equipment in
the austere setting and have many uses. Placed via the lumen
of the vein graft and then into the distal artery, this type of
catheter serves to stent open the anastomosis while suturing
it with individual 5-0 Prolene. This maneuver reduces the
risk of narrowing the anastomosis and may also reduce the
 23  /  Vascular Surgery in the Austere Environment 259

A B

C D
FIGURE 23-16  A series of photographs showing the insertion of a shunt before external fixator and the author’s method of protecting the
anastomosis, as well as the final definitive result.

number of sutures. After the anastomosis is complete, hepa-

rinized saline (5000U/500mL) can be injected down the cath-
eter to reduce the risk of distal thrombosis. The catheter can
then be withdrawn and attention paid to the proximal anas-
tomosis. By ensuring that one of the side-tributary stumps
of the vein graft is kept long during harvesting, this portal
can also be used to reintroduce the catheter into the vein
lumen and then into the proximal artery for administration
of heparin flush. The proximal anastomosis can be completed
around the catheter before its removal, and the long side trib-
utary can be ligated. In Figure 23-16, there were no slings
available or arterial clamps and the umbilical catheter acted as
means of occluding the arterial flow, held in place by a pair of
forceps.
Single vessel injury in the forearm need not be repaired but
can be ligated. However, repair is mandatory if either the
radial or ulnar artery was previously ligated as is so common
in machete wounds (Fig. 23-17). When both radial and ulnar
arteries are injured, the ulnar artery should be repaired as it FIGURE 23-17  A machete wound to the forearm.
usually the dominant vessel.
tasks: (1) identify the zone of bleeding, (2) obtain proximal
and distal control, and (3) achieve hemostasis with or without
Abdominal Vascular Injuries restoration of critical flow. From a trauma point of view, the
On opening the abdomen for exsanguinating abdominal vas- abdomen is divided into three zones (Fig. 23-18). In general,
cular trauma, the surgeon must perform the following three hematomas due to blunt injury in zones II and III are not
260 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
disturbed. All hematomas in zone I are explored as are expand-
ing hematomas in zones II and III. Zone I can be divided into
supramesocolic and inframesocolic areas by the transverse
mesocolon. Proximal control can be very challenging, but
knowledge of techniques such as the Cattell-Braasch maneu-
ver29 for IVC injury and the left-sided medial visceral rotation
I In Figure 23-19, the patient suffered a fragment injury from
II II
III
FIGURE 23-18  Zones of the abdomen.
A B
FIGURE 23-19 Left visceral rotation in order to obtain exposure of the supramesocolic aorta.
(Mattox maneuver) for supramesocolic aortic injury is man-
datory if the patient is to have a chance of survival.
Successful application of surgical technique is not the sole
determinant of outcome. Most patients with significant
intraabdominal hemorrhage require a massive transfusion
and postoperative ventilation. Even then, the chance of avoid-
ing a fatal outcome is low.30,31 If there is a cumulative blood
loss of 6 L or more, mortality can approach 100%.32 This is
the context for the difficult nature of decisions facing surgeons
working in a resource-limited environment. Knowing that
massive intraabdominal bleeding is likely to end up in patient
mortality, the surgeon may be faced with the decision of
whether to initiate treatment or, instead, to triage the patient
to an “expectant” category. Resources that are expended in
trying to save a potentially futile situation may be wasted, but
one may face significant pressure to attempt salvage from the
patient’s family members and from the attending hospital
staff. In these difficult scenarios, it is best to try to save the life
but also to set clear limits and recognize nonsalvageable situ-
ations in order to stop care and conserve resources.
a rocket-propelled grenade to the abdomen. In this case, a left
anterolateral thoracic incision was made in order to apply an
aortic clamp before opening the abdomen. A left medial vis-
ceral rotation (Mattox maneuver) was performed, and clamps
were applied to the supraceliac aorta in an attempt to control
the hemorrhage. Although aortic control was achieved, the
liver was badly macerated; and the patient succumbed to hem-
orrhage and shock.
In Figure 23-20, the Cattell-Braasch maneuver is demon-
strated exposing the inferior vena cava, which was bleeding
consequent to a gunshot wound. More often than not hem-
orrhage from the vena cava is partly constrained by retro-
peritoneal tissues, reducing the opportunity for immediate
exsanguination. In the illustrated case, the injury track in-
cluded the anterior and posterior walls of the stomach, the
anterior and posterior wall of the third part of the duode-
num, and the vena cava, resulting in a large zone I hema-
toma. The Cattell-Braasch maneuver was performed in this
scenario to gain proximal and distal control of the inferior
vena cava. Hemostasis was secured with swabs (sponges)-on-
sticks, applied proximal and distal to the venous injury,
which was eventually repaired with a lateral running 3-0
Prolene suture. In more difficult circumstances, ligation of
the IVC would have been a justifiable option.

A B
FIGURE 23-20  Through–and-through gunshot wound with injury to the inferior vena cava approached by performing the Cattell-Braasch
maneuver.
A B
FIGURE 23-21  A one-shot arteriogram.
Lower Limb Vascular Injuries
The diagnosis of extremity vascular trauma, including the
utility and effectiveness of continuous-wave Doppler and
other imaging modalities is detailed in Chapter 5. To review,
patients with hard signs of vascular injury mandate immedi-
ate operative intervention, whereas patients without hard
signs but with suspicious injury patterns should be monitored
with an especially high index of suspicion. Lower extremity
injury patterns known to be associated with vascular trauma
include displaced medial tibial plateau fractures, distal femoral
shaft fractures, and gunshot wounds in proximity to lower
limb neurovascular structures. In these instances, the patient
should be examined not once but over a period of time using
a combination of physical examination and noninvasive pres-
sure measurements using a handheld Doppler. As discussed in
Chapter 5, continuous-wave Doppler alone and in conjunc-
tion with measurement of pressure ratios (i.e., IEI or ankle-
brachial pressure index [ABPI] have a sensitivity and specificity
of greater than 95%).33,34 Specifically, an IEI or ABPI of 0.9 or
greater is normal and suggests that no further diagnostic
studies or interventions are needed. An IEI or ABPI of less
than 0.9 is an indication for arteriography, if the facilities are
available, or for operative exploration.35
If available, contrast arteriography is also useful in the
setting of a reduced IEI in patients with multiple candidate
sites of injury along the vascular axis (i.e., penetrating wounds
at multiple levels of the extremity). This can be performed in
23  /  Vascular Surgery in the Austere Environment 261
C
the operating theater using local anesthetic and a cut-down
on the common femoral artery. Once the artery is exposed, an
umbilical vein catheter can be introduced via limited arteri-
otomy. Modern day micropuncture catheters (4 Fr or 5 Fr) are
also useful for this maneuver and may obviate the need for an
open operative exposure. Once the catheter is positioned in
the common femoral artery, an x-ray plate is wrapped in a
sterile drape and positioned beneath the area of interest on
the injured lower extremity before injection of 20 mL of con-
trast (usually 50% Hypaque) down the catheter. Exposure
should be timed to occur as the surgeon is administering the
last 2 mL of contrast (Fig. 23-21).36
In general, ligation above the trifurcation of the tibial arter-
ies should be avoided in order to reduce the likelihood of
severe limb ischemia and amputation. Ligation of the common
femoral artery increases the risk of amputation by 50% and
the risk of limb loss associated with popliteal artery ligation
is 75%. As such, the proximal and midlevel lower extremity
axial arteries should be repaired if at all possible.29 The redun-
dant nature of tibial artery circulation to the leg and foot
means that uninterrupted flow through one of the three
vessels is all that is required to maintain limb viability and
salvage. In other words it is generally acceptable to ligate or
leave unrepaired two of the three tibial vessels as long as one
remaining vessel is uninjured throughout its length.
Once the lower extremity vascular injury has been identi-
fied, proximal and distal control should be achieved. Operat-
ing in virgin territory and staying out of the hematoma is the
262 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
A B
FIGURE 23-22  A gunshot injury to the groin. Initial extraperitoneal exposure of the external iliac artery to gain proximal control. Arterial and
venous shunting to maintain perfusion, followed by fasciotomy. Twelve hours later the definitive procedure was performed using the long
saphenous vein from the other leg to repair the femoral artery and femoral vein.
preferred technique in most cases. For common femoral artery
injuries, this requires either division of the inguinal ligament
or an extraperitoneal approach to the external iliac artery to
gain proximal control (Fig. 23-22). Below the hematoma, the
vessels are isolated and clamped. In routine developed-world
practice, Fogarty catheters are used to ensure good inflow and
backflow and to remove thrombus. If Fogarty catheters are not
available and if thrombus seems to be present (manifested by
poor inflow), the clamp is applied more proximally in an area
of good pulsation and; a small arteriotomy is made below this
level. An umbilical catheter may then be inserted and the
thrombus washed out by attaching the spiggoted end to a
syringe and infusing copious amounts of heparinized saline
until one is confident that the artery is clear of thrombus. This
action can be performed on the distal outflow vessel as well.
It is very important to close the small arteriotomy carefully so
as not to cause any intimal injury. This author has used this
technique on several occasions to be confident in securing
optimal inflow and backflow from the distal vessel.
Once the vascular injury site has been controlled and the
bleeding stopped, it is important to take stock of the situation.
Questions that may be particularly relevant in an austere
setting include: How much blood has been lost? How long ago
did the injury occur? What resources (i.e., surgical tools, blood
bank) are available? What is the physiology of the patient?
In the austere setting, the surgeon may not have access to
sophisticated blood-serum analysis but can assume that the
patient who has lost 1 L or more of blood from an arterial
injury is physiologically unwell. In these situations, this author
makes liberal use of damage control vascular techniques,
including use of a temporary vascular shunt to preserve blood
flow and to limit extremity ischemia time. In cases of com-
bined arterial and venous trauma, one may use a shunt in
both the artery and the vein because maintenance of venous
outflow may contribute to arterial patency. Shunting the vein
first also reduces venous bleeding once arterial flow has been
reestablished.
Following control of the vascular injury and placement of
a temporary vascular shunt or shunts, the situation should be
reassessed. In all cases, but especially those in an austere
setting, the surgeon should consider whether it is necessary to
complete the definitive operation during that setting or to
defer reconstruction until the patient is physiologically
improved. Having the shunt in place also allows one to assess
whether vascular reconstruction is even necessary as the shunt
C
can be temporarily occluded and distal limb perfusion can be
assessed with the continuous-wave Doppler. In some instances
in which collateral circulation has been preserved, there may
be an arterial signal in the leg or foot distal to the manually
occluded shunt. In these cases it may be that arterial repair
can be delayed for a period of time or even indefinitely. Ligat-
ing the axial artery and leaving the leg and foot relatively
ischemic but viable may be the appropriate damage control
maneuver in some cases in the austere setting. In these
instances the leg and foot can be monitored with repeat IEI
measurements and assessment for clinical signs of ischemia.
Revascularization can then be performed at an interval period
of time if ischemia worsens, although this may be deferred for
weeks or longer if collateral circulation is significant.
This author has frequently left a shunt in place for 24 hours
and brought the patient back to the operating theater the fol-
lowing day. Vascular shunts have been used for many years to
maintain perfusion of injured limbs during transfer to other
facilities and have been known to remain patent for up to 54
hours.37-40 Temporary shunts permit time for a fuller apprecia-
tion and surgical treatment of the injury, allowing for the
complete débridement of nonviable soft tissue before com-
mitting to definitive vascular procedure. Shunting also allows
for the proper consideration of definitive soft-tissue coverage
options, using muscle or a fasciocutaneous flap to cover the
vascular reconstruction. In this way, one may avoid the situa-
tion in which a perfectly good vascular repair has been per-
formed only for the reconstruction to span a soft-tissue defect
that has no support or possibility of soft-tissue coverage.
The long saphenous vein from the extremity contralateral
to the injury is the preferred conduit for definitive vascular
repair. While the saphenous vein from the injured extremity
can be used, if there is a concomitant venous injury in the
limb, that saphenous vein may provide an element of venous
return making its harvest ill-advised. Major veins of the lower
limb should be repaired with the same care as arterial injuries.
The femoropopliteal vein is usually repaired first to allow for
venous return before repairing any artery injury. Ligation of
major veins in the lower limbs (external iliac, common
femoral, superficial femoral) results in significant edema in
50% of patients compared to 7 % after repair.27 There may
also be an argument for the necessity of popliteal vein recon-
struction to prevent limb loss.41 However, this should be con-
sidered in the context of the physiology of the patient and
operative time required. If deemed inappropriate, ligation of

A B
FIGURE 23-23 Consider primary amputation as the procedure of choice in a resource-limited environment.
lower extremity venous injury may have to be performed as a
matter of damage control.
The absolute indications for fasciotomy include prolonged
ischemia time, combined arteriovenous injury, complex
injuries (including bone and soft tissue), and crush injury.
However, in the austere environment, prophylactic fasciotomy
should be routine because time scales cannot be assumed and
preoperative information (i.e., injury timing, circumstances)
is frequently misleading. Furthermore, it is unlikely, in the
resource-limited environment, that the surgeon will be able to
closely monitor and reassess the patient in whom there is a
concern for the development of compartment syndrome.
Ideally, the fasciotomy should be performed before the ortho-
pedic and vascular procedures. There are some who doubt
whether routine fasciotomy is necessary, citing the risk of
infection and long-term consequences. However, routine fas-
ciotomy is this author’s standard practice, especially in the
austere setting.42
In summary, in the setting of a mangled extremity in which
there is a fracture and a major vascular injury, this author’s
preferred order of management is as follows: (1) exploration
and control (proximal and distal) of the injury, (2) perfor-
mance of fasciotomy, (3) placement of a temporary vascular
shunt, (4) débridement of soft-tissue wounds, (5) external
fixation of the fracture, and (6) harvest of long saphenous vein
and definitive vascular repair after the patient is physiologi-
cally improved. The vascular reconstruction should then be
covered by muscle and the wounds dressed with fluffed-up
gauze held in place by a light crepe bandage. The wounds
should not be touched by anyone other than the surgeon; and
after 5 days the patient should be returned to the operating
theater, the dressings removed, and the wound closed by
delayed primary closure or split skin graft.
Futility of Treatment
When dealing with extremity vascular trauma in the austere
environment, it is not always easy to make the right decision
in regard to limb salvage. Significant risk of mortality and
morbidity follows a failed attempt at limb salvage. There are
at least five scoring systems available to assist one in making
the decision as to whether to amputate the extremity or to
perform a limb-saving procedure.43 However, reports suggest
that these scoring systems are not reliable44; and, moreover,
there are no scoring systems that relate to the austere
environment.
23  /  Vascular Surgery in the Austere Environment 263
In the author’s opinion, limb salvage in the austere envi-
ronment should be considered only if the following five condi-
tions are met:
1. There was less than 6 hours’ time from point of injury.
2. There was less than 30% soft-tissue loss.
3. Bone shaft is in continuity. If fractured, the ends are
fixed in continuity with external fixation.
4. Major nerve damage is easily repairable (i.e., less than
2 cm to 3 cm segmental loss).
5. Vascular reconstruction is able to be covered with viable
and available soft tissue.
In the author’s experience, if these conditions are not present
and the surgeon is in a significantly resource-limited envi-
ronment, primary amputation is the procedure of choice
(Fig. 23-23).
Soft-Tissue Injury
The management of the soft-tissue defect associated with vas-
cular trauma is important to consider. Misdirected attempts
to preserve local tissue for vascular coverage can lead to
inadequate débridement, wound sepsis, and more-extensive
secondary débridement resulting in further exposure of the
repaired vessel at the base of a necrotic and contaminated
wound. The common sequel in this unfortunate situation is
delayed and often life-threatening hemorrhage from an
exposed and disrupted vascular anastomosis, necessitating
emergency ligation. This is a disaster and leads to outcomes
no better than those observed more than 60 years ago during
the World War II. If the initial vascular operation is not per-
formed properly, the problem is merely passed from one
surgeon, as he or she leaves the mission, to the incoming clini-
cian who has to pick up these pieces while wondering whether
the patient would have done better with ligation and a primary
amputation.
Therefore it is incumbent on the surgeon who intends to
practice in the austere environment to learn the techniques
that will enable graft coverage, including the raising of muscle
flaps followed by a split skin graft. The technique of fasciocu-
taneous grafts is also important for surgeons in these challeng-
ing situations to understand. There are many opportunities to
learn such techniques through attending various flap courses,
watching and assisting plastic surgical colleagues, and reading
the extensive literature that is available.45,46 Box 23-1 summa-
rizes the muscle flaps that this author considers most useful
for the vascular surgeon to learn.
264 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT

Vascularized Composite Muscle Rectus Abdominus Flap

Flaps for Coverage of Vascular This is an excellent flap based on the inferior epigastric artery
Reconstruction and is used to cover large soft-tissue defect over the groin
when there is insufficient sartorius muscle to permit coverage
Brachioradialis Flap of exposed vessels. An incision is made in the groin crease
Figure 23-24 depicts a gunshot wound to the distal brachial 3 cm above the inguinal ligament, and the rectus muscle is
artery whereby both the distal brachial and radial and the harvested up to the interdigitations with the costal cartilage.
ulnar arteries were significantly damaged. A long saphenous It is mobilized off of the posterior rectus sheath after ligation
vein graft was performed to the brachial and radial artery and of the superior epigastric artery and is swung down over the
covered by the brachioradialis muscle after preserving its groin defect (Fig. 23-25).
blood supply from the distal radial artery. The patient subse-
quently underwent a split skin graft with an excellent result. Soleus and Gastrocnemius Muscle Flaps
Soleus muscle provides a very useful flap to cover distal leg
wounds. The soleus muscle has two pedicles from the poste-
rior tibial and peroneal arteries, which supply the muscle
Box 23-1 Muscle and Fasciocutaneous Flaps
from both the proximal and distal sites. The muscle can
Neck, supraclavicular fossa Axilla and upper arm survive on either pedicle and can therefore be mobilized prox-
Sternocleidomastoid imally or distally. The medial or lateral gastrocnemius muscle
Pectoralis major is also useful to mobilize to cover more-proximal leg wounds
Latissimus dorsi (Fig. 23-26).
Antecubital fossa to proximal forearm Fasciocutaneous Flaps
Flexor digitorum
Brachioradialis In Figure 23-27, a lateral malleolar flap is used to cover a defect
Radial forearm flap in the forefoot. Figure 23-28 demonstrates a fasciocutaneous
Forearm fasciocutaneous flap saphenous artery flap used to cover the tibia. The anterior
Chest border of the flap includes the long saphenous vein to preserve
Pectoralis major the saphenous artery. Figure 23-29 shows a groin flap based
Omentum on the superficial circumflex iliac artery covering a distal ulnar
Rectus abdominus artery anastomosis with significant tissue loss. A sural artery
Latissimus dorsi flap used to cover a calcaneal defect can be very useful to cover
Groin to upper thigh the posterior tibial artery (Fig. 23-30).
Groin flap Radial Forearm Flap
Rectus femoris
Rectus abdominus The radial forearm flap, a fasciocutaneous free flap based on
Tensor fascia lata the radial artery with drainage from the cephalic vein, can be
Sartorius mobilized to cover posterior defects and any part of the
Popliteal fossa to midcalf forearm or distal upper limb (Fig. 23-31).
Medial and lateral gastrocnemius
Soleus Forearm Amputation
Vastus lateralis
Lateral malleolar flap Sometimes it is necessary to perform difficult amputations
Sural artery flap (Fig. 23-32), and it is always worth carrying a USB stick con-
taining the steps required to perform these taxing procedures.

A B
FIGURE 23-24  Brachioradialis flap.
 23  /  Vascular Surgery in the Austere Environment 265

A B

C D
FIGURE 23-25 Rectus abdominis flap. A, Infected groin with ligation of the femoral vessels. The sartorius was destroyed. B, Mobilization of
the rectus abdominis muscle. C, The tunnel was created. D, Coverage of the wound with the muscle.

plastic surgery. For the surgeon to be able to do the best for

FIGURE 23-26 Soleus muscle flap.
One doesn’t want to be caught out and to be required to
receive instructions via a text message!47
Working in Austere Environments
This chapter has focused particularly on vascular surgery; but,
as can be seen, this specialty overlaps general, orthopedic, and
his or her patients in the austere environment requires a
degree of proficiency in all of these areas. It is true that in
austere environments a vascular surgeon must, by necessity,
become the type of general surgeon seen before the rise of
superspecialization. In these challenging environments, one’s
hand is also likely to be turned to urology, neurosurgery, pedi-
atric surgery, and obstetrics and gynecology, among other
medical disciplines. To train or to prepare for these challeng-
ing but extremely rewarding situations, one must commit to
learning the skills and the knowledge required, including
observing and working with colleagues attending courses and
participating with an experienced group during such austere
missions.
Successfully completing an austere medical or surgical
mission requires mental and physical resiliency and not just
expert surgical skill and technique. Accomplishing austere
missions, whether during wartime situations or Third World
medical missions, requires coping with stress associated with
being away from home in a country with different cultures
and different religious beliefs. In these settings, one’s team
frequently consists of known partners and/or friends but also
of expats from all over the world who have their own cultures.
Because of this, one must be prepared to adapt and to become
part of a unit that is both insular and yet diverse.
There is no doubt that it is getting more dangerous to
work abroad in conflict zones and that security cannot be
266 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
A B
FIGURE 23-27  A, Lateral malleolar flap. B, Lateral malleolar flap after 5 days.
A
B
FIGURE 23-28 Saphenous fasciocutaneous flap.
guaranteed even when working for the established and well-
known agencies such as the International Committee of the
Red Cross (ICRC) and Medecins sans Frontieres (MSF).
A recent symposium in London entitled “Health Care in
Danger” highlighted the problems faced by health workers.48
It is paramount that one obeys all of the security rules of the
organization that one deploys with. While one’s freedom of
movement might be significantly limited during an austere
surgical mission, such precaution is often necessary not only
FIGURE 23-29 Groin flap used to cover ulna artery anastomosis.
for personal safety but also for the safety and success of the
larger project.
On coming home from a deployment or a mission, it is
important to attend available debriefing sessions. These ses-
sions improve resiliency, draw a line under one’s period away,
and help one complete the mission. If one immediately returns
to a normal work and family schedule without a period of
time to decompress, it may be difficult to adapt. It is not
uncommon for surgeons who have been on medical or surgi-
cal missions to have feelings of guilt relating to the native
people cared for and left behind. If not addressed properly and
professionally, these recollections and sentiments can perco-
late into and even overwhelm one’s work and home life. If one
has spent time in a particularly dangerous situation, it does
take time to get over this; and it is important to keep in contact
with others who have been on the mission to share experiences
and improve resiliency. It is normal for one to feel elated on
return from an austere mission, only for a more-reflective
mood and even sadness to follow. However, intentional steps
to debrief, decompress, and improve resiliency are generally
effective.
The beauty of an austere mission lies in one’s challenging
but extremely rewarding role as a physician and surgeon. In
these settings, one’s job is to perform the operations and look
after the patients on the ward while being mindful that many
surgeons who have passed through the mission, as well as the
 23  /  Vascular Surgery in the Austere Environment 267

A B
FIGURE 23-30 Sural artery flap in a child with skin loss over the calcaneum.

C B
FIGURE 23-31  A radial artery flap.

A B C
FIGURE 23-32  Forequarter amputation.
268 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
local staff, have been in that setting over a long period of time.
It is likely that these and others associated with the mission
have seen it all. As always, the surgeon should treat the team
with humility, understanding that his or her role is only for a
finite period of time while many of those working in the
mission will have to endure the stresses of the situation for
much longer periods of time. As always, one should avoid
engaging in the politics of the situation, should never dimin-
ish the value of a team member, and should leave the frustra-
tions one has at home. Medical and surgical missions in the
austere environment are truly in a different place and time.
One should engage the mission, enjoy it, and give it his or her
best shot!
REFERENCES
1. Dennis JW, Frykberg ER, Veldenz HC, et al: Validation of nonoperative
management of occult vascular injuries and accuracy of physical exami-
nation alone in penetrating extremity trauma: 5- to 10-year follow-up.
J Trauma 44:243–253, 1998.
2. Sofianos C, Degiannis E, Van den Aardweg MS, et al: Selective surgical
management of zone II gunshot injuries of the neck: a prospective study.
Surgery 120:785–788, 1996.
3. Demetriades D, Charalambides D, Lakhoo M: Physical examination and
selective conservative management in patients with penetrating injuries
of the neck. Br J Surg 80:1534–1536, 1993.
4. Atteberry LR, Dennis JW, Menawat SS, et al: Physical examination alone
is safe and accurate for evaluation of vascular injuries in penetrating Zone
II neck trauma. J Am Coll Surg 179:657–662, 1994.
5. Bishara RA, Pasch AR, Douglas DD, et al: The necessity of mandatory
exploration of penetrating zone II neck injuries. Surgery 100:655–660,
1986.
6. Meyer JP, Barret JA, Schuler JJ, et al: Mandatory vs selective exploration
for penetrating neck trauma. Arch Surg 122:592–597, 1987.
7. Apfelstaedt JP, Muller R: Results of mandatory exploration for penetrat-
ing neck trauma. World J Surg 18:917–920, 1994.
8. Bove T, Van den Brande P: Is the use of ankle saphenous vein for carotid
artery patch closure justified? Acta Chir Belg 95:275–277, 1995.
9. O’Hara PJ, Hertzer NR, Krajewski LP, et al: Saphenous vein patch rupture
after carotid endarterectomy. J Vasc Surg 15:504–509, 1992.
10. Galante JM, London JA, Pevec WC: External-internal carotid artery trans-
position for repair of multiple pseudoaneurysms from penetrating injury
in a pediatric patient. J Pediatr Surg 44:E27–E30, 2009.
11. Hill SJ, Thomas JM, Nott DM: Reconstruction of the iliofemoral venous
circulation using internal jugular vein autograft. Ann R Coll Surg Engl
79:460–461, 1997.
12. Ramasamy A, Midwinter M, Mahoney P, et al: Learning the lessons from
conflict: pre-hospital cervical spine stabilisation following ballistic neck
trauma. Injury 40:1342–1345, 2009.
13. Wood J, Fabian TC, Mangiante EC: Penetrating neck injuries. Recom-
mendations for selective management. J Trauma 29:602–605, 1989.
14. Teehan EP, Padberg FT, Thompson PN, et al: Carotid arterial trauma:
assessment with the Glasgow Coma Scale (GCS) as a guide to surgical
management. Cardiovasc Surg 5:196–200, 1997.
15. He J, Liu H, Hunag B, et al: Investigation of morphology and anatomic
variations, of circle of Willis and measurement of diameter of cerebral
arteries by 3D-TOF angiography. Sheng Wu Yi Xue Gong Cheng Xue Za
Zhi 24:39–44, 2007.
16. Kakkar S, Angelini P, Leachman R, et al: Successful closure of post-
traumatic carotid-jugular arteriovenous fistula complicated by congestive
heart failure and cerebrovascular insufficiency. Cardiovasc Dis 6:457–462,
1979.
17. Connolly JE, Kwaan JHM, Stemmer EA: Improved results with carotid
endarterectomy. Ann Surgery 186:334–340, 1977.
18. Bagheri SC, Khan A, Bell RB: Penetrating neck injuries. Oral Maxillofacial
Surg Clin N Am 20:393–414, 2008.
19. Losken A, Rozycki GS, Feliciano DV: The use of the sternocleidomastoid
muscle flap in combined injuries to the esophagus and carotid artery or
trachea. J Trauma 49:815–817, 2000.
20. Dossa C, Shepard AD, Wolford DG, et al: Distal internal carotid exposure:
a simplified technique for temporary mandibular subluxation. J Vasc Surg
12:319–325, 1990.
21. Larsen PE, Smead WL: Vertical ramus osteotomy for improved exposure
of the distal internal carotid artery: a new technique. J Vasc Surg 15:226–
231, 1992.
22. Coll DP, Lerardi R, Mermer RW, et al: Exposure of the distal internal
carotid artery: a simplified approach. J Am Coll Surg 186:92–95, 1998.
23. Abbott LC, Lucas DB: The function of the clavicle: its surgical signifi-
cance. Ann Surg 140:583–597, 1954.
24. Maylivahanan N, Mellor I, Malawar MM: Claviculectomy for bone
tumors. Indian J Orthop 40:115–118, 2006.
25. Mohiuddin C, Kirton OC, Lukose D, et al: Ligation of the subclavian
artery after blunt trauma presenting as massive hemothorax. J Trauma
64:1126–1130, 2008.
26. Demetriades D, Chahwan S, Gomez H, et al: Penetrating injuries to the
subclavian and axillary vessels. J Am Coll Surg 188:290–295, 1999.
27. Agarwal N, Shah PM, Clauss RH, et al: Experience with 115 civilian
venous injuries. J Trauma 22:827–832, 1982.
28. DeBakey ME, Simeone FA: Battle injuries of the arteries in World War II.
Ann Surg 123:534–536, 1946.
29. Cattell RB, Braasch JW: A technique for exposure of the third and fourth
portions of the duodenum. Surg Gynecol Obstet 111:378–379, 1960.
30. Asensio JA, Chahwan S, Hanpeter D, et al: Operative management and
outcome of 302 abdominal vascular injuries. Am J Surg 180:528–534,
2000.
31. Stannard AK, Brown C, Benson J, et al: Outcome after vascular trauma
in a deployed military trauma system. Br J Surg 98:228–234, 2011.
32. Rotondo MF, Schwab CW, McGonigal MD, et al: Damage control: an
approach for improved survival in exsanguinating penetrating abdominal
injury. J Trauma 35:375–382, 1993.
33. Lynch K, Johansen K: Can Doppler pressure measurement replace “exclu-
sion” arteriography in the diagnosis of occult extremity trauma? Ann Surg
214:737–741, 1991.
34. Hood DB, Yellin AE, Weaver FA: Vascular trauma. In Dean R, editor:
Current vascular surgical diagnosis and treatment, Norwalk, CT, 1995,
Appleton and Lange, p 405.
35. Levy BA, Zlowodzki MP, Graves M, et al: Screening for extremity arterial
injury with the arterial pressure index. Am J Em Med 23:689–695, 2005.
36. O’Gorman RB, Feliciano DV: Arteriography performed in the emergency
center. Am J Surg 152:323–325, 1986.
37. Eger M, Goldman L, Goldstein A, et al: The use of a temporary shunt in
the management of arterial vascular injuries. Surg Gynaecol Obstet
132:67–70, 1971.
38. Rasmussen TE, Clouse WD, Jenkins DH, et al: The use of temporary
vascular shunts as a damage control, adjunct in the management of
wartime vascular injury. J Trauma 61:8–15, 2006.
39. Ding W, Wu X, Li J: Temporary intravascular shunts used as a damage
control surgery adjunct in complex vascular injury: collective review.
Injury 39:970–977, 2008.
40. Brounts LR, Wickel D, Arrington ED, et al: The use of a temporary intra-
luminal shunt to restore lower limb perfusion over a 4,000 mile air evacu-
ation in a special operations military setting: a case report. Clin Med
1:5–9, 2008.
41. Sfeir RE, Khoury GS, Kenaan MK: Vascular trauma to the lower extrem-
ity: the Lebanese War experience. Cardiovasc Surg 3:653–657, 1995.
42. Abouezzi Z, Nassoura Z, Ivatury RR, et al: A critical reappraisal of indica-
tions for fasciotomy after extremity vascular trauma. Arch Surg 133:547–
551, 1998.
43. Ly TV, Travison TG, Castillo RC, et al: Ability of lower-extremity injury
severity scores to predict functional outcome after limb salvage. J Bone
Joint Surg Am 90:1738–1743, 2008.
44. Bosse MJ, MacKenzie EJ, Kellam JF, et al: A prospective evaluation of the
clinical utility of the lower-extremity injury-severity scores. J Bone Joint
Surg Am 83:3–14, 2001.
45. Masquelet AC, Gilbert A: An atlas of flaps of the musculo-skeletal system,
London, 2001, Blackwell.
46. Wolff KD, Hölzle F: Raising of microvascular flaps: a systemic approach,
Berlin, 2005, Springer.
47. Nott DM: A chance of life. BMJ 337:1376–1377, 2008.
48. Moszynski P: Kidnapped British health worker is found murdered in
Pakistan. BMJ 344:e3136, 2012.
Vascular Trauma: Training the
Surgeon of the Future
MARK MIDWINTER AND MARK W. BOWYER
Introduction
The issue of surgical training—whether vascular or general—
faces a number of significant current and future challenges.
The introduction of work-hour restrictions in the United
States, the United Kingdom, and the European Union has led
to dramatically decreased opportunities for exposure to
patients and clinical material for trainees.1-7 The full impact
of these work-hour directives has yet to be fully assessed.
However, a recent study by the Royal College of Surgeons of
England suggests that the quality of patient care has sharply
declined because of the lack of continuity of care, and it
further suggests that operative exposure is insufficient to
ensure competency in an adequate range of procedures for
independent practice.8 The development of ever–increasingly
complex procedures, including endovascular techniques, has
strained the ability of surgical residency or fellowship pro-
grams to endow competence and proficiency in all the required
areas of practice. At the same time, there is increasing scrutiny
of the quality of health care, brought about by a number of
high-profile cases involving medical errors, such as the Bristol
Enquiry in the United Kingdom and the “to err is human”
report in the United States.9-13
Additionally, there has also been an increasing trend toward
conservative management of solid organ injury, which has
resulted in significantly less opportunity for trainees to under-
take open surgical procedures.14-16 The increasing specializa-
tion of vascular surgeons and their training has also diluted
the available training cases for general surgery residents with
the majority of open vascular cases being done by vascular
surgeons and vascular residents/fellows.17-20 Overall, and in
spite of the fact that many still consider vascular surgery to be
an integral part of general surgery training, senior trainees are
getting less experience in this area. Over the last 10 years, the
average number of major vascular repairs for trauma that were
reported by graduating chief residents to the American Board
of Surgery as being performed over the entire residency
program in general surgery decreased from 5.0 in 2001-2002
to 2.1 in 2010-2011 (see Table 24-1).21 It is important to bear
in mind that these data reflect average experience, and as such
there are significant numbers of trainees who have no experi-
ence caring for patients with major vascular trauma. It is also
revealing to look at the logbook data reported for numbers of
neck explorations for trauma (0.3), for treatment of cardiac
injury (0.3), for fasciotomy (1.2), and for trauma splenecto-
mies (2.5) that were undertaken by recent graduates of U.S.
training programs. Reported experience concerning exposure
of the brachial artery by graduating residents was similarly
24 
scant with an average of 0.1 cases per trainee in 2009-2010 and
0.0 in 2010-2011.
Based on the data presented, it is clear that general surgery
residents in the U.S. have a suboptimal experience with the
surgical management of vascular trauma. In Canada, vascular
surgery has been removed from the Canadian general surgery
training objectives. In a recent survey of 29 Canadian surgical
residents, 90% reported an intention to perform vascular pro-
cedures after training despite the same cohort self-reporting
of inadequate training in 10 of the 13 procedures surveyed.22
Unsurprisingly, the authors of this study concluded that
current trainees may lack the skills and abilities to deal with
vascular emergencies. Furthermore, in spite of the growing
prevalence of specialist-trained vascular surgeons, there are
still many areas in the world (developed and underdeveloped)
where the primary surgeon may not be a vascular surgical
specialist and where opportunities to practice a vascular skill
set are infrequent. While it may be argued that the solution to
this problem is to ensure that a fully trained vascular surgical
specialist is available for each and every trauma case, this staff-
ing arrangement is not practical in many hospitals and is
certainly unfeasible in the austere domains of military and
humanitarian surgical practice. Thus the need to train com-
petent practitioners who can handle vascular trauma is
universal.23-26
In the developed world where, in comparison to previous
practice, vascular trauma is increasingly funneled toward spe-
cialist trauma or vascular surgeons, opportunities to gain
experience in vascular trauma are also limited.25 The numbers
of major vascular repairs for trauma that were reported to the
American Board of Surgery by vascular surgery fellows—
though significantly greater than that reported by graduates
of general surgery residencies—are small, with the average
number of cases reported as 7.6 in 2001-2002 and 10.8 in
2010-2011 (Table 24-2).21 Further, 76% of these procedures
were peripheral in nature with surgical experience of vascular
trauma in the thorax and neck being particularly low, averag-
ing between 0.3 and 0.8 cases per resident, respectively. Addi-
tionally, vascular fellows reported an average experience of
fasciotomy between 0.8 and 1.4 cases over the last decade, with
0.1 to 0.3 open brachial artery exposures over the last 4 years.
When looking at recertification data emanating from U.S.
vascular surgeons, the reported number of trauma cases is also
suboptimal. In 2003, only 46% of surgeons reported having
undertaken any trauma cases in the previous 12 months; in
2009, this proportion had diminished to 23%. In both cohorts,
the accumulated annual experience amounted to an average
of 4 procedures.27
269
 24  /  Vascular Trauma: Training the Surgeon of the Future 269.e1

ABSTRACT
Significant changes in residency programs and exposure to
vascular trauma cases during training and professional
career, as well as new approaches to management of vas-
cular injury, including the developments of endovascular
techniques, mandate a reappraisal of how both vascular
specialists and general surgeons are prepared to manage
vascular trauma. New strategies in delivering both techni-
cal and nontechnical skills training are required to deliver
quality care to the patient with a vascular injury. While
specialist vascular surgeons will deliver some of this care,
there are many situations where this is not practical; so
nonvascular specialists must also have a skill set to deal with
a patient whose complex injury includes a vascular injury.
The ideal curriculum with unambiguous goals and with
testable competencies is being defined. Courses are being
developed to deliver vascular trauma training that uses a
synthesis of techniques, including animal-model training,
human cadaveric training, and simulation-based training.
It has been recognized that crew resource management
(CRM), as utilized in other safety critical industries such
as aviation, is an important component in minimization
of errors and requires team-based training. This chapter
explores the current positions and solutions and looks to
how, through future-defined curricula, surgeons may best
use the technologies available to gain the necessary exper-
tise to deliver the best care to patients with vascular injury.

Key Words:  trauma skills-training,

team-training,
simulation,
education
270 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT

Table 24-1 The Average Number of Selected Cases over the Duration of Training
2001- 2002- 2003- 2004- 2005- 2006- 2007- 2008- 2009- 2010-
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Major vascular cases for trauma 5.0 4.9 4.3 4.7 4.6 4.7 4.4 4.7 3.2 2.1
Neck exploration for trauma 0.3 0.4 0.3 0.4 0.3 0.3 0.3 0.3 0.3 0.3
Cardiac injury 0.3 0.4 0.3 0.4 0.3 0.3 0.3 0.3 0.3 0.3
Fasciotomy 1.2 1.3 X X X X X X 1.5 1.2
Splenectomy for trauma 3.1 3.2 3.2 3.0 2.0 3.1 3.1 3 2.8 2.5

Data collated from <http://www.acgme.org/residentdatacollection/documantation/staitistical_reports.asp>

Note: This data was reported by graduating chief residents and was supplied as part of the case log submitted to the American Board of Surgery
from 2001 to 2011.
Numbers represent the mean for each procedure; and, if missing (X), that procedure was not requested during that particular year.

Table 24-2 The Average Number of Selected Cases over the Duration of Training
2001- 2002- 2003- 2004- 2005- 2006- 2007- 2008- 2009- 2010-
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Total Vascular Trauma (Major) 7.6 8.1 8.6 8.7 10.9 10.6 10.9 12.5 11.3 10.8
—Thoracic 0.3 0.3 0.3 0.3 0.4 0.4 0.3 0.4 0.3 0.4
—Neck 0.4 0.5 0.4 0.5 0.5 0.6 0.5 0.8 0.6 0.6
—Abdominal 0.8 1.0 1.2 1.1 2.0 1.5 1.6 2.3 2.1 2.2
—Peripheral 5.9 6.3 6.7 7.8 8.0 8.2 8.4 9.0 8.3 7.6
Fasciotomy 0.9 1.0 0.8 1.2 1.0 1.2 1.0 1.4 1.4 1.4
Open exposure brachial artery X X X X X X 0.1 0.1 0.3 0.3

Data collated from: http://www.acgme.org/acgmeweb/tabid/274/DataCollectionSystems/ResidentCaseLogSystem/CaseLogsStatisticalReports

.aspx.
Note: This data was reported by vascular fellows and was supplied as part of the case log submitted to the American Board of Surgery from
2001 to 2011.
Numbers represent the mean for each procedure; and, if missing (X), that procedure was not requested during that particular year.

Though it is difficult to judge proficiency and competence
by volume data alone, it is certain that the experience of train-
ees is anything but uniform. Specialists are expected to gradu-
ate with a wide spectrum of abilities; but they, when called on
to care for vascular trauma, may or may not have the requisite
skill set to ensure the best outcome. Likewise, only a small
minority of vascular specialists report that the management
of vascular trauma comprises part of their clinical practice.
It is clear that the experiential approach is not sufficient as
a means of endowing surgical trainees with the right skills. As
such, there is a critical need to improve the way training is
conducted in order to secure the best care for patients with
vascular trauma. The remainder of this chapter explores the
evolving challenges faced by those tasked with training the
surgeon of the future and discusses current and near-term
modalities that are likely to improve the uniformity of training
in the management of vascular trauma.
Vascular Training in Evolution
Training in surgery has traditionally followed an apprentice-
ship model, with the trainee undergoing supervised exposure
to decision-making and technical skills under the tutelage of
a “craft” master. Historically, the acquisition of vascular
techniques—whether by master or apprentice—has followed
a model whereby the development of new skills occurs via
adaption and remolding of previously learned skill sets.
However, the move from open surgery to the endovascular
approach represents a paradigm shift in the management of
vascular disease, and the opportunity to transfer previously
learned skills to these new realms of practice is concordantly
lower. New endovascular therapies pose technical challenges,
similar to those experienced by practitioners of laparoscopic
and minimally invasive surgery (MIS). These include reduced
tactile sensation, a two-dimensional (2-D) (rather than a
three-dimensional [3-D]) perspective, and the need to over-
come proprioceptive and visual issues.28,29 New decision-
making algorithms and treatment opportunities often require
new training models and educational curricula—applicable
to both established specialists and surgical trainees—while
paying heed to new restrictions in duty hours. The relentless
and inevitable drive to subspecialize has required practitioners
to master new techniques at the cost of narrowing clinical
focus and constraining the surgical armamentarium required
for injury stabilization and vessel repair. With these issues in
mind, it is timely to consider new and emerging ways of deliv-
ering training to surgeons expected to manage patients with
vascular trauma.
Vascular Trauma Training
Considerations
As previous chapters demonstrate, effective trauma manage-
ment presents specific challenges, with the requirement for
rapid, systematic assessment and decision making to prevent
patient deterioration. However, every injury pattern is unique
with some factors coming to light only in the operative phase
of management, and it is not always possible to rehearse and
 24  /  Vascular Trauma: Training the Surgeon of the Future 271
preplan all aspects of surgical management. This mandates
that any training algorithm must include core principles that
can be adapted and can flexibly deployed to deal with the
individual situation at hand.
Training must be set at two distinct levels: (1) the decision-
making and technical skills required by nonvascular specialists
to prevent deterioration, to surgically stabilize the patient, and
to set the conditions for further specialist intervention and (2)
the advanced specialist skills necessary to deal with complex
injuries, postoperative complications, and longer-term man-
agement. Training may be delivered via a vascular or trauma
surgery curriculum (i.e., as part of a generic surgical training
rotation or as part of a dedicated vascular program/fellowship
for the specialist) through supervised and controlled exposure
to patients and their management. Such training must be part
of a properly planned curriculum, tailored to meet the learn-
ing outputs required of the target audience.
Clinical educators generally consider surgical training to
have the following two separate components: (1) a “hands-on”
practical learning of technical skills and (2) the acquisition of
knowledge and cognitive skills. Cognitive orientation centers
around the ability to organize relevant information and to a
construct a strategy that enables the best use of the relevant
skill. In other words, cognitive orientation is needed in order
to make appropriate decisions.30 Didactic lectures, textual
material and, more recently, case-based training have been
used for transfer of information and cognitive skills. Technical
and cognitive components of clinical training are inseparable;
they inform each other. Since Dewey’s 1938 pioneering work,31
experiential learning has been recognized as an important part
of how adults acquire new knowledge and skills (i.e., “learning
by doing” is a particularly effective method for advancing
cognitive and technical skills). Modern theory emphasizes the
problem-centered approach and the need to understand the
contextual orientation of the adult learner.32 Effective and sys-
tematic training is a byproduct of the quality of the curricu-
lum that is developed to enhance that training.
Within the United Kingdom, the vascular curriculum is
set by the Intercollegiate Surgical Curriculum Programme
(ISCP).33 The ISCP benefits from the input of specialty advi-
sory committees (SACs) representing each of the ten surgical
specialties. It is also informed by and collaborates with the
Surgical Royal Colleges of Great Britain and Ireland and other
professional bodies, including the Local Education and Train-
ing Boards (established in 2013) a and the General Medical
Council (GMC). In 2012 , vascular surgery became established
as a fully-fledged surgical specialty and left the aegis of the
General Surgery SAC, with a dedicated training pathway
leading to specialist certification, separate from that of general
surgery.
In the United States, vascular surgery has been (and is still
considered by many to be) an integral part of general surgery
training and practice.34 Before 1960, no specific training pro-
grams existed in vascular surgery, and vascular surgery was
practiced by general and cardiothoracic surgeons. The first
vascular surgery–specific training programs were, in essence,
apprenticeships directed by some of the pioneers of vascular
surgery.35 Training opportunities were advanced considerably
when the membership of the Society for Vascular Surgery
(SVS) voted in 1979 to develop accredited vascular training
programs. Initially, 17 programs were approved, rising to 52
programs by 1982.36 In 1982, the first 14 American Board of
Surgery (ABS) Certificates of Special Qualifications in General
Vascular Surgery were issued, each earned after successful
completion of a written examination. In the 1990s, leading
vascular surgeons pushed for recognition of vascular surgery
as a specialty distinct from general surgery, based on the
underlying premise that patient outcomes were improved
when care was provided by a specialist in vascular surgery
rather than a general surgeon who occasionally performed
vascular operations.37-39 Subsequently, vascular surgery became
a distinct specialty of surgery on March 17, 2005, when (with
approval of the American Board of Medical Specialties) the
ABS agreed to offer a Primary Certificate in Vascular Surgery.34
In October 2005, training program requirements for this cer-
tificate were approved; and the traditional requirement for 5
years of training and certification in general surgery was elimi-
nated. Effective July 1, 2006, the ABS converted its certificate
in vascular surgery from a subspecialty certificate to a specialty
(primary) certificate. These landmark changes heralded the
development of several new training paradigms. Multiple flex-
ible training pathways—leading to either dual certification
(Traditional: 5 years general plus 2 years vascular training;
Early Specialization Program: 4 years general plus 2 years vas-
cular training) or vascular surgery certification alone (Inte-
grated: 1 plus 5; Independent: 3 plus 3)—are now available.
The current trend in surgical training within the U.S. is
toward a structured, competency-based curriculum with
objective and ongoing documentation of proficiency within
residency training and then going into independent practice.
Toward this end, national organizations including the Ameri-
can College of Surgeons (ACS), the ABS, the Residency Review
Committee—Surgery, the American Surgical Association, the
Association for Program Directors in Surgery, and the Asso-
ciation for Surgical Education have established a national con-
sortium called the Surgical Council on Resident Education
(SCORE) to reform general surgical residency education.40
The thrust of SCORE’s endeavors is to develop a national cur-
riculum that will include a spectrum of educational offerings
delivered in a modular system. The curriculum includes
didactic content; simulated experiences; clinical and surgical
experiences; and valid, reliable performance assessments. The
Association for Program Directors in Vascular Surgery has
begun to adopt some of the same principles in the develop-
ment of vascular curricula. The aim is to ensure alignment of
the core content of the training program, the core competen-
cies expected as learning outcomes, and the assessment prac-
tices. This will confirm that—no matter what program or tract
a resident completes—measurable and acceptable levels of
competence are achieved in all required areas.
As yet, the ideal curriculum for training in vascular trauma
has not been delineated and will likely be specific to national
situations as well as the needs of and learning styles of indi-
vidual learners. However, the ideal curricula will clarify goals
and objectives in unambiguous terms, driven by consensus of
expert opinion. The obvious goal is to produce competent and
proficient practitioners who can appropriately diagnose and
apply cognitive, technical and teamwork skills to the manage-
ment of patients presenting with vascular trauma, aided by
a thorough understanding of anatomy and current open-
surgical and endovascular techniques. The remainder of this
chapter will focus on the wide variety of tools that are cur-
rently employed to train in vascular surgery in general and
vascular trauma in particular.
272 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
Vascular Trauma Training Tools
As previously emphasized, effective training begins and ends
with effective curricula. The tools currently available to teach
the management of vascular trauma include the following:
1. Clinical case material—care of patients
2. Didactic lectures
3. Textbook and digital media
4. Case-based discussion
5. Team-based training
6. Animal-model–based training
7. Human-cadaver–based training
8. Simulation-based training
a. Synthetic models—Low and high fidelity
b. Virtual reality
Ideally, curricular offerings with regard to the management
of vascular trauma will incorporate several of these tools, each
selected according to the goals and objectives of the educa-
tional program. Clinical case material has long been the main-
stay of vascular trauma training but can no longer be counted
on to provide sufficiently high volume. Didactic lectures, text-
book and digital media, and case-based discussion represent
the bulk of traditional curricular efforts but have limited
applicability if not focused and incorporated within a mean-
ingful curriculum. Likewise, animal models and human
cadavers have proved important in the training of surgeons;
but their use must be based on a thorough needs assessment
and on a good understanding of their inherent limitations.
The use of animals for training has several advantages and
a number of distinct limitations. Animals provide excellent
representations of human physiology, necessitating careful
and appropriate choices and executions of surgical maneuvers
in order to avoid excess hemorrhage and death. Animal tissues
require standard operating equipment and supplies; they
bleed when cut; and they exhibit damage if not handled, dis-
sected, and sutured carefully.41,42 However, maintenance of an
animal lab is expensive and logistically intensive, requiring the
means for veterinary support, animal care facilities, sterile
operating room (OR) facilities, and proper disposal of the
animals. Animal laboratories are rightly subject to stringent
care standards in order to ensure animal welfare is respected.
The use of animals is a highly visible and emotionally charged
issue decried by very active and vocal animal rights groups.43
The other key disadvantage of animal models concerns differ-
ences in anatomy: animals are usually inadequate for teaching
anatomic vascular exposures. The availability of live animal
models for training purposes is highly variable across the
world and is prohibited in many areas. Though still available
in the U.S., multiple and repeated efforts to outlaw the use of
live animals for trauma training continue unabated.44 A recent
bill put before Congress seeks to require the Secretary of
Defense to use only human-based methods for the training of
Armed Forces in the management of severe combat injuries—
thereby effectively outlawing the use of animals by 2016.44
Though this particular initiative is likely to be defeated, many
similar endeavors will threaten the place of such training
within surgical curricula. The surgical community must there-
fore be proactive in searching for replacements to live-tissue
training as this model is unlikely to be universally available in
the future.
Cadaver-based training is particularly useful for teaching
vascular exposures in humans, a skill essential to the effective
treatment of vascular injuries.43,45 The availability and cost of
cadavers is highly variable, as is the cultural acceptability of
using cadaveric material around the world. For instance, the
cost of obtaining cadavers for one such trauma course (the
ASSET course) is highly variable, ranging up to $8000, depend-
ing on the U.S. state concerned. Even in areas where it is pos-
sible to obtain cadaveric, material the number of adequate
specimens may not be sufficient to meet the need. Of interest
is the low willingness of medical professionals to donate their
own bodies for medical education. In a recent survey of
medical professionals in India, only 22% of physicians stated
that they were willing to donate their bodies for medical edu-
cation (though only 7% had already registered to do so); but
68% expected the public to do the same.46
Though cadavers give an excellent representation of human
anatomy, the anatomy is specific to that particular cadaver. As
there is great variability in human anatomy, this represents a
potential limitation. Additionally, most cadavers are elderly
and deconditioned; and, as such, translating the lessons
learned on an 80-year-old woman with diminished muscle
mass to a 20-year-old combat soldier may be difficult. The way
in which a cadaver is preserved also affects the utility of the
cadaver model. Cadaver tissue preserved in formalin has very
different characteristics than tissue found in a fresh or fresh-
frozen cadaver. Cadavers have no vessel flow and do not bleed.
Attempts have been made to improve the fidelity of cadaveric
specimens by cannulating the vessels of very fresh cadavers
and perfusing them with artificial blood in a pulsatile
fashion.47-49 Initially developed for neurosurgical training,
such perfused cadaver models have been modified as potential
tools for training on trauma surgical procedures. Pulsatile
flow can be obtained using a modified intraaortic balloon
pump system and injuries created in the heart, lung, liver, and
inferior vena cava, allowing for repair in a “bleeding human
model.”49 Though this technique improves the fidelity of the
cadaveric model, it requires significant preprocessing and
equipment, as well as very fresh cadaveric material, making it
impractical for widespread use and adoption.
New ways of surgical training have been developed in order
to respond to the limitations of more traditional methods, and
the remainder of this chapter will focus on team-based train-
ing and simulation.
Team-Based Training for
Vascular Trauma
The last decade has seen an explosion of interest in training
hospital teams using methods similar to those utilized by the
aviation industry.50-55 Nontechnical skills are the cognitive and
social skills that enable people working in safety-critical
industries to function effectively and safely. Decision-making
and nontechnical skills significantly influence the quality of
care afforded to the injured patient, especially with regard to
nonoperative management strategy. It is abundantly clear that
the surgeon is just one part of the health-care team and that
the team as a whole that must function optimally in order to
secure the best possible outcome. No amount of technical
virtuosity on the part of the surgeon will prevent such errors,
which can only be addressed through effective training in
teamwork, decision making, and communication. As such,
CRM is now high on the clinical agenda with the UK House
of Commons Health Committee recently acknowledging the
 24  /  Vascular Trauma: Training the Surgeon of the Future 273
critical influence of human factors on patient safety.56 Exam-
ples of a CRM skills include the following:
• Teamwork/team coordination
• Communication
• Leadership/followership
• Decision making
• Conflict resolution
• Assertiveness
• Management of stress and fatigue
• Workload management
• Prioritization of tasks
• Situational awareness
There is increasing evidence that CRM skills-training sig-
nificantly improves patient outcomes.53 A Veteran’s Adminis-
tration study reported a 50% reduction in surgical mortality
between CRM-trained surgical teams versus non–CRM-
trained surgical teams.51 Further studies in the VA system
showed a reduction of 18% in mortality rates in 74 facilities
that received training compared to a 7% reduction in 34
control facilities.57 The U.S. Department of Defense (DoD)
has implemented a program called TeamSTEPPS to address
CRM issues in DoD facilities, and it is currently used widely
both in civilian and military settings.55 This approach has also
been used in Norway, using a live porcine model, to develop
team skills in damage control surgery in a rural setting.58
In general, CRM within both military and civilian trauma
systems is underresearched, although a set of related studies
from the aviation, the organizational sciences, and the social
psychology domains illustrate the potential for future study in
this area.59
Clinical CRM training should involve the whole team so
that all members share a common purpose and develop a
full understanding of individual and team roles. While likely
to be important in civilian settings, there is no doubt that
exceptional nontechnical skills are essential for the military
trauma team practicing in austere circumstances. As such,
CRM training is a core feature of the UK Defence Medical
Services predeployment Military Operational Surgical Train-
ing (MOST). This course, which has a significant vascular
trauma component, will be discussed in greater detail later in
this chapter.
Simulation-Based Training for
Vascular Trauma
Simulation-based training is becoming widely established
within surgical education, and laboratories dedicated to
teaching the technical aspects of surgical skill have become
increasingly popular.43,60 This training offers obvious benefits
to novice surgeons who are learning invasive procedural skills
and to practicing surgeons who need skill refreshment.
Simulation-based training provides a safe, structured envi-
ronment for motor skills acquisition, with the aim of prepar-
ing trainees for real-life OR experience. Trainees may improve
their performance, may overcome learning curves, and may
manage simulated procedural complications without risk to
patients.61-64 The importance of simulation in training has
been recognized by the Residency Review Committee for
Surgery, with the most recent ACGME Program Require-
ments for General Surgery stating that resources should
include “simulation and skills laboratories.” The Agency for
Healthcare Research and Quality supports the effectiveness of
simulation training “especially for psychomotor and commu-
nication skills,” although it is recognized that supportive data
is limited.65 However, the available evidence suggests that
technical skills gained in the simulation laboratory do transfer
to the OR29,66—a benefit also demonstrated for endovascular
simulators in animal67 and human68 studies. Practice of open
surgical skills on low-fidelity models (e.g., synthetic models)
has also been shown to improve technical skill acquisition and
retention.69-71
Current trends in medical and surgical skills training
confirm movement away from the traditional apprenticeship
model of graded responsibility to a more structured approach,
with stepwise progress toward the attainment of technical
competence.72,73 The concept of the “pretrained novice” used
by educational psychologists refers to a learner who has auto-
mated the required suite of basic psychomotor skills and
spatial judgments.74 Enabling a trainee to reach this position
via simulation is attractive because subsequent OR training is
likely to be a higher-yield experience for the learner and is
likely to be safer for the patient. Simulation-based training
should commence with initial cognitive training,75 should
include predefined proficiency levels that trainees must reach
before moving to the next level,76,77 and should offer distrib-
uted practice sessions to reinforce acquired skills.78,79 This
structured approach avoids the random presentation of cases
typical of experiential Halstedian learning. Cases should
include complicated and crisis scenarios, so that correct man-
agement of potential problems is therefore practiced. Simula-
tion programs should guard against overtraining, should
include validated methods of assessment, and should have
protected time for feedback and error analysis64 because this
has been shown to improve performance. Although the
optimal type of feedback has not been established, the facility
to undertake near-instant feedback that is informed by objec-
tive assessment data, which has been captured during the
simulated procedure, would seem desirable.80,81 In contrast to
the traditional “learning by doing” model (where assessment
is often subjective and biased toward individual supervisors),
performance data obtained from simulators allows mentors to
objectively evaluate problems and to address these systemati-
cally before moving on to the next stage. Appropriate mentor-
ship within the curriculum is crucial.82
Simulation is a tool within a curriculum and is not its
end74,83; the curriculum developers set the context with regard
to subject matter and schedule of learning.84 However, in order
to make the best use of simulated training, it is best that edu-
cators and simulation experts align their efforts from the
outset and work in tandem.85 Certainly the potential for use
of simulation for technical skills is significant for vascular
trauma training. Simulations may include both open and
endovascular skills and may cover the following learning
outputs:
• Assessment, planning, and prioritization
• Surgical approaches and anatomy
• Control of hemorrhage
• Repair of vascular structures
Simulators applicable to vascular surgery range from
partial-task trainers to high-fidelity mock operating rooms.
The key to successful simulation is “willing suspension of
disbelief ” on the part of the learner—in that the he or she
finds it difficult to distinguish between the simulator and
a live patient or scenario. Simulators designed to mimic
274 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
endovascular or laparoscopic procedures are better able to
accomplish this, whereas those designed to represent open
vascular surgical procedures are generally of lower fidelity and
may suffer from inadequate face and content validity—which
can directly affect applicability of simulator-acquired skills to
real world scenarios.
Sidhu et al studied a group of surgical residents learning
vascular anastomoses skills and found that skill transfer was
better when they were trained on a higher-fidelity model
(human cadaver brachial arteries) when compared to those
training on a lower-fidelity (plastic models) variant.69 This
lesson must not be overlooked by those responsible for devel-
oping simulation models—it is not enough to incorporate a
simulator into a curriculum without first ensuring that it has
the appropriate level of fidelity to meet the goals and objec-
tives required.
Like endoscopy and laparoscopy, practitioners of endovas-
cular surgical techniques use screen-based technologies,
enabling more opportunity for faithful simulation as com-
pared to open surgery. Several endovascular simulators are
currently commercially available, providing a variety of train-
ing options, such as angioplasty and stenting of the carotid,
renal, iliac, and superficial femoral arteries; caval filter deploy-
ment; and aortic aneurysm stent repair. These are classified as
high-fidelity simulators as haptic (touch), aural, and visual
interfaces are simulated, providing near-realistic representa-
tions.86,87 The inventory of commercially available endovascu-
lar simulators includes the following:
1. The Mentice VIST simulator (Mentice, Gothenburg,
Sweden; www.Mentice.com).
This simulator comprises a mechanical unit housed within
a full-sized plastic mannequin cover, a high-performance
desktop computer, and two display screens. Modified
instruments are inserted through the access port using a
haptic interface device. Tactile feedback is created by a
series of motorized carts which lock onto the inserted
instrument, allowing the subject to manipulate the sim-
ulated instrument in real time with force feedback.
Commercially available simulation modules include
occlusive arterial disease in the coronary, carotid, renal,
and iliofemoral regions, uterine artery embolization, and
over-the-wire lead placement for biventricular pacing.
The learner is able to select appropriate instruments and
is able to perform interventional procedures using the
simulated fluoroscopic screen. Performance is measured
using metric parameters such as volume of contrast fluid
used, fluoroscopy time, and markers of stent placement
accuracy.
2. ANGIO Mentor (Simbionix, Cleveland, Ohio; http://
simbionix.com/simulators/angio-mentor/). The ANGIO
Mentor endovascular trainer has a similar range of arte-
rial procedures to the VIST and also boasts advanced
haptic technology. It differs from the VIST in that there
is greater emphasis on patient monitoring, drug admin-
istration, and response to physiological disturbance.
The ANGIO Mentor has an ever-expanding library of
modules with curricula that include 12 different endo-
vascular procedures and over 100 patient scenarios. In
addition, a patient rehearsal studio is built into the sim-
ulator that allows clinicians to create a patient specific
3D virtual anatomic model based on the patients CT
scan, allowing the physician to practice an endovascular
procedure before performing it on that particular
patient using his or her anatomy.
3. Simantha Simsuite Endovascular Simulator (Medical
Simulation Corporation, Denver, Colorado; http://
medsimulation.com/Products/asp). The Simsuite is a
larger simulator system with up to six interactive screens
to facilitate multidisciplinary team training. Similar to
the Angiomentor system, response to patient physiology
is featured substantially in the simulation, although
appropriate case selection and management are also fea-
tured. Medical Simulation Company has also developed
a portable trainer called Compass, as well as an iPad-
based simulation curriculum called Infinity.
4. CathLab VR Simulator (CAE Healthcare, Mon-
treal, Quebec http://www.cae.com/en/healthcare/endo
vascular.asp). This simulator was originally known as
the Endovascular Accutouch (Immersion Medical,
Gaithersburg, MD) until the company was acquired by
CAE. The updated CathLab VR endovascular simulator
incorporates many of the features described in the
devices described above.
Chaer et al conducted the first randomized study examin-
ing the transfer of simulator-trained endovascular skills to the
clinical environment.68 Twenty general surgery residents
without prior endovascular experience were randomized to a
2-hour period of simulator training versus no training. Par-
ticipants were then supervised through two endovascular
interventions in patients with lower extremity occlusive
disease. Using a global performance rating scale, the residents
who received simulation training scored higher by their super-
visors than the control group in the first endovascular case,
and this finding persisted with second case performance. A
separate review performed by the Best Evidence Medical Edu-
cation (BEME) collaboration found that “the weight of the
best available evidence suggests that high-fidelity medical
simulations facilitate learning under the right conditions.”88 It
also found that the quality of the supportive literature was
generally poor and was based around narrative and qualitative
analyses. Further studies are required to determine how degree
of exposure to simulation relates to benefit, to investigate the
optimal strategy for incorporation into training curricula, and
to better understand for which interventional procedures
endovascular simulation is best suited.
The European Board of Vascular Surgery (EBVS) has been
the vanguard of using simulation as an assessment tool (prob-
ably out of necessity due to the wide spectrum of training
differences in training among the countries of the European
Union). Qualification as a vascular surgeon by the EBVS
requires a demonstration of knowledge and cognitive ability
coupled with a technical and endovascular skills assessment.89
Validation studies of the EBVS skills assessment has been
conducted, which has promoted acceptance and continued
use of simulation in the evaluation of vascular surgical
candidates.90,91
However, in spite of advances in simulation for training in
endovascular therapy, it is important to note that the vast
majority of vascular trauma is (and will likely continue to be
in the near future) treated using open surgical techniques. As
such, there is an unmet need to develop open skills simulation
and assessment for the management of vascular trauma. Sidhu
and colleagues92 have developed a comprehensive vascular
skills assessment (CVSA) for surgical trainees. Candidates
 24  /  Vascular Trauma: Training the Surgeon of the Future 275
undergo a series of four 20-minute vascular skills stations
where control and repair of inferior vena cava injury, a
femoral embolectomy, a graft-to-artery anastomosis, and an
ultrasound-guided line insertion are assessed by a vascular
surgeon using a previously validated global rating scale.93 The
CVSA has excellent construct validity and correlates well with
postgraduate-year level, although the actual performance
scores obtained by the residents were low (with a mean score
of 50%), reinforcing the need for improved and targeted
training.
Several barriers to widespread integration of endovascular
simulators into training programs exist. The devices are
expensive (in excess of $100,000) and require regular calibra-
tion, maintenance, and updating as reliability remains prob-
lematic. Current training on the simulator is also limited by
realism with regard to tactile feedback and graphical inter-
faces. Transferability of endovascular and open skills from the
virtual reality realm to the OR remains to be definitively
proven. However, there is little doubt that the concept of simu-
lation is here to stay. As technology continues to advance,
more sophisticated simulators will become available to help
surgeons achieve clinical competence, thereby reducing the
number of errors and ultimately improving patient safety.
Current Vascular Surgery
Training Curricula
A number of courses and curricula have been developed to
teach basic and advanced vascular trauma skills. The following
section highlights a selection of such courses that are embraced
by leading surgical organizations designed to meet this
challenge.
The Definitive Surgical Trauma
Care Course
The Definitive Surgical Trauma Care (DSTC) course traces its
origins to a meeting of five internationally known trauma
surgeons from the U.S., Canada, France, and Australia. These
five members of the Societé International de Chirugie (SIC)
and the International Association for the Surgery of Trauma
and Surgical Intensive Care (IATSIC) determined that there
was a worldwide need to enhance surgical training in the
technical aspects trauma care.94 DSTC is designed to teach
qualified surgeons and advanced surgical trainees strategic
thinking and decision making in the management of severely
injured patients, and provide them with the surgical skills
required to manage major organ injury. Taught by experi-
enced trauma-trained surgeons, it is an intensive 2-day
course comprising lectures, interactive case discussions, and
laboratory-based surgical skills training. The surgical skills lab
is variably comprised of cadaver, animal (pig or goat), or both
animal and cadaver models, depending on local availability
and cultural sensitivities regarding the use of such models. In
2014, DSTC courses were taught in 41 centres around the
world at sites including Spain, Israel, Canada, Denmark, the
Netherlands, Australia, New Zealand, South Africa, Austria,
Portugal, Norway, Sweden, Germany, France, Greece, Singa-
pore, and Argentina. This truly international course provides
a broad overview of techniques applicable to the patient who
requires surgery and intensive care for major trauma. The
flexibility of the course ensures that it can be adapted to local
conditions although some degree of standardization is lost.
The course includes vascular exposures and hemorrhage
control but does not set out to teach repair or advanced man-
agement of vascular trauma injuries.
Definitive Surgical Trauma
Skills (DSTS)
Definitive Surgical Trauma Skills (DSTS) is a 2-day (originally
3-day) hands-on practical cadaveric workshop course for
civilian surgeons who are required to perform life-preserving
surgery on severely injured patients, as part of their on-call
duties, and for military and humanitarian surgeons who may
deploy to conflict zones.95 This course was a collaborative
effort between the Royal College of Surgeons of England, the
UK Defence Medical Services, and the Uniformed Services
University of the Health Sciences in the United States. Though
there is significant content overlap with the DSTC course,
DSTS was developed specifically to meet local needs and to
include an emphasis on cardiothoracic injuries and vascular
surgical techniques. In the words of the original conveners:
To manage trauma competently there is a need to master opera-
tive skills that cover the whole of the abdominal cavity, including
the pelvis and the retroperitoneum. General surgeons should be
competent and confident to carry out trauma thoracotomies and
able to cope with central and peripheral vascular trauma. Further
skills and knowledge are also required … encompassing trauma
epidemiology, critical decision making and, not least, a detailed
knowledge of surgical anatomy.94
Taught by an experienced international faculty of civilian and
military surgeons, the course emphasizes the concepts of
damage control resuscitation and surgery using limited didac-
tic material, multiple case discussions and extensive “bedside”
exposure in the human cadaver lab. These scenario-driven
sessions are supported by surgical anatomy tutorials using
the extensive prosected specimen preparations of the Royal
College of Surgeons of England, under the supervision of a
senior clinical anatomist.
DSTS covers all of the techniques required for vascular
exposure of the vessels in the torso, as well as the junctional
and proximal extremities. Techniques such as shunting,
primary repair, and vessel patching are taught, although the
course emphasizes damage control over definitive vascular
repair. As such, DSTS in its current form provides familiariza-
tion with the essence of vascular repair but is not designed to
formally teach vascular surgery. The use of fresh frozen cadav-
ers, combined with excellent anatomic prosections and the
real-time input of a senior anatomist, provides a level of ana-
tomic accuracy and tactile realism unique to this course. The
Royal College of Surgeons of England has developed other
curricula to teach vascular surgery to include the Specialty
Skills in Vascular Surgery Course96 and the Advanced Skills in
Vascular Surgery Course.97 Though these courses are designed
to teach the principles of vascular surgery, they are not
designed to teach the management of vascular trauma.
Advanced Trauma Operative
Management
The Advanced Trauma Operative Management (ATOM)
course uses standardized porcine models to teach the repair
276 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
of penetrating trauma. It is offered in over 26 sites in the
United States, Canada, Africa, the Middle East, and Japan. The
ATOM course was developed at Hartford Hospital (Hartford,
CT, USA) and uses a standardized simulation in which proper
methods of repairing severe penetrating trauma are taught
and evaluated.98 The ATOM course was designed to enhance
surgeons’ knowledge, confidence, and skills in repairing pen-
etrating injuries. ATOM employs a 1 : 1 faculty–to-student
ratio and a rigidly standardized curriculum to teach the surgi-
cal management of injuries to the bladder, small intestine,
kidney, ureter, spleen, pancreas, stomach, diaphragm, duode-
num, liver, lung, inferior vena cava, and heart. Though it is an
excellent primer in the management of penetrating trauma,
the vascular-specific component of the course is limited to the
inferior vena cava (IVC) and the heart, where injuries bleed
profusely and must be managed correctly if the pig is to
survive. A survey of perceptions among ATOM participants
was reported in 2005 and documented postcourse improve-
ment in participant self-confidence with regard to repairing
penetrating injuries.99 A worldwide follow-up survey of 1001
ATOM course participants was conducted in 2008 with 444
responding (46%).100 ATOM participants perceived that the
course allowed them to identify injuries more rapidly, to have
a more organized operative approach, and to control bleeding
more quickly than before the course.
The ATOM course was gifted to the American College of
Surgeons in 2009 and is now managed by the surgical skills
subcommittee of the American College of Surgeons Commit-
tee on Trauma (ACSCOT). The rigid standardization and the
faculty-to-student ratio have made this course an excellent
tool by which to impart knowledge on the management of
penetrating trauma. Limitations include the associated costs,
the lack of exposure to human anatomy, and the lack of
emphasis regarding exposure and repair of vascular trauma
(other than the IVC and heart). Additionally, the use of live
animals limits utility in certain areas of the world, and it
should be anticipated that such use will be further restricted
in the future.
Advanced Surgical Skills for
Exposures in Trauma (ASSET)
ACSCOT established a Surgical Skills Committee in 2005 that
was tasked to develop a standardized, skills-based course tar-
geted at surgical exposure of those vital structures most likely
to be involved following potentially or immediately life- or
limb-threatening injuries. This resulted in the establishment
of a new educational course known as Advanced Surgical
Skills for Exposure in Trauma (ASSET). The committee estab-
lished the following three educational objectives for the course
participants: to gain knowledge in the proper surgical expo-
sure of life-threatening injuries, to improve self-confidence in
operative exposure, and to promote technical competence in
accessing vital structures. The intended audience include
senior surgical residents (postgraduate years [PGY]-4 and
PGY-5), trauma and acute care surgery fellows, and practicing
general surgeons involved with trauma care. To develop the
curriculum, the committee developed a comprehensive list of
life- and limb-threatening injuries for potential inclusion.
Using a modified-Delphi process, the committee members
ranked each item for priority and relevance in the practice of
trauma surgery; a specific surgical exposure had to be endorsed
by at least 90% of the committee membership for inclusion.
The various injuries were then grouped by anatomic region as
follows: (1) head and neck, (2) thorax, (3) abdomen and
pelvis, (4) retroperitoneum, and (5) extremities. Course mate-
rials were generated for each of these areas and vetted by
members of the committee to achieve a consensus view of the
materials taught. The ASSET course was piloted in March
2008 at the Uniformed Services University in Bethesda, MD,
USA. Four beta courses were then conducted to further codify
and refine ASSET, which began to be formally offered by the
American College of Surgeons in March 2010. This course
rapidly gained a foothold with a total of 19 course sites estab-
lished in the U.S. and Canada by the end of 2011, with 54
courses offered and over 500 students and 100 instructors
trained.
The ASSET course in its final form is conducted over a 6- to
7-hour time period using fresh or fresh-frozen cadavers with
a student–to-faculty ratio of four to one. The entire course is
conducted in the cadaver dissection lab at the table side with
minimal didactics. The course is designed specifically to teach
vascular exposure for management of trauma. The dissections
are guided by a case-based approach, wherein a few Power-
Point slides are used to present a case (e.g., a patient shot in
the upper arm with loss of pulses and a presumed brachial
artery injury), followed by a few slides of relevant anatomy
and a brief narrated video showing step by step how to do the
procedure. The students are then urged to rapidly perform the
exposure with the help of the faculty who seek to instill a sense
of urgency as if this were an actively bleeding patient. Faculty
are guided by a manual with the specific goals and objectives
for each dissection, but are also encouraged to engage the
students in additional dialog reinforcing the dissections with
their personal clinical pearls and tips. A richly illustrated lab
manual and a DVD containing all the vascular exposures are
also provided to the students. Both the manual and the DVD
can be purchased outside the course.101
In an analysis of the first four beta courses, it was noted
that the general level of trauma experience was low, even
among senior course participants.102 Participants were asked
to assess comfort level in performing the vascular exposures
both before and after attending ASSET. As seen in Table 24-3,
there was a significant improvement in confidence; addition-
ally, when asked to rate the course using a five-point Likert
Table 24-3 Comparison of Mean Pre-ASSET
and Post-ASSET Surgical Self-
Assessed Confidence (SSAC) and
Mean Instructor Assessed
Participant Evaluation
Pre- Post- Instructor
Region/Level SSAC SSAC Difference* Evaluation
Neck 2.76 3.69 0.93 4.12
Chest 2.49 3.71 1.22 4.03
Abdomen 3.28 4.00 0.72 4.00
Pelvis 2.97 3.97 1.00 4.02
Lower extremity 2.88 3.97 1.09 4.07
Upper extremity 2.63 3.96 1.33 3.93
* = p < 0.05.
Note: A five-point Likert scale is used for these scores.
 24  /  Vascular Trauma: Training the Surgeon of the Future 277

scale, participants had an average response of 4.8 to the state- and their expertise is combined with other “lessons learned”
ment: “I learned new knowledge”; 4.8 to: “I am better prepared to ensure that the syllabus is always relevant to what the teams
to obtain exposure of injured structures”; and 4.91 to: “I will encounter on the ground. In this way, the highest level of
would recommend this course to a colleague.” preparation for the whole trauma team is assured and their
The ASSET course is relatively new, and long-term assess- collective learning curve minimized. Notably, MOST aims to
ment will be required to fully evaluate its efficacy. It is one of break down traditional boundaries between disciplines giving
the few courses available that directly addresses the specific integrated training where patient care, team capabilities, and
problems with training surgeons to care for vascular trauma outcomes remain the focus. Surgeons train alongside anesthe-
previously elucidated in this chapter. The ASSET course was tists, operating department practitioners (ODPs), theater
developed to teach vascular exposure and specifically does not nurses, and emergency physicians, thereby allowing the whole
teach vascular repair. This factor, course expense, variability team to understand and rehearse the priorities in managing a
in cadaveric availability, and the fact that the cadaveric model casualty with vascular trauma.
does not bleed comprise the major limitations of ASSET.
Nonetheless, it would appear that the course is tailored to European Vascular Masterclass (the
meet the needs of surgeons wishing to learn how to perform
the vascular exposures key to the management of vascular
Pontresina Course)
injury. In response to work-hour restrictions imposed by the
European Working Time Directive and in an attempt to
The Military Operational Surgical
Training Course
The Military Operational Surgical Training (MOST) course is
not specifically aimed at vascular injury but nevertheless has
a significant vascular component. It is directed at nonvascular
military specialists who will be called on to deliver vascular
surgical trauma care as part of a wider military trauma surgi-
cal capability. MOST is conducted at the Royal College of
Surgeons of England (RCSE) and is recognized by both RCSE
and the Royal College of Anaesthetists. It delivers whole-team
surgical trauma training to UK military surgical teams to pro-
vide integrated surgical trauma care to military and civilian
casualties of conflict. It utilizes scenario-directed human ca-
daveric dissection, small-group decision-making workshops,
and 3G simulation to impart technical and nontechnical (crew
resource management and teamwork) skills, utilizing the latest
military protocols and equipment (Fig. 24-1 and Fig. 24-2).103
Course participants are exposed to the full range of surgical FIGURE 24-1  Cadaveric-based, multidisciplinary team training on
and resuscitative techniques used to save life and limb. MOST the MOST course revising vascular access, vascular control, and man-
course faculty members have recent operational experience, agement for the nonspecialist vascular surgical team.

A B
FIGURE 24-2  A, Simulation training on the MOST course rehearsing the surgical team in resuscitation and preparation of a major extremity
injury in the operating room. This includes both technical and nontechnical skills assessment. B, Simulation of a major extremity injury on the
MOST course used to practice extremity injury assessment, vascular control, and CRM principles.
278 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
standardize vascular training in the European Union, leading
European vascular centers developed a European Vascular
Masterclass (EVM) course with the specific aim to train vas-
cular surgeons on realistic open and endovascular simulators
using a standardized teaching approach.70,104 This approach
uses stepwise teaching of a consensus-formulated approach to
performing open vascular procedures. Task-specific learning
processes are understood to be acquired in the following two
phases: fast-phase learning and slow-phase learning. Fast-
phase learning is set within individual skill sessions, with
complementary slow-phase learning occurring between ses-
sions during times of rest.105 The European Vascular Master-
class provides hands-on experience with pulsatile realistic
models (open simple and complex aortic repair, endovascular
aortic reconstruction, carotid endarterectomy, and distal
bypass surgery) and virtual simulators (for carotid, iliac, and
renal interventions). The physical models have been devel-
oped by Synbone (www.synbone.ch) but are not currently
widely available, nor have they been validated as effective
teaching tools. The EVM is meeting a perceived educational
need to train basic and advanced vascular surgical techniques,
but once again was not developed to address vascular injuries
from trauma.
Summary
As outlined in this chapter there are numerous challenges in
educating the surgeon caring for vascular trauma. Work hour
restrictions are here to stay, a trend that will increasingly
intrude on the time allotted to train the next generation. We
must be more efficient in the way that we teach and maximize
the time available through employment of high-impact, vali-
dated curricula designed to meet the goal of producing com-
petent and proficient practitioners. Furthermore, designers of
curricula must take advantage of the numerous educational
tools discussed in this chapter, with simulation taking on an
ever-increasing role in the training of vascular traumatolgists.
The fidelity of endovascular simulators is excellent, but simu-
lators that allow for the training of open surgical procedures
are in their infancy. Several excellent physical models that
approximate human tissue characteristics are currently in
development and will no doubt make a big impact on future
training. Comprehensive curricula must teach the manage-
ment of vascular trauma incorporating surgical exposure of
blood vessels (as is done with the DSTS, ASSET, MOST, and
some DSTC courses), control of bleeding (as is taught in
limited fashion in the ATOM and some DSTC courses), and
basic vascular techniques (both open and endovascular). Such
a comprehensive vascular trauma curriculum does not cur-
rently exist, and it is incumbent on the community of sur-
geons caring for patients with vascular trauma to address this
deficit in the near future in order to ensure a legacy of highly
skilled surgeons who are able to manage all aspects of vascular
trauma.
REFERENCES
1. Pickersgill T: The European working time directive for doctors in train-
ing. BMJ 323:1266, 2001.
2. Lamont PM, Scott DJ: The impact of shortened training times on the
discipline of vascular surgery in the United Kingdom. Am J Surg 190:
269–272, 2005.
3. Pellegrini CA, Warshaw AL, Debas HT: Residency training in surgery in
the 21st century: a new paradigm. Surgery 136:953–965, 2004.
4. Bell RH, Jr, Banker MB, Rhodes RS, et al: Graduate medical education
in surgery in the United States. Surg Clin North Am 87:811–823, 2007.
5. Barden CB, Specht MC, McCarter MD, et al: Effects of limited work
hours on surgical training. J Am Coll Surg 195(4):531–538, 2002.
6. Benes V: The European Working Time Directive and the effects on train-
ing of surgical specialists (doctors in training): a position paper of the
surgical disciplines of the countries of the EU. Acta Neurochir (Wien)
148(11):1227–1233, 2006.
7. Ferguson C, Kellog K, Hutter M, et al: Effect of work-hour reforms on
operative case volume of surgical residents. Curr Surg 62:535–538, 2005.
8. Thomas RL, Karanja N: Comparison of SHO Surgical Log Books a
Generation Apart. Ann R Coll Surg Eng 9(Suppl):356–359, 2009.
9. Smith R: Regulation of doctors and the Bristol inquiry. Both need to be
credible to both the public and doctors. BMJ 317(7172):1539–1540,
1998.
10. Walshe K, Offen N: A very public failure: lessons for quality improve-
ment in healthcare organisations from the Bristol Royal Infirmary. Qual
Health Care 10(4):250–256, 2001.
11. <http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is
-Human/To%20Err%20is%20Human%201999%20%20report%20
brief.ashx>.
12. Leape LL, Berwick DM: Five years after To Err Is Human: what have we
learned? JAMA 293(19):2384–2390, 2005.
13. Dutta S, Dunnington G, Blanchard MC, et al: And doctor, no residents
please! J Am Coll Surg 197:1012–1017, 2003.
14. Bulinski P, Bachulis B, Naylor DF, Jr, et al: The changing face of trauma
management and its impact on surgical resident training. J Trauma
54(1):161–163, 2003.
15. Brigham RA, Salander JM: Lack of a significant exposure to trauma by
residents. Mil Med 154(11):581, 1989.
16. Gaarder C, Skaga NO, Eken T, et al: The impact of patient volume on
surgical trauma training in a Scandinavian trauma centre. Injury 36:
1288–1292, 2005.
17. Joels CS, Langan EM, 3rd, Cull DL, et al: Effects of increased vascular
surgical specialization on general surgery trainees, practicing surgeons,
and the provision of vascular surgical care. J Am Coll Surg 208(5):692–
697, 2009.
18. Grabo DJ, DiMuzio PJ, Kairys JC, et al: Have endovascular procedures
negatively impacted general surgery training? Ann Surg 246:472–477,
2007.
19. Lin PH, Bush RL, Milas M, et al: Impact of an endovascular program on
the operative experience of abdominal aortic aneurysm in vascular fel-
lowship and general surgery residency. Am J Surg 186:189–193, 2003.
20. Cronenwett JL: Vascular surgery training: is there enough case material?
Semin Vasc Surg 19:187–190, 2006.
21. <http://www.acgme.org/residentdatacollection/documentation/
statistical_reports.asp>.
22. Boutros J, Sekhon M, Webber E, et al: Vascular surgery training, expo-
sure, and knowledge during general surgery residency: implications for
the future. Am J Surg 193:561–566, 2007.
23. van Bockel JH, Bergqvist D, Cairols M, et al, European Section and
Board of Vascular Surgery of the European Union of Medical Specialists:
Education in vascular surgery: critical issues around the globe-training
and qualification in vascular surgery in Europe. J Vasc Surg 48(6 Suppl):
69S–75S, 2008.
24. Veller MG: Education in vascular surgery-critical issues: a Southern
African perspective. J Vasc Surg 48(6 Suppl):84S–86S, 2008.
25. Burkhardt GE, Rasmussen TE, Propper BW, et al: A national survey of
evolving management patterns for vascular injury. J Surg Educ 66(5):
239–247, 2009.
26. Eckert M, Cuadrado D, Steele S, et al: The changing face of the general
surgeon: national and local trends in resident operative experience. Am
J Surg 199(5):652–656, 2010.
27. Eidt JF, Mills J, Rhodes RS, et al: Comparison of surgical operative expe-
rience of trainees and practicing vascular surgeons: a report from the
Vascular Surgery Board of the American Board of Surgery. J Vasc Surg
53(4):1130–1139, 2011.
28. Gallagher AG, McClure N, McGuigan J, et al: An ergonomic analysis of
the fulcrum effect in the acquisition of endoscopic skills. Endoscopy
30(7):617–620, 1998.
29. Gallagher AG, Cates CU: Approval of virtual reality training for carotid
stenting: what this means for procedural-based medicine. JAMA
292(24):3024–3026, 2004.
30. Saltzman PD: Saltzman PD, editor: Best Practices in Surgical Education:
Innovations in Skills Training, Cincinnati, OH, 2010, Ethicon Endo-
Surgery, Inc.
 24  /  Vascular Trauma: Training the Surgeon of the Future 279
31. Dewey J: Experience and education, New York, 1938, Simon &
Schuster.
32. Knowles MS, Holton EF, Swanson RA: The adult learner, ed 5, Woburn,
MA, 1998, Butterworth-Heinemann.
33. Intercollegiate Surgical Curriculum Programme. <https://www.iscp.ac
.uk/surgical/syllabus.asp.x>.
34. Mills JL, Sr: Vascular surgery training in the United States: a half-century
of evolution. J Vasc Surg 48(Suppl 6):90S–97S, 2008.
35. Goldstone J: New training paradigms and program requirements. Semin
Vasc Surg 19:168–171, 2006.
36. DeWeese JA: Accreditation of vascular training programs and certifica-
tion of vascular surgeons. J Vasc Surg 23:1043–1053, 1996.
37. DeWeese JA: Should vascular surgery become an independent specialty.
J Vasc Surg 12:605–606, 1990.
38. Barnes RW, Ernst CB: Vascular surgical training of general and vascular
surgery residents. J Vasc Surg 24:1057–1063, 1996.
39. Stanley JC, Barnes RW, Ernst CB, et al: Vascular surgery in the United
States: workforce issues. Report of the Society for Vascular Surgery and
the International Society for Cardiovascular Surgery, North American
Chapter, Committee on Workforce Issues. J Vasc Surg 23:172–181, 1996.
40. Bell RH: Surgical council on resident education: a new organization
devoted to graduate surgical education. J Am Coll Surg 204(3):341–346,
2007.
41. Reeds MG: Trauma training using the live tissue model. J Trauma 69:
999–1000, 2010.
42. Sohn VY, Miller JP, Koeller CA, et al: From the combat medic to the
forward surgical team: the Madigan model for improving trauma readi-
ness of brigade combat teams fighting the Global War on Terror. J Surg
Res 138:25–31, 2007.
43. Ritter EM, Bowyer MW: Simulation for Trauma and Combat Casualty
Care. Minim Invasive Ther Allied Technol 14(224–234):2005.
44. 112th Congress H.R. 1417—“Battlefield Excellence through Superior
Training Practices Act”, April 7, 2011. <Http://www.gpo.gov/fdsys/pkg/
BILLS-112hr1417h/pdf/BILLS-112hr1417h.pdf>.
45. Gambhir RPS, Agrawal A: Training in Trauma Management. Medical
Journal of the Armed Forces of India 66:354–356, 2010.
46. Ballala K, Shetty A, Malpe SB: Knowledge, attitude, and practices regard-
ing whole body donation among medical professionals in a hospital in
India. Anat Sci Educ 4:142–150, 2011.
47. Aboud E, Al-Mefty O, Yasargil MG: New Laboratory model for neuro-
surgical training that simulates live surgery. J Neurosurg 97:1367–1372,
2002.
48. Aboud E: Live Surgery Practice using Perfused Human Cadavers. Paper
presented at: Alternatives in the Mainstream: Innovations in Life Science
Education and Training. 2nd InterNICHE Conference, Oslo Norway,
2005 May 12–15. Accessed at: <http://new.interniche.org>. Dec 17, 2011.
49. Aboud ET, Krisht AF, O’Keefe T, et al: Novel simulation training for
trauma surgeons. J Trauma 71:1484–1490, 2011.
50. Sundar E, Sundar S, Pawlowski J, et al: Crew resource management and
team training. Anesthesiol Clin 25:283–300, 2007.
51. Dunn EJ, Mills PD, Neily J, et al: Medical team training: applying crew
resource management in the Veterans Health Administration. Jt Comm
J Qual Patient Saf 33:317–325, 2007.
52. France DJ, Leming-Lee S, Jackson T, et al: An observational analysis of
surgical team compliance with perioperative safety practices after crew
resource management training. Am J Surg 195:546–553, 2008.
53. Armour Forse R, Bramble JD, McQuillan R: Team training can improve
operating room performance. Surgery 150:771–778, 2011.
54. Sanfey H, McDowell C, Meier AH, et al: Team training for surgical
trainees. Surgeon 9(Suppl 1):S32–S34, 2011.
55. King HB, Battles J, Baker DP, et al: TeamSTEPPS: Team Strategies and
Tools to Enhance Performance and Patient Safety. In Henrickson K,
Battles JB, Keyes MA, et al, editors: Advances in Patient Safety: New
Directions and Alternative Approaches, vol 3, Performance and Tools,
Rockville, MD, 2008, Agency for Healthcare Research and Quality (US).
56. House of Commons Health Committee: Patient Safety. Sixth Report of
Session 2008-2009, London, The Stationery Office Limited, 2009.
57. Neily J, Mills PD, Young-Xu Y, et al: Association between implementa-
tion of a medical team training program and surgical mortality. JAMA
304:1693–1700, 2010.
58. Hansen KS, Uggen PE, Brattebø G, et al: Team-oriented training for
damage control surgery in rural trauma: a new paradigm. J Trauma
64(4):949–953, 2008.
59. Midwinter M, Mercer S, Lambert AW, et al: Making difficult decisions
in major military Trauma: a crew resource management perspective. J R
Army Med Corps 157(3 Supp1):299–304, 2011.
60. Bowyer MW: Educational Case Study: The National Capital Area
Medical Simulation Center of the Uniformed Services University of the
Health Sciences. In Saltzman PD, editor: Best Practices in Surgical Edu-
cation: Innovations in Skills training, Cincinnati, OH, 2010, Ethicon
Endo-Surgery, Inc.
61. Ziv A, Wolpe PR, Small SD, et al: Simulation-based medical education:
an ethical imperative. Acad Med 78:783–788, 2003.
62. Reznick RK, Macrae H: Teaching surgical skills–changes in the wind.
N Engl J Med 355:2664–2669, 2006.
63. Satava RM: Virtual reality surgical simulator. The first steps. Surg Endosc
7:203–205, 1993.
64. Tsuda S, Scott D, Doyle J, et al: Surgical skills training and simulation.
Curr Probl Surg 46:271–370, 2009.
65. Marinopoulos SS, Dorman T, Ratanawongsa N, et al: Effectiveness of
continuing medical education: evidence report/technology assessment
No. 149 (prepared by the Johns Hopkins Evidence-Based Practice
Center, under contract No. 290-02-0018) (Agency for Healthcare
Research and Quality, Rockville, MD) AHRQ Publication No. 07-E006,
2007.
66. Seymour N: VR to OR: a review of the evidence that virtual reality simu-
lation improves operating room performance. World J Surg 32:182–188,
2008.
67. Berry M, Lystig T, Beard J, et al: Porcine transfer study: virtual reality
simulator training compared with porcine training in endovascular
novices. Cardiovasc Intervent Radiol 30:455–461, 2007.
68. Chaer RA, DeRubertis BG, Lin SC, et al: Simulation improves resident
performance in catheter-based intervention: results of a randomized,
controlled study. Ann Surg 244:343–352, 2006.
69. Sidhu RS, Park J, Brydges R, et al: Laboratory based vascular anastomo-
sis training: a randomized controlled trial evaluating the effects of bench
model fidelity and level of training on skill acquisition. J Vasc Surg 45:
343–349, 2007.
70. Pandey V, Wolfe JH, Moorthy K, et al: Technical skills continue to
improve beyond surgical training. J Vasc Surg 43:539–545, 2006.
71. Black SA, Harrison RH, Horrocks EJ, et al: Competence assessment of
senior vascular trainees using a carotid endarterectomy bench model.
Br J Surg 94:1226–1231, 2007.
72. Hamdorf JM, Hall JC: Acquiring surgical skills. Br J Surg 87:28–37, 2000.
73. Neequaye SK, Aggarwal R, Van Herzeele I, et al: Endovascular skills
training and assessment. J Vasc Surg 46(5):1055–1064, 2007.
74. Gallagher AG, Ritter EM, Champion H, et al: Virtual reality simulation
for the operating room: proficiency based training as a paradigm shift
in surgical skills training. Ann Surg 24:364–372, 2005.
75. Van Herzeele I, Aggarwal R, Neequaye S, et al: Cognitive training
improves clinically relevant outcomes during simulated endovascular
procedures. J Vasc Surg 48:1223–1230, 2008.
76. Ahlberg G, Enochsson L, Gallagher AG, et al: Proficiency-based virtual
reality training significantly reduces the error rate for residents during
their first 10 laparoscopic cholecystectomies. Am J Surg 193:797–804,
2007.
77. Seymour N, Gallagher A, Sanziana R, et al: Virtual reality training
improves operating room performance: results of a randomized, double-
blinded study. Ann Surg 236:458–464, 2002.
78. Verdaasdonk EG, Stassen LP, van Wijk RP, et al: The influence of differ-
ent training schedules on the learning of psychomotor skills for endo-
scopic surgery. Surg Endosc 21:214–219, 2007.
79. Moulton CA, Dubrowski A, Macrae H, et al: Teaching surgical skills:
what kind of practice makes perfect? A randomized, controlled trial.
Ann Surg 244:400–409, 2006.
80. Darzi A, Mackay S: Assessment of surgical competence. Qual Health
Care 10:64–69, 2001.
81. Smith SG, Torkington J, Darzi A: Objective assessment of surgical dex-
terity using simulators. Hosp Med 60:672–675, 1999.
82. Gould DA, Reekers JA, Kessel DO, et al: Simulation devices in interven-
tional radiology: validation pending. J Vasc Interv Radiol 17:215–216,
2006.
83. McClusky DA, 3rd, Smith CD: Design and development of a surgical
skills simulation curriculum. World J Surg 32:171–181, 2008.
84. Satava RM: Identification and reduction of surgical error using simula-
tion. Minim Invasive Ther Allied Technol 14:257–261, 2005.
85. Arora S, Lamb B, Undre S, et al: Framework for incorporating simula-
tion into urology training. BJU Int 107:806–810, 2011.
86. Aggarwal R, Cheshire N, Darzi A: Endovascular simulation-based train-
ing. Surgeon 6:196–197, 2008.
87. Tsang JS, Naughton PA, Leong S, et al: Virtual reality simulation in
endovascular surgical training. Surgeon 6(4):214–220, 2008.
280 SECTION 4  /  HOT TOPICS IN VASCULAR INJURY AND MANAGEMENT
88. Issenberg SB, McGaghie WC, Petrusa ER, et al: Features and uses of
high-fidelity medical simulations that lead to effective learning: a BEME
systematic review. Med Teach 27:10–28, 2005.
89. Bismuth J, Donovan MA, O’Malley MK, et al: Incorporating simulation
in vascular surgery education. J Vasc Surg 52:1072–1080, 2010.
90. Pandey VA, Wolfe JHN, Lindahl AK, et al, on behalf of the European
Board of Vascular Surgery: Validity of an exam assessment in surgical
skill: EBSQ-VASC pilot study. Eur J Vasc Endovasc Surg 27:341–348,
2004.
91. Pandey VA, Wolfe JH, Liapis CD, et al: The examination assessment of
technical competence in vascular surgery. Br J Surg 93:1132–1138, 2006.
92. Sidhu RS, Chen J, Baxter K, et al: Development of a comprehensive
vascular skills assessment for surgical trainees. Am J Surg 197:591–594,
2009.
93. Reznick R, Regehr G, MacRae H, et al: Testing technical skill via an
innovative “bench station” examination. Am J Surg 173:226–230, 1997.
94. Ryan JM, Roberts P: Definitive surgical trauma skills: a new skills course
for specialist registrars and consultants in general surgery in the United
Kingdom. Trauma 4:184–188, 2002.
95. Royal College of Surgeons of England. <https://www.rcseng.ac.uk/
courses/course-search/dsts.html>. Accessed 30 January 2015.
96. Royal College of Surgeons of England. <https://www.rcseng.ac.uk/
courses/course-search/specialty-skills-in-vascular-surgery>. Accessed
30 January 2015.
97. Royal College of Surgeons of England. <https://www.rcseng.ac.uk/
courses/course-search/advanced-skills-in-vascular-surgery>. Accessed
30th Jan 2015.
98. Jacobs LM, Burns KJ, Kaban JM, et al: Development and evaluation of
the Advanced Trauma Operative Management course. J Trauma 55:471–
479, 2003.
99. Jacobs LM, Burns KJ, Luk SS, et al: Follow-up survey of participants
attending the Advanced Trauma Operative Management (ATOM)
course. J Trauma 58:1140–1143, 2005.
100. Jacobs L, Burns K, Hull S: Advanced Trauma Operative Management
course: participant survey. World J Surg 34:164–168, 2010.
101. American College of Surgeons. <https://web4.facs.org/ebusiness/Pro-
ductCatalog/product.aspx?ID=431>. Accessed 30 January 2015.
102. Kuhls DA, Risucci DA, Bowyer MW, et al: Advanced Surgical Skills for
Exposure in Trauma (ASSET): a new surgical skills cadaver course for
surgery residents and fellows. JACS 74(2):664–670, 2013. 2012 submit-
ted unpublished data.
103. Towell E, Cornick E: Getting the MOST from Conflict Zones: any
lessons for the NHS? Royal College of Surgeons of England 92:306–307,
2010.
104. European Vascular Course. <http://www.vascular-course.com/european
-vascular-master-class>. Accessed 30 January 2015.
105. Walker MP, Brakefield T, Hobson J, et al: Dissociable stages of human
memory consolidation and reconsolidation. Nature 425:616–620, 2003.
 SECTION 5

International
Perspectives
Australia and New Zealand
IAN D. CIVIL
Region-Specific Epidemiology
Australia and New Zealand have a combined population of
approximately 27 million people (approximately the popula-
tion of Texas) spread over a very large land mass of nearly 8
million square kilometers (roughly the size of the continental
United States). In Australia and New Zealand, ownership and
use of firearms and, in particular, handguns are limited by
strict laws. With large farming areas in both countries, fire-
arms are present but at a much lower per capita rate than in
the United States (22.6 guns per 100 people in New Zealand;
15 guns per 100 people in Australia; 88.8 guns per 100 people
in the United States).1 Additionally, the incidence of a mass
shooting events in Australia and New Zealand has been very
low to nonexistent, with only one major event in each country
in the last 20 years.2
As in most countries, despite being illegal, the carrying of
knives is harder to police. Among most cultural groups in
Australia and New Zealand, interpersonal violence most com-
monly involves blunt mechanisms rather than stabbings or
shootings.3 As a result the vast majority (over 90%) of trauma
in both Australia and New Zealand is of a blunt mechanism
with penetrating mechanisms being the cause in less than 10%
of trauma patients.4 Most vascular trauma that occurs in the
community is therefore to lower extremity vessels in associa-
tion with fractures and dislocations (Fig. 25-1), to the thoracic
aorta in association with deceleration injury (Fig. 25-2), and
to the cervical vessels in association with blunt trauma (Fig.
25-3). Penetrating trauma occurs with the usual distribution
of injury from accidental injuries such as arms lacerated when
placed though windows and less commonly from interper-
sonal violence with firearms. Given the increasing rate of
endovascular procedures performed by a range of providers
and in areas such including those in intensive care units
(ICUs), a significant proportion of penetrating vascular
trauma in Australia and New Zealand arises from iatrogenic
mechanisms (e.g., damage to the femoral, the subclavian, and
the carotid vessels).5
Although there are no longstanding national trauma reg-
istries, there are a number of well-established institutional
registries including the Auckland City Hospital Trauma Reg-
istry established in 1994, and cumulative reports indicate an
incidence of vascular injury comprising approximately 1.5%
of trauma admissions.6-8 In this extensive trauma experience,
roughly 75% of vascular injuries have occurred due to blunt
mechanisms and 25% from penetrating mechanisms. Over the
past three decades, there have been no major changes in the
etiology of vascular trauma, although the absolute numbers
have increased gradually in line with population growth.9
25 
Region-Specific Systems of Care
There is considerable variation in the systems of care under
which trauma care is provided in Australia and New Zealand.
In general, it is not well systematized, although the state of
Victoria in Australia has run an effective statewide trauma
system for over a decade and has been able to demonstrate
both a significant reduction in mortality and an improved
functional outcome for survivors.10,11 The American College
of Surgeons (ACS) verification system has been adopted by
the Royal Australasian College of Surgeons (RACS), and some
hospitals and regions have embraced this process improve-
ment strategy in systems for the delivery of care. In general,
however, trauma care is provided by a range of hospitals
whose size and capability varies widely. In the large metropoli-
tan centers of Australia and New Zealand, there exist hospitals
that match to a greater or lesser degree the trauma care capa-
bilities of an ACS Level I trauma center. In the regional and
provincial areas, base hospitals usually have the capabilities of
an ACS Level II center. In more rural and remote areas, trauma
capabilities are limited. In the rural areas, most trauma patients
are taken to the nearest regional hospital, which is the only
real option. In the cities and urban areas, there is usually some
form of geographic boundary used to define the receiving
medical center. Only in Victoria has a really effective destina-
tion policy been developed that is highly efficient in ensuring
major trauma patients are taken to one of only two adult or
one pediatric (Level I) centers.
Surgical Training and Certification
The RACS is the only training oversight body for surgeons in
Australia and New Zealand, and the college trains in nine
surgical disciplines including vascular surgery. Prior to 1997,
vascular surgery was integral to general surgical training with
further expertise being available in post-fellowship positions,
but lately there has been a separate training program that has
graduated about 10 vascular surgeons per year. There is no
separate training program in trauma surgery; and additional
expertise in this area, beyond what might be obtained in
general, orthopedic, neurosurgical, or vascular surgical train-
ing is only available in post-fellowship programs either within
Australia and New Zealand or overseas. Thus it is possible to
be deemed by the registering authorities as a certified general
surgeon or a certified vascular surgeon, but not a certified
trauma surgeon as this specialty is not one of the nine recog-
nized by the regulatory entities. Overall, in New Zealand and
Australia there is approximately 1 surgeon for every 6000
people. However, with respect to the specific specialties likely
283
 25  /  Australia and New Zealand 283.e1

ABSTRACT
Penetrating trauma is uncommon in Australia and New
Zealand, comprising less than 10% of all trauma admis-
sions. Most vascular trauma is therefore blunt and is com-
prised of extremity injuries associated with severe fractures,
thoracic aortic disruption associated with deceleration, or
blunt cerebrovascular injury. Vascular trauma is managed
by both general surgeons and vascular surgeons with the
latter being a recognized specialty. Trauma surgery is not
a recognized specialty, and those with an interest in this
area have usually done post-fellowship training either in
Australia, New Zealand, or overseas.
A systems approach to trauma care is recognized in
principle but the effective organization of trauma care
delivery is extremely variable between the states in Austra-
lia, and in New Zealand. Only in the state of Victoria is
there a well-organized trauma system with clear destination
policies and a well-organized statewide trauma registry.
This system, which has been in existence for over 10 years,
has demonstrated significant improvements in mortality as
well as in quality of life for survivors.
Training surgeons to care for vascular trauma is prob-
lematic. The incidence is low and the experience diversely
spread between both general surgical trainees and vascular
surgical trainees. While trainee volume of practice forms an
integral part of the assessment of adequacy of training,
expectations of competency within any specific area of
practice are limited. To acquire and maintain competence
in the care of patients suffering vascular trauma, trainees
and qualified surgeons are encouraged to complete the
Definitive Surgical Trauma Care (DSTC) course, to under-
take post-fellowship training in trauma and to have experi-
ence somewhere outside Australia or New Zealand and
where the incidence of penetrating trauma and vascular
injury allows adequate experience in this areas of practice.

Key Words:  Australia,

New Zealand,
vascular injury,
trauma systems
284 SECTION 5  /  INTERNATIONAL PERSPECTIVES
FIGURE 25-1  Dislocated knee associated with distal ischemia.
FIGURE 25-2  Computed tomography (CT) showing blunt thoracic
aortic rupture.
to manage vascular trauma, there is 1 general surgeon for
every 16,000 persons and 1 vascular surgeon for every 145,000
(RACS surgical workforce projections 2025).12
Access to Care
In Australia and New Zealand there are private health-care
systems, but most trauma and acute care is managed within
the public or national health-care system. This system affords
a baseline of routine and emergency care for all citizens of
Australia and New Zealand. Personal private or government-
FIGURE 25-3  Common carotid traumatic dissection secondary to
blunt trauma.
supported insurance allows patients to access the private
system for semiacute and elective needs, and in New Zealand
a universal no-fault accident insurance (Accident Compensa-
tion Corporation) allows private care of injuries after the first
10 days post injury. (unless the patient is still an inpatient in
a public health-care facility, which is then obligated to con-
tinue providing care). Almost all episodes of trauma signifi-
cant enough to warrant admission to the hospital are managed
in the public or national health-care program.
Prehospital Care
Prehospital care in New Zealand is provided by a single pre-
hospital provider in each geographic area. One provider, the
Order of St John, is responsible for over 90% of all prehospital
care in New Zealand. There is a single emergency telephone
number, and three mirrored call centers manage all emergency
ambulance calls. While tasked by these call centers, air ambu-
lances are not part of the road provider system; but, like it,
they are funded partly by the government for noninjury work.
This occurs partly by the Accident Compensation Corpora-
tion for injury work and partly by sponsorship and charitable
donations. In Australia each state and territory has its own
ambulance system and integrated air ambulances.
Advanced Trauma Life Support (ATLS) was introduced into
Australia and New Zealand in 1988 (referred to as Early Man-
agement of Severe Trauma); and it has been mandatory for all
surgical trainees since 1994. Since 1997, the Definitive Surgical
Trauma Care (DSTC) course has been run in Australia and
since 2003 in New Zealand; and there are currently four courses
in Australia and one in New Zealand each year. DTSC is
strongly recommended by the General Surgeons’ associations
for trainees who began training in 2012.
Region-Specific Considerations
for Diagnosis
As most vascular trauma is the result of a blunt mechanism,
evidence-based contemporary diagnostic strategies are in
place. Clinical examination, the ankle-brachial index (ABI)
Doppler, and the computed tomography angiography (CTA)

FIGURE 25-4  Aortogram showing placement of a thoracic aortic
stent-graft.
are commonly used as diagnostic modalities for lower extrem-
ity vascular trauma. Chest radiography— followed by contrast-
enhanced CTA of the chest, abdomen, and pelvis—is the
common approach for injuries significant enough to risk
blunt aortic injury. As in many parts of the world, blunt cervi-
cal vascular injury has been underappreciated with rates of
approximately 0.2% of trauma admissions. With greater use
of a screening protocol and much more liberal use of CTA
concurrent with computed tomography (CT), imaging of the
head and C-spine rates of cervical vascular injury are now
closer to 1%. Penetrating vascular trauma is often associated
with hard signs of vascular injury, such as hemorrhage or
profound ischemia. As has been well outlined in this textbook,
in the absence of hard signs, further evaluation using CTA or
duplex ultrasound is typical in most centers in Australia and
New Zealand.
Region-Specific Treatment Strategies
With a large focus on blunt thoracic aortic injury, Australian
and New Zealand surgeons have been quick to embrace endo-
vascular technology for the repair of these injuries. Since
approximately 2005, the vast majority of blunt aortic injuries
in these countries have been repaired with endovascular stent-
grafts, nearly all of which have been placed by certified vascu-
lar surgeons (Fig. 25-4). This practice has been associated with
excellent results; and, in a population that is somewhat easier
to follow than some regions of the world, endovascular repair
in Australia and New Zealand has been associated with few
mid- and long-term problems.13 However, the role of deb-
ranching procedures to revascularize the left subclavian artery
before, during, or after endograft treatment of blunt aortic
injury is not well defined.
25  /  Australia and New Zealand 285
FIGURE 25-5  A combat-action tourniquet applied to a patient with
a laceration of the brachial artery.
In the setting of penetrating trauma to the limb or a
severely mangled extremity (including traumatic amputa-
tion), Australia and New Zealand have recognized the impor-
tance and utility of modern tourniquets. Led by recent military
experience and study, tourniquets have been deemed impor-
tant in civilian circumstances; and all ambulances used for
acute response to trauma in New Zealand are equipped with
two combat action tourniquets (CAT). Since initiation of this
policy, there have been numerous anecdotal experiences of
tourniquet application controlling extremity hemorrhage and
allowing the injured patient to be quickly stabilized. In these
cases, hemorrhage has been controlled at or close to the scene
of injury with the tourniquet; and initiation of resuscitation,
transport to the hospital, and even operative repair have been
conducted in controlled circumstances (Fig. 25-5).
Penetrating neck injuries are uncommon; and traditionally
those in zone II (between the cricothyroid cartilage and the
angle of the mandible), having penetrated the platysma,
underwent operative exploration. More recently, in the era of
sensitive and specific contrast CTA, a recognition has devel-
oped that in the absence of hard signs the likelihood of vas-
cular or visceral injury is low. This evolution has led to a
modern practice in Australia and New Zealand of selective
exploration, in which many penetrating neck wounds are now
imaged with CTA and observed.14 Because of the low inci-
dence of penetrating trauma, as well as what are generally
longer transport times in most parts of Australia and New
Zealand, the need for resuscitative thoracotomy is extremely
rare. However, this potentially lifesaving maneuver is still
taught to general surgical trainees as part of the DSTC course;
and occasionally there are reports of its successful application
in Australasia.
Strategies to Sustain and Train
the Next Generation of
Trauma Surgeons
With such a low incidence of vascular trauma in Australia and
New Zealand, a greater focus needs to be placed on training
and maintenance of currency using structured courses such as
286 SECTION 5  /  INTERNATIONAL PERSPECTIVES
the DSTC course. General surgical training is currently a
5-year program comprised of 6-month rotations with at least
1 year spent in a smaller regional hospital. Despite regular
on-call duties, many trainees will have minimal exposure to
significant vascular trauma during their residency. Mandating
the DSTC course and developing others like it, some possibly
dedicated exclusively to vascular injury control and repair, is
an attempt to address this deficiency. However, few trainees
will feel fully competent to deal with the spectrum of vascular
trauma unless they spend time training overseas in centers
with higher incidence of this injury pattern.
Vascular surgery has a 6-year training program, and again
the exposure of this group to vascular trauma is limited. In
regional hospitals, the general surgical team will be responsi-
ble for the overall care of the injured patient, including any
vascular injury. In contrast, in larger metropolitan hospitals
vascular injury will usually be devolved to the vascular surgery
service after initial resuscitation. Penetrating vascular injuries
(including iatrogenic trauma) will usually be treated by the
vascular surgeons who will also be responsible for the endo-
vascular treatment of blunt aortic and other patterns ame-
nable to this less-invasive approach.
Because of the challenges associated with low volumes
of vascular trauma, surgical graduates from either vascular
surgery or general surgery with an interest in trauma are
encouraged to work for a period overseas in a region with a
high incidence of penetrating trauma and to bring this experi-
ence back to Australia and New Zealand to their individual
and institutional practices to assist in training the future gen-
eration of trauma specialists.
REFERENCES
1. <http://en.wikipedia.org/wiki/Number_of_guns_per_capita_by
_country>. Accessed 23 Dec 2012.
2. Hsee L, Civil I: A 12 year review of gunshot injuries: Auckland City Hos-
pital Experience. N Z Med J 121(1287), 2008. <http://www.nzma.org.nz/
journal/121-1287/3401/content.pdf>.
3. Spicer R, Miller T, Langley J, et al: Comparison of injury case fatality rates
in the United States and New Zealand. Inj Prev 11:71–76, 2005.
4. Cameron P, Dziukas L, Hadj A, et al: Major trauma in Australia: a regional
analysis. J Trauma 39:545–552, 1995.
5. Thompson I, Muduioa G, Gray A: Vascular trauma in New Zealand: an
11 year review of NZVASC, the NZ Society of Vascular Surgeons’ audit
database. NZ Med J 117(1201), 2004.
6. King MR, Paice R, Civil ID: Trauma data collection using a customised
trauma registry. NZ Med J 109:207–209, 1996.
7. Sugrue M, Caldwell EM, D’Amours SK, et al: Vascular injury in Australia.
Surg Clin North Am 81:211–219, 2002.
8. Gupta R, Rao S, Sieunarine K: An epidemiological view of vascular
trauma in Western Australia: a 5 year study. Aust NZ J Surg 71:461–466,
2001.
9. Civil ID, King MR, Paice RP: Penetrating trauma in Auckland: 12 years
on. Aust NZ J Surg 68:261–263, 1998.
10. Cameron PA, Gabbe BJ, Cooper DJ, et al: A statewide system of trauma
care in Victoria: effect on patient survival. MJA 189:546–550, 2008.
11. Gabbe BJ, Simpson PM, Sutherland AM, et al: Improved functional out-
comes for major trauma patients in a regionalized inclusive trauma
system. Ann Surg 225:1009–1015, 2012.
12. http://www.surgeons.org/search/?keyword=surgical+workforce. Accessed
23 December 2012.
13. Day CP, Buckenham TM: Endovascular repair of the thoracic aorta: pre-
dictors of 30-day mortality in patients on the New Zealand Thoracic
Aortic Stent Database (NZ TAS). Eur J Vasc Endovasc Surg 37:160–165,
2009.
14. Insull P, Adams D, Segar A, et al: Is exploration mandatory in penetrating
zone 2 neck injuries? Aust NZ J Surg 77:261–264, 2007.
Asia: Sri Lanka
AMILA S. RATNAYAKE, BANDULA SAMARASINGHE,
MANDIKA WIJEYARATNE, AND ABDUL H. SHERIFFDEEN
Introduction
Sri Lanka has emerged from a 30-year-long civil war that com-
menced in 1983. A group calling themselves Liberation Tigers
of Tamil Eelam (LTTE) fought the governmental forces of Sri
Lanka for a separate state in the north and east parts of the
country. A feature of this conflict was the large number of
patients with penetrating vascular injuries from mortars and
T56 gunshots, in addition to frequent bomb blasts and suicide-
bomb attacks that were carried out mainly in Colombo, the
country’s capital, and in the rest of the country.
The challenges to the vascular surgeons/services in the
country during this period were numerous. The conflict pro-
duced combatant injuries caused by bullets, grenades, shells
and anti-personal mines. Civilian injuries as a consequence of
the conflict were those caused by bomb blasts and suicide
bombers. These injuries were in addition to the preexisting
civilian vascular workload from vehicular accidents and con-
flicts ending in stab injuries and low-velocity gunshots. A
unique type of injury specific to the country is the “trap gun”
injury (Fig. 26-1), which is caused by a homemade device
consisting of a loaded shotgun or a length of metal pipe loaded
with gunpowder with a kneehigh cord attached to the trigger
and tied to a tree stump. The intention of farmers is to ward
off wild animals like wild boar from foraging and destroying
their crops. Humans unknowingly walk across the path, pull
on the trip wire, and set off the trigger, shooting themselves
around the knee.
Finally, as the number and complexity of endovascular
interventions grow, there has been an increase in the
number of access site pseudoaneurysms, presenting further
challenges.
Epidemiology
The military campaign was characterized by phases of intense
conflict to times of relative lull. An incidence of 2.2% of vas-
cular injuries in 5821 injured security personnel was reported
during a 6-month period of combat from December 2008 to
June 2009.1 Rifle bullets and high-velocity fragments were the
causes of most injuries, the majority affecting the distal half
of lower extremities, the popliteal vessels being involved in
34% of the instances.1
In the civilian setting, in a study from a tertiary-care center,
out of a total of 1500 admissions, 70 (4.6%) patients had a
total of 81 vascular injuries. 46% of these injuries were war
related, with 41% due to high-energy blasts from artillery
shells, mortars, rocket-propelled grenades, high-explosive
26 
bombs, and antipersonnel mines. Civilian conflicts that
resulted in vascular injuries were caused by stab injuries (26%)
and gunshots (17%) that included high-velocity rifles, machine
guns, low-velocity shotguns, and trap guns. Vehicular acci-
dents, industrial accidents, and iatrogenic trauma accounted
for the balance of 33% of the cases (Figs. 26-1, 26-2, and
26-3).2 In another urban setting, 77 patients with trap gun
injuries were consecutively admitted to this hospital during a
5-month period.3
Systems of Care and Transport
The Sri Lankan Army medical corps has organized its casualty
care structure into three lines categorized as first, second, and
third lines of care depending on the distance from the front
line, the available resources, and the casualty handling
capability.4
First Line of Care
The first line of care is sited very close to the front line for
provision of basic casualty care immediately after injury. This
primary care includes arrest of bleeding, establishment of
intravenous access, pain relief, and fracture immobilization.
There was a variety of types of tourniquets used, including a
piece of twinned cloth to less-sophisticated military tourni-
quets consisting of a belt and buckle (Fig. 26-4). Standard
modern tourniquets were unavailable. The use of the former
varieties of tourniquets was a lifesaving rather than a limb-
saving exercise. Occasionally the lag time to reach a center for
definitive vascular reconstruction was short enough to salvage
the limb. The authors introduced intelligent packing to effec-
tively control bleeding, replacing these tourniquets, while pre-
serving collateral circulation to keep the limb viable.
Second Line of Care
The second line of care consisted of the advance dressing
station (ADS), the main dressing station (MDS), and field
hospitals.
The ADS was sited close to three regimental aid points,
sited 400 meters to 5 kilometers from the front line. It was
manned by a single medical officer, two nurses, and three
nurse assistants and was capable of emergency combat resus-
citation, including intubation, chest-drain insertion, arrest of
bleeding, and intravenous infusion of crystalloids.
Each MDS was sited close to 3 ADSs with the capability of
stabilizing and airlifting casualties to specific care facilities. It
was manned by one senior medical officer, four nurses, six
nurse assistants, and other supportive care personnel. Staff at
287
 26  /  Asia: Sri Lanka 287.e1

ABSTRACT
Sri Lanka has emerged from a 30-year war that majorly
challenged its vascular services. Combatant injuries caused
by bullets, grenades, shells, and antipersonnel mines were
additional burdens on the civilian workload from vehicular
accidents and conflicts ending in stab wounds and gunshot
wounds. “Trap gun” injury (caused by a homemade device
consisting of a loaded shotgun or a length of metal pipe
loaded with gunpowder with a knee-high cord attached to
the trigger and tied to a tree stump) is unique to the
country.
Delayed presentation to tertiary-care facilities is the
norm in Asian settings primarily attributable to the lack of
well-organized prehospital trauma care and transport. The
majority of vascular injuries causing ischemia are managed
entirely on clinical parameters because immediate access
to imaging is limited. Nevertheless, on-table angiography
has been of value when there are multiple injuries in a given
limb and when the site of the vascular injury is uncertain.
Preliminary four-compartment calf fasciotomy and muscle
contractility has determined viability and suitability for
vascular repair when presentation was beyond 6 hours.
Noncontractile muscle in up to two compartments was
considered acceptable. Arterial repairs were treated with
contralateral reversed saphenous vein interposition, while
the majority of venous injuries were ligated. Reperfusion
problems have been minimal, and this may be attributed
to the low threshold for fasciotomy and, in some instances,
the use of intraluminal shunts. In contaminated wounds,
early wound débridement before vascular repair resulted
in significantly better outcomes. Endovascular techniques
are used in a limited fashion to manage traumatic
pseudoaneurysms.

Key Words:  vascular trauma,

fasciotomy,
ischemia time,
reperfusion injury
 288 SECTION 5  /  INTERNATIONAL PERSPECTIVES

the MDS had the capacity to transfuse uncross matched group Colombo (the capital city) and Galle (a large city on the
O blood and to perform basic lifesaving surgical procedures southern coast of the island). In Colombo and Galle, fire fight-
such as tracheotomies, amputations, and wound exploration ers and hospital ambulance staff, respectively, were trained
to achieve hemostasis. and certified in prehospital care. However, the most common
response to injury in Sri Lanka is the “scoop and run” method.
Third Line of Care Readily available transport facilities are commandeered to
The third line of care is the tertiary military base hospitals rush patients to hospitals, and these are often vans or the
and general hospitals capable of definitive surgical care with ubiquitous three-wheeler (also known as a “trishaw” or “tuk-
specialized services that included vascular, cardiothoracic, tuk”), open-passenger transport vehicles.5 Patients are bundled
and neurosurgical services supported by intensive care unit into these small vehicles with little or no attention to the type,
facilities. extent, and severity of injuries (Fig. 26-6). Unlike the military
In 2008-2009, the military base hospital (MBH) Anurad- system where discipline is a premium factor, the civilian
hapura, situated 180 kilometers from the conflict zone, was system suffers from a lack of protocols. The quality of care
converted into a center for definitive extremity vascular care. given at first-contact hospitals, which are manned by medical
General surgeons trained in vascular surgery were deployed to officers or general surgeons, depends on many factors. Diag-
this hospital to minimize the delay to revascularization. The nostic acumen depends on the medical-school experience of
MBH was equipped with two operating theaters, a three-bed the first contact doctor because only a minority of medical
intensive care room, and an 80-bed ward (Fig. 26-5). teaching hospitals provides a vascular service. The probability
The civilian setting remains poorly organized. Prehospital of the general surgeon attending to a vascular injury depends
care with ambulances is available in a few cities such as on his postgraduate training, commitment, and the workload
in general. Thus most patients with a vascular injury are trans-
ferred to one of two vascular centers in Colombo or Kandy.
In a study of 134 patients treated for extremity vascular trauma
over a 9-month period, it was found that initiating wound
débridement in the field contributed to significantly lower
postoperative complication rates.6 The authors recommend
pretransfer care consisting of early wound débridement, arrest
of bleeding, and four-compartment fasciotomy. Compliance
with such a protocol is unpredictable and generally poor, and
there is no method to enforce this. Furthermore, in the case
of mass casualties, it may not be possible for a single surgeon
to deliver even basic care. In such instances, triage and transfer
as quickly as possible to a tertiary-care center is the standard
practice.5
FIGURE 26-1  Trap gun, which is an improvised homemade shotgun. The use of temporary shunts in such a peripheral setting is
(Courtesy Mahanama Gunasekara.) contentious. Inexperienced surgeons using improvised shunts

45

40

35
Other
30 Ligation
Number of vessels

Iry repair
25
IPVG
20

15

10

0
Axillary artery
Axillary vein

Brachial artery
Brachial vein

Forearm artery
Forearm vein

Illiac

Femoral artery
Femoral vein

Popliteal artery
Popliteal vein

Tibioperoneal artery
Tibioperoneal vein

Profunda femoris artery

Profunda femoris vein

FIGURE 26-2  Anatomical distribution and types of

repair of 128 combatants who sustained military
vascular trauma. Iry, Primary; IPVG, interposition
vein graft.
 26  /  Asia: Sri Lanka 289

35

30

25
Number of vessels

20

15

10

0
Blast injuries Cuts/stabs Gunshots Auto crash Industrial Iatrogenic
accidents
FIGURE 26-3  Mode of vascular injury in 81 consecutive injuries at a civilian center.

45

40

35

30
Number of vessels

25

20

15

10

0
Vein graft Direct repair Primary PTEF graft Endovascular
amputation stenting
FIGURE 26-4  Types of repair in 81 consecutive injuries at a civilian center. PTEF, Polytetrafluoroethylene.

A B C
FIGURE 26-5  (A, B, C) The military base hospital (MBH) Anuradhapura.
290 SECTION 5  /  INTERNATIONAL PERSPECTIVES
FIGURE 26-6  The trishaw (also known as a “tuk-tuk” or “three-
wheeler”) is a common mode of casualty transport in Sri Lanka.
(i.e., pieces of cut, sterile, intravenous set tubing) that may
damage the intima of adjacent healthy artery, causing dissec-
tion and promoting thrombosis, is a serious concern. On the
other hand the author, a vascular surgeon, used temporary
shunts successfully to buy time in instances where several
patients with limbs dying from vascular injuries arrived at one
hospital at the same time.1
Considerations for Diagnosis
At the MBH, the majority of diagnoses were made clinically.
The most reliable were hard signs in the presence of extremity
injury (i.e., absent pulses despite adequate blood pressure;
pulsatile bleeding). Hand-held Doppler flow recorders were
used when available. We use caution in such situations because
inexperienced staff may misinterpret a poor wave form as
being adequate flow and may not refer them appropriately.
Facilities for vascular imaging (e.g., CT, magnetic resonance
imaging (MRI), and conventional angiography) are not avail-
able in these institutions. Also, in the civilian setup, clinical
examination was aided by the hand-held Doppler flow detec-
tor. Decisions on surgical exploration were based on evidence
of distal ischemia, pulsatile bleeding, and expanding hema-
toma or thrill/bruit.2 However, in both settings the final
decision to proceed with revascularization or amputation
depended on limb viability.
Muscle ischemia is traditionally estimated using ischemia
time. Other clinical indices include compartment tenseness
and tenderness, as well as diminished ankle and toe move-
ments. Intracompartmental-pressure measurements and fas-
ciotomy with muscle examination and stimulation to detect
color and contractility provide more objective evidence. Intra-
compartmental pressure monitoring was not done because it
needed repeated measurements and often added to the delay.
In both settings, ischemia time was not a prime consider-
ation. Even times of over 12 hours were overlooked, and revas-
cularization using the other criteria given above resulted in
viable limbs and healthy patients.1,2 More often than not, open
fasciotomy and observation of muscle color and contractility
to stimulation was used. Limbs with up to two noncontractile
compartments were considered for revascularization, while
those with more than two were recommended for primary
amputation. The former were carefully monitored for evi-
dence of reperfusion injury in the postoperative period. The
other considerations before vascular repair were the Mangled
Extremity Severity Score (MESS) and severity associated with
bone and nerve injuries.7,8
Treatment Strategies
The reversed contralateral long saphenous vein interposition
graft was the most common mode of arterial reconstruction
in both civilian and military settings. It is interesting to note
that direct suture was carried out in 46% of arterial repairs in
the civilian setting, whereas it was attempted in only 7% of
the military casualties. This could be due the extent of intimal
damage caused by thermal injury and by vibratory forces from
the missiles in the military setting, necessitating sacrifice of
extra length of the damaged artery.
The technique and steps of vascular repair have been well
documented.9 Rapid wound débridement is followed by isola-
tion of the proximal and distal segments of the damaged
artery and vein. Soft clamps are applied. Passage of a suitably
sized embolectomy catheter proximally and distally is manda-
tory even if there is sufficient back flow. Reversed interposition
grafts from the great saphenous vein were the most common
technique used to restore blood flow (51% to 70%). Other
techniques included patch angioplasty (2.6%) and ligation
(7%) of major vessels. Ligation was the last resort in situations
where this was a lifesaving procedure in the presence of major
life-threatening abdominal, thoracic, or head injuries. Elective
amputation was the eventual outcome in all 7 patients. The
use of prosthetic grafts is controversial. The potential for
infection in the midst of a contaminated wound would appear
to be a contraindication, but this has not been the experience
of some authors.10 In an Asian setting, the balance between
cost, availability, and infection has to be studied to justify its
use. It was used in one instance in a civilian setting with a
satisfactory outcome, and there is a case for the use of pros-
thetic grafts in a controlled setting.
The use of temporary intravascular shunts (TISs) in a
tertiary-care setting has proved to be beneficial and less con-
troversial compared to their use in a field or primary care
setting (Fig. 26-7).11 A single surgeon trained in vascular anas-
tomotic techniques may be confronted with several patients
needing vascular repair at the same time. The use of TIS even
with improvised intravenous plastic administration tubing
has proved to be practical in buying time to undertake formal
repair based on a triage principle of prioritization.1 In both
scenarios, major veins were repaired on a selective basis.
Repairs were considered only on the axillary, femoral, and
popliteal veins using either the direct suture or the vein-graft
technique.1,2 All other veins were ligated.
In the military setting, prophylactic four-compartment fas-
ciotomies were carried out in the majority of cases as soon as
they were assessed1; whereas, in the civilian setting, they were
done on a selective basis using the criteria of delay of more
than 6 hours or of obvious swelling.2 These fasciotomies were
necessitated by the large caseload over a short period, which
taxed medical staff to the maximum with limited resources.
The civilian setting in a tertiary-care center allows a “watch
and see” policy to decide on fasciotomy. However, whenever
there is a doubt, we advocate a policy of, “It is better to
have a scarred viable leg than no leg at all” and recommend

FIGURE 26-7  Sterile intravenous tubes used as temporary intralumi-
nal shunting.
fasciotomy preoperatively- or postoperatively (Fig. 26-8). All
fasciotomy wounds were closed later with split-thickness skin
grafts.1
Vascular injuries do not present themselves in isolation.
Associated bone injuries were seen in 30% of the injuries, and
nerve injuries in 15%.1 In both the military and the civilian
settings, vascular reconstruction took precedence over bone
management in order to minimize ischemia time. In the mili-
tary setting, the use of external immobilizing procedures, such
as Plaster of Paris casts or external fixators, were used when
available.1 The timing of management of fracture concomi-
tant with major vascular disruptions is a source of debate.
Prior skeletal fixation is recommended by some,12 while others
have highlighted the advantage of reducing ischemia time by
proceeding with the vascular reconstruction first.13,14
The setting for immediate orthopedic intervention has
several prerequisites. These include trained surgeons/junior
surgeons, instruments and appliances, x-ray facilities (prefer-
ably a C-arm fluoroscopy unit and an extra radiographer),
assistants, and trained nursing staff. It may be difficult to find
this combination even in a tertiary-care hospital in an Asian
setting at the best of times, as the orthopedic workload that
they already carry is quite heavy. When external fixators are
available, their use is the procedure of choice to obtain quick
stabilization of the limb.
Nerve injuries identified at the time of the vascular recon-
struction were repaired primarily.2 All patients were treated
postoperatively with intravenous antibiotics and heparin 1000
IU per hour, if there was no contraindication like uncontrol-
lable oozing from complex soft-tissue injuries.1,2
In a civilian or a military setting, the majority of patients
presenting with vascular injuries are young men: and hemor-
rhage control and early reestablishment of circulation are
premium priorities.
26  /  Asia: Sri Lanka 291
FIGURE 26-8  Four compartment fasciotomy in military practice.
In the Asian setting, the points of delay before a patient is
taken for surgery are many. Access to the site of the accident,
patient retrieval, lack of prehospital care in civilian settings,
delay in transport from primary-care settings, poor commu-
nication facilities, and poor diagnostic and imaging facilities
for diagnosis add to delays in revascularization. Even in a
military setting, the time lag from injury to surgery was 6
hours in Sri Lanka as compared to Iraq (2 hours) and
Afghanistan (2 1 2 hours).15,16 This was despite the availability
of helicopter service from the second line. Most of the delay
was at the time of retrieval due to hostile terrain and bad
weather.1
In the absence of facilities for emergency contrast angiog-
raphy or CT scans, assessment by clinical examination and
with the hand-held Doppler flow detector appear effective.17,18
A number of studies have established the primacy of clinical
examination over diagnostic angiography in such acute set-
tings.19 We recommend that selective angiography should be
reserved for patients with multiple external injuries.20,21
The optimal time for revascularization has been a topic of
considerable debate since Welch et al suggested 6 hours in
1946.22 In otherwise stable patients, our policy is to revascular-
ize all viable limbs, even those with a long period of isch-
emia.1,2 The risk of ischemia reperfusion injury has been cited
as a reason for conservative management in patients with
prolonged ischemia. Despite accepting patients with noncon-
tractile muscles in up to two compartments detected from
fasciotomy, we did not encounter clinically significant effects
from reperfusion in our series.2 Describing a series of 148
patients from North India, Menakaru reported excellent out-
comes despite an average delay of 9.3 hours. Limb survival
rates of 86% to 94%1,2,23 have been reported using this gener-
ous approach. We must, however, emphasize that delay to
revascularization must be minimized and that trauma man-
agement teams must investigate and explore methods to
reduce it.
292 SECTION 5  /  INTERNATIONAL PERSPECTIVES
Sustain and Train the
Next Generation
The 30-year conflict is over but this does not mean that there
is room for complacency. There is evidence that the incidence
of traffic accidents in Sri Lanka is on the increase.24 The
human versus wild animal conflict will continue as long as
man encroaches into forestland. The use of trap guns will
continue. The need to train doctors and surgeons on aware-
ness and management is a challenge that the vascular surgeons
have to meet. Most medical schools in Sri Lanka have adopted
the modular system of teaching/training; and, creating aware-
ness in the vascular module to include diagnosis, communica-
tion skills, resuscitation, and arrest of bleeding as well as rapid
transfer to a facility with resources to handle the problem.
needs to be emphasized.
The Trauma Secretariat of the Ministry of Health runs a
course for first contact doctors on preliminary care of the
injured.25 It also has an arm that is training paramedics in
prehospital care, and its vision is to have trained ambulance
personnel serving all hospitals in Sri Lanka.
The College of Surgeons of Sri Lanka has recently opened
a hands-on training facility where workshops on detection,
fasciotomy techniques, and training in vascular anastomosis
are regularly held.26
The Post Graduate Institute of Medicine of Sri Lanka is the
only training body for all postgraduates in Sri Lanka.27 It has
a dedicated training program for those aspiring to specialize
in vascular surgery. Trauma surgery is not, however, a recog-
nized specialty in Sri Lanka.
Also, the military needs to provide combat surgeons with
training in the management of the traumatic ischemic limb
and needs to hire more of those trained combat surgeons.
There is a dire need to open dedicated trauma centers in the
key cities of Sri Lanka. These centers will need to be equipped
for rapid diagnoses and will need to have the necessary operat-
ing equipment, such as vascular instruments, sutures, pros-
thetic grafts, and stents. Exchanges of experiences with other
trauma-care institutions on a global scale will further enhance
interest, dedication, and expertise in Sri Lanka, as well as in
other counties.
REFERENCES
1. Ratnayake A, Samarasinghe B, Halpage K, et al: Penetrating peripheral
vascular injury management in a Sri Lankan military hospital. Eur J
Trauma Emerg Surg 39:123–129, 2013.
2. De Silva WDD, Udayasiri RA, Weerasinghe CW, et al: Challenges in the
management of extremity vascular injuries: a wartime experience from a
tertiary center in Sri Lanka. WJES 6:24, 2011.
3. Handagala DM, Gunasekera WD, Arulkumaran R: Trap-gun injuries—a
menace in rural agricultural areas. Ceylon Med J 51(4):152, 2006.
4. Munasinghe S: Defeating terrorism. The Sri Lankan Experience. Medical
support. Business today. July 2011.
5. System-wide improvements. In Strengthening care for the injured: success
stories and lessons learned from around the world, 2010, World Health
Organization, pp 54–58.
6. Abeysekera KNW, Wijeyaratne SM, Sheriffdeen AH: Reducing early post-
operative complications in vascular trauma surgery of the extremities.
Ann R Coll Surg Engl 85:286, 2003.
7. Johansen K, Daines M, Howey T, et al: Objective criteria accurately
predict amputation following lower extremity trauma. J Trauma 30:568–
572, 1990.
8. Ingram R, Hunter G: Revascularization, limb salvage and/or amputation
in severe injuries of the lower limb. Curr Orthop 7(1):19–25, 1993.
9. Aires AB, Barros D’Sa: Upper and lower limb vascular trauma. In Green-
halgh RM, editor: Vascular surgical technique, Philadelphia, 1989, WB
Saunders, pp 47–65.
10. Vertrees A, Fox C, Quan R, et al: The use of prosthetic grafts in complex
military vascular trauma: a limb salvage strategy for patients with severely
limited autologous conduit. J Trauma 66(4):980–983, 2009.
11. Hossny A: Blunt popliteal artery injury with complex lower limb isch-
emia: is routine use of temporary intraluminal arterial shunts justified?
J Vasc Surg 40(1):61–66, 2004.
12. Aires AB, Barros D’Sa: A decade of missile-induced vascular trauma. Ann
Royal Coll Surg Eng 64:37–44, 1982.
13. Mc Henry TP, Holocomb JB, Aoki N, et al: Fractures with major vascu-
lar injuries from gunshot wounds: implications of surgical sequence.
J Trauma 53(4):717–721, 2002.
14. Hancock HM, Stannard A, Burkhardt GE, et al: Hemorrhagic shock
worsens neuromuscular recovery in a porcine model of hind limb vascu-
lar injury and ischemia-reperfusion. J Vasc Surg 53(4):1052, 2011.
15. Clouse WD, Rasmussen TE, Peck MA, et al: In-theater management of
vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg
204:625–632, 2007.
16. Chambers LW, Rhee P, Baker BC, et al: Initial experience of us marine
corps forward resuscitative surgical system during Operation Iraqi Free-
dom. Arch Surg 140:26–32, 2005.
17. Starnes BW, Beekley AC, Sebesta JA, et al: Extremity vascular injuries on
the battlefield: tips for surgeons deployed to war. J Trauma 60:432–442,
2006.
18. Peck MA, Clouse WD, Cox MW, et al: 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 45:1197–1205, 2007.
19. Glass GE, Pearse MF, Nanchahal J: Improving lower limb salvage follow-
ing fracture with vascular injury: a systematic review and new manage-
ment algorithm. J Plast Reconstr Aesthet Surg 62:571–579, 2009.
20. Fox CJ, Gillespie DL, O’Donnell SD, et al: Contemporary management of
wartime vascular trauma. J Vasc Surg 41:638–644, 2005.
21. Ramanathan A, Perera DS, Sheriffdeen AH: Emergency femoral arteri-
ography in lower limb vascular trauma. Ceylon Med J 40:105–106,
1995.
22. Miller HH, Welch CS: Quantitative studies on the time factor in arterial
injuries. Ann Surg 130:428–437, 1949.
23. Menakuru SR, Behera A, Jindal R, et al: Extremity vascular trauma in
civilian population: a seven year review from North India. Injury
36(3):400–406, 2005.
24. Somasundaraswaran AK: Accident statistics in Sri Lanka. IATSS Res
30(1):115–117, 2006.
25. Prof AH Sheriffdeen, http://www.traumaseclanka.gov.lk. Accessed 21
October 2011.
26. Prof AH Sheriffdeen, http://lankasurgeons.org. Accessed 21 October
2011.
27. Prof AH Sheriffdeen, http://www.cmb.ac.lk/pgim. Accessed 21 October
2011.
Europe: Croatia
ZVONIMIR LOVRIĆ AND PREDRAG PAVIĆ
Region-Specific Epidemiology
In peacetime, vascular trauma in Croatia (approximately
4,500,000 inhabitants) is rare and due mostly to blunt mecha-
nisms or stab wounds and very rarely to projectile wounding.
According to the Croatian National Institute of Public Health
data, the number of reported major vascular injuries does not
exceed 90 injuries per year, including head, trunk, and extrem-
ity injuries. The Republic of Croatia experienced a Homeland
War from 1991-1995 while detaching from the former Yugo-
slavia (Fig. 27-1). In the beginning of the aggression on
Croatia, there were no war surgery–skilled surgeons.1-3 In
major hospitals (university hospitals—in Croatian language
called “clinical hospitals”), vascular surgery divisions existed
decades before the war, mostly dealing with rare peacetime
vascular injuries. Therefore, at the onset of the Homeland War,
the sudden appearance of a high number of vascular injuries
put a ponderous assignment not only on vascular surgeons,
but on all surgeons across the country. Since general surgery
training in Croatia includes elements of traumatology,
abdominal surgery, thoracic surgery, and vascular surgery,
almost all surgeons had encountered occasional cases of vas-
cular trauma before the war.
War Vascular Injuries
Data from the Homeland War revealed a much higher inci-
dence of vascular injuries, especially those to the extremities.4-10
In general, autologous vein was recommended as the best
option for a substitute arterial conduit for extremity vascular
reconstruction.9-11 Yet, due to the war conditions with dozens
of wounded in a short period of time and instances in which
the saphenous vein was damaged or not usable, some surgeons
used synthetic grafts for vascular reconstruction. In the begin-
ning of the war (1991), some of the hospitals had to be trans-
formed into combat hospitals due to their proximity to the
battlefield (Fig. 27-2). One example is Osijek University Hos-
pital (Figs. 27-1 and 27-2) where the first author worked at
the time. During a 16-month period, 77 (1.7%) patients out
of a total 4545 injured were admitted with major extremity
vascular injuries. Of this cohort, 70% had significant injuries
to the head, thorax, abdomen, or other extremities; and more
than 70% were wounded by penetrating shell fragments. All
of these patients were evacuated to our surgical hospital by
ground transportation (ambulance or personal vehicle) within
45 minutes of injury, and 30% had no first aid performed or
available during transport. More than 35% of the injured
arteries were repaired primarily either with arteriorrhaphy or
27 
by end-to-end anastomosis. Synthetic material (30% of cases)
and saphenous vein (30% of cases) were also used as bypass
or interposition grafts.6-8 The cumulative, long-term limb-
salvage rates were the same among the groups, regardless of
type of extremity vascular repair.
An extreme case of extremity vascular injury was injury
resulting from a close-range penetrating missile injury to the
proximal, below-knee popliteal artery. This injury resulted in
a compound tibial plateau fracture, a large soft-tissue wound,
and an 8-cm defect in the popliteal artery. In this case, the
popliteal artery was reconstructed using a PTFE graft sewn to
the anterior tibial artery and with the placement of an extraan-
atomic, end-to-side anastomosis of the fibular artery (Fig.
27-3). This complex repair has been confirmed to be patent
and functioning 19 years after the injury. Another example
of complex extremity vascular injury was an injury in a
4-year-old girl wounded by a penetrating shell fragment that
resulted in transection of the common femoral artery and
vein. In this case, vascular reconstruction of both vessels
(artery and vein) was performed using PTFE interposition
grafts (Fig. 27-4).
Preoperative angiography was performed in only 1 patient
with extremity vascular injury, and all others underwent
immediate operation based on obvious signs at the time of
arrival. The austere conditions of surgical hospitals in which
these patients were treated also limited the ability to perform
any preoperative angiographic imaging. All patients who
underwent repair of extremity vascular injuries were given
intravenous heparin during and after the operation, and all
received prophylactic antibiotic therapy (penicillin, metroni-
dazole, and aminoglycoside). Lower extremity fasciotomy was
performed selectively and was required in only a small number
of patients.
Region-Specific System of Care
The medical care in Croatia is organized in three levels:
primary, secondary, and tertiary. Secondary care is available
through general and university hospitals, also called “clinical
hospitals.” All clinical hospitals have vascular surgery divi-
sions, mostly as a part of the department of surgery. Some
general hospitals have vascular surgeons, with or without
separated wards. All major vascular injuries are transported
and managed in these university or clinical hospitals. Since the
traumatology and vascular surgery divisions are usually part
of the larger department of surgery, the collaboration between
the two specialties is usually well organized and expeditious.
In Croatia the trauma surgeon is trained and proficient at
293
 27  /  Europe: Croatia 293.e1

ABSTRACT
In Croatia (4,500,000 inhabitants), vascular trauma is rare.
The number of reported major vascular injuries does not
exceed 90 per year, including head, trunk, and extremity
injuries.
Experience from the Homeland War (1991-1995)
revealed a much higher incidence of vascular injuries, espe-
cially those to the extremities. Secondary care in Croatia is
provided through general hospitals and university (clinical)
hospitals. All clinical hospitals have vascular surgery divi-
sions; major vascular injuries are transported and managed
in clinical hospitals. The system of hospital trauma care
expects that the trauma surgeon (being available 24 7 in the
hospital) is the first on call when the injured patient arrives.
The vascular surgeon is always available on-call and if nec-
essary can assume management of vascular injury. In poly-
traumatized patients or in cases of complex traumatic
injuries, the multidetector computed tomography scan
(MDCT) is used without (or with, if necessary) contrast
angiography to assess for vascular injury. When dealing
with an isolated vascular injury, digital subtraction angiog-
raphy (DSA) is performed if possible and is still recognized
as the gold standard. The management strategy typically
requires urgent vascular reconstruction in the form of
primary vessel repair or with the use of a conduit, prefer-
ably saphenous vein. In some cases, ligation of the vessel
or even amputation is indicated. Trauma surgery training
in Croatia includes 3 months of vascular surgery education
thus potentiating the trauma surgeon to manage vascular
injury capably. At a minimum, the objective of such training
is to allow the trauma surgeon to be able to reconstruct a
major vascular injury with primary repair or with conduit
interposition grafting, depending on the surgeon’s skills
and experience and the severity of injury.

Key Words:  vascular injury,

diagnostics,
reconstruction,
education
294 SECTION 5  /  INTERNATIONAL PERSPECTIVES

A B

A D

C
FIGURE 27-1  A, The surgical building of Osijek University hospital after heavy artillery shelling in the Homeland War (1991-1995), (B and C)
including the surgical ward originally on the ground floor (D) and then moved to the basement corridors.

caring for bone and joint trauma and is therefore considered
the same as an orthopedic surgeon in other parts of the world.
The system of trauma care predicts that the trauma surgeon
(being available 24-7 in the hospital) is the first to be contacted
when the injured patient arrives. In this context, the trauma
surgeon defines the primary management and diagnostic pro-
cedures. In contrast, the vascular surgeon is not necessarily
present in the hospital at the time of the patient’s arrival but
is available on-call. This vascular surgeon may simply consult
on the case or may assume complete management depending
upon the complexity of the injury and the experience of the
surgeon. In cases of concomitant injuries, a multidisciplinary
team is assembled and is able to conduct simultaneous opera-
tions (e.g., extremity and abdominal) if needed.
The law in Croatia licenses general surgeons to perform
vascular reconstruction for trauma in the absence of a vascu-
lar surgeon, and such decisions depend on the individual’s
skill and level of comfort with the case. Usually patients having
undergone extremity vascular repair are admitted to the
intensive care unit (ICU) for at least 24 hours and possibly
 27  /  Europe: Croatia 295

FIGURE 27-3  Radiologic image of reconstructed popliteal artery with

B synthetic graft (PTFE) and extraanatomic end-to-side insertion of
fibular artery.
FIGURE 27-2  A, B, Improvised ICU and operating areas in the base-
ment of Osijek University hospital after damage had occurred from
shelling during the Homeland War. (Photographs captured from the
movie “War Surgery in Osijek 1991.”)

longer depending on other injuries and their hemodynamic

and physiologic stability. The ICU in Croatia is managed by
an anesthesiologist who may also be referred to as an intensiv-
ist. The interaction and collaboration between vascular and
trauma surgeons in Croatia is professional and is focused on
the best course of action for the injured patient.

Region-Specific Considerations
for Diagnosis
When managing multiply-injured patients, the dynamics and
priorities of diagnostic procedures are directed by the trauma
surgeons. If there is clinical suspicion for vascular injury, this
evaluation is conducted in close consultation with a vascular
surgeon if one is available.
In the case of a polytrauma patient who is hemodynami-
cally normal and is able to have imaging outside of the operat-
ing room, the multidetector computed tomographic (MDCT)
scan is the test of choice to include contrast-enhanced angi-
ography if necessary. When managing an isolated vascular
injury, selective digital subtractive angiography (DSA) is the
gold standard. In addition to rendering a diagnosis of vascular
injury, DSA also facilitates a possible endovascular solution in
select patterns of injury. It is important to note that in Croatia,
endovascular treatment of vascular injury is very rarely indi-
cated or performed. Although a radiologist is on-call in the
hospital 24 hours a day, this may not be an interventional
radiologist. As such, a contrast-enhanced MDTC is performed
FIGURE 27-4  Operative photo of a reconstructed common femoral
artery and femoral vein with synthetic graft in a 4-year-old girl after
shell fragment injury. (From Lovrić Z, Wertheimer B, Čandrlić K, et al:
The reconstruction of major femoral vessels in four-year-old girl wounded
with shrapnel. J Cardiovasc Surg 34:267–269, 1993.)
in most cases of severe extremity injury with suspicion of a
vascular component. This study allows the trauma and vascu-
lar surgeons to examine the findings and to consult interven-
tional radiology for further imaging as necessary.
Region-Specific Treatment Strategies
If the patient’s presentation requires an urgent operation and
repair, primary reconstruction of the vessel is performed if
possible. If this is not possible because the injury is more
extensive, an end-to-end anastomosis may be considered.
296 SECTION 5  /  INTERNATIONAL PERSPECTIVES
From the authors’ experience during the Homeland War, a
vein patch or a reversed saphenous vein interposition graft are
the more commonly preferred options. However, in some situ-
ations when the saphenous vein has been destroyed or is not
able to be obtained, a synthetic conduit such as PTFE may be
used as an interposition or bypass graft.
The difference between high-energy, wartime injuries and
low-energy civilian wounds should also to be considered when
selecting the type of vascular repair and the type of conduit.
The contaminated nature of penetrating wartime injuries
makes the use of saphenous vein grafts especially appealing
because they are felt to be better incorporated and more resis-
tant to infection than synthetic grafts. In contrast, less-
contaminated blunt injuries may be more amenable to the use
of synthetic graft material such as PTFE to reconstruct vascu-
lar trauma. It is important to remember that, in some cases,
ligation of the vessel or even primary amputation is indicated
as a quick damage control maneuver.
Strategies to Sustain and Train
the Next Generation of
Trauma Surgeons
The training of surgeons in Croatia is currently being
reformed. Once the reforms are complete, it will take 5 years
of to become a surgeon. During the training, 2 years are spent
in a “common trunk” of general surgery followed by 3 years
of training in one of several subspecialties, such as trauma or
orthopedic, abdominal, vascular, or cardiac. The common
trunk training does involve 3 months of vascular surgery edu-
cation and thus potentiates the trauma surgeon, as well as
other surgical subspecialists, to be capable of diagnosing and
managing vascular trauma. In addition, the laws in Croatia
support the trauma surgeon in performing an urgent vascular
reconstruction. The only limitations for these individuals in
managing the spectrum of vascular trauma may be those
related to lack of current experience with this complex injury
pattern. Even in small hospitals, when time is a restrictive
factor and transportation to the major hospital doubtful or
impractical, a trauma surgeon should be capable of managing
vascular trauma, including reconstructing vascular injuries
with primary suture repairs or an interposition grafts.
In Croatia the challenge of how best to improve the skills
of trainees in trauma surgery is also complicated by the de­
clining number of open vascular reconstructions. Although
endovascular procedures are rare in vascular trauma, they are
more common in the treatment of age-related disease, which
detracts from the open vascular experience of trainees.11
Learning from the history of war, the management of vascular
trauma should be one of the foundations of the trauma
surgery training paradigm.12-14
REFERENCES
1. Janoši K: Organization of surgery in the war conditions in Osijek. Medi-
cinski Vjesnik 23(3–4):93–98, 1991.
2. Janoši K, Lovrić Z: War surgery in Osijek 1991/92. Croat Med J 36(2):104–
107, 1995.
3. Lackovic Z, Markeljevic J, Marusic M: Croatian medicine in 1991 war
against Croatia: a preliminary report. Croatian Med J 33(War Suppl 2):
110–119, 1992.
4. Lovric Z: Reconstruction of major arteries of extremities after war inju-
ries. J Cardiovasc Surg 34:33–37, 1993.
5. Lovric Z, Wertheimer B, Candrlic K, et al: War injuries of major extremity
vessels. J Trauma 36:248–251, 1994.
6. Lovric Z, Wertheimer B, Candrlic K, et al: Reconstruction of the popliteal
artery after war injury. Unfallchirurg 97:375–377, 1994.
7. Lovric Z, Lehner V, Kosic-Lovric LJ, et al: Reconstruction of major arter-
ies of lower extremities after war injuries: long-term follow up. J Cardio-
vasc Surg 37:223–227, 1995.
8. Lovric Z, Lehner V, Wertheimer B, et al: Tourniquet occlusion technique
for lower extremity artery reconstruction in war wound. J Cardiovasc
Surg 38:153–155, 1997.
9. Radonić V, Barić D, Tudor M, et al: Gefässverletzungen im Krieg. Chirurg
66:883–886, 1995.
10. Radonić V, Barić D, Petričević A, et al: Military injuries to the popliteal
vessels in Croatia. J Cardiovasc Surg 35:27–32, 1994.
11. Luetić V, Sosa T, Tonković I, et al: Military vascular injuries in Croatia.
Cardiovasc Surg 1(1):3–6, 1993.
12. Rasmussen TE, Woodson J, Rich NM, et al: Vascular trauma at a cross-
roads. J Trauma 70:1291–1293, 2011.
13. Rich NM: Vascular trauma historical notes. Perspect Vasc Surg Endovasc
Ther 23:7–12, 2011. [Epub 2011 Apr 17].
14. Rich NM, McKay PL, Welling DR, et al: Vascular trauma: selected histori-
cal reflections from the western world. Chin J Traumatol 14:67–73, 2011.
Scandinavia and Northern
Europe
HANNU SAVOLAINEN AND ARI K. LEPPÄNIEMI
Introduction
Europe has traditionally had a very strong foundation in vas-
cular surgery—the specialty has its origins on that continent.
The first suture of an injured brachial artery was performed
by Halliwell as reported by Richard Lambert in a letter to
William Hunter in 1759.1 The principles used in vascular
surgery today were introduced by Alexis Carrel, a Frenchman,
who moved to the United States after his medical studies in
Lyon and who received the Nobel Prize in medicine in 1912.2
During the first half of the 20th century, Portugal, France,
Germany, and the United Kingdom were the leading countries
in vascular diagnostics and surgery. Angiography has Euro-
pean origins (Egas Moniz), as well as cardiac imaging (Werner
Forssmann) and computerized tomography (CT; Godfrey
Hounsfield)—all Nobel Prize laureates as well.3-5 The Seld-
inger technique, which is used today to access vessels for
imaging and interventions, comes from Scandinavia (Sven-
Ivar Seldinger)6; and the first balloon angioplasty was per-
formed in Europe (Andreas Gruentzig).7 Initially, vascular
surgery was part of thoracic surgery in northern Europe, but
in 2005 it was recognized as a separate specialty in Europe.8
Europe covers less than a tenth of Earth’s land surface (10
million sq km) with a population of 733 million people in 45
countries. The European Union has 28 member countries and
has been a significant organ for peace during the decades it
has existed, but the history of Europe is that of strife, conflict,
and war. Cultural, religious, ethnic, political, and other differ-
ences have prevented any uniform tradition of medicine from
being accepted on the continent. Despite a history of war,
most of Europe has enjoyed a high standard of living for
decades, even centuries, and an element of legal protection of
the work force for more than a century. That has meant regu-
lation of traffic, construction, industries, and many other
areas of life—meaning that the way of living and the work
environment—produces few injuries. An example from a
study by Magee et al from Oxford University is telling: 47
vascular injuries requiring operation in 10 years, 11 of them
for penetrating injuries, all as a result of stabbing.9 For more
than a decade, there have been no significant armed conflicts
in Europe; Sweden has not seen a war in almost 2 centuries.
The former northern colonial superpower, the Netherlands,
has enjoyed an immensely high standard of living for 5 cen-
turies. It is the Netherlands where science is most generously
funded in the world.
For decades, the economic and social development in
Northern Europe has been stable; for example, all five Scan-
dinavian countries are among the 20 richest in the world
according to the gross domestic product (GDP). The border
28 
between Finland and Russia is one with extremes in economic
and health-care terms. Russia is very large as a country (300
million inhabitants), but its economy is still only slightly
larger than that of Spain with 46 million inhabitants and one-
tenth that of the European Union. Even inside Russia, regional
differences are significant. Finland’s neighbor to the southeast,
Estonia, has joined the European Union and the North Atlan-
tic Treaty Organization (NATO); but it is still struggling some-
what economically, just as are its southern neighbors, Latvia
and Lithuania, although the national debt of Estonia is very
low compared to most European countries. The overall favor-
able financial development in Northern Europe has meant
easier and more-common adoption of technology in the man-
agement of vascular disorders.
As a specialty, vascular surgery has gone through a revolu-
tion during the past decade and has become very technology
driven.10 The emergence of endovascular management options
within the past decade has caused an immense paradigm shift
and has even obscured the borders between angioradiology
and vascular surgery. The development has been so rapid that
endovascular options in trauma management did not really
even exist according to a European review of vascular injuries
published in 2002.11 As a result of the shift, a combination of
interventional radiology and surgery in the management of
many emergent and elective vascular problems has become
everyday practice, especially in wealthier countries with well-
equipped hospitals. This change is also reflecting itself in the
treatment of vascular injuries, bringing along additional chal-
lenges in organizing the care of these patients.
Region-Specific Epidemiology
In contrast to the United States and some other countries with
high incidence of penetrating trauma, a significant proportion
of vascular injuries in Northern Europe are caused by blunt
trauma and, increasingly, by iatrogenic injuries. In a nation-
wide study from Sweden, the proportion of iatrogenic injuries
increased progressively from 57% in 1987-1993 to 79% in
2002-2005 (Fig. 28-1).12 This was also reflected in the sites of
arterial vascular injuries where 63% of the injuries were in the
thigh and groin, more often on the right side (Fig. 28-2). Of
the noniatrogenic vascular injuries, 45% were caused by blunt
trauma (Fig. 28-1), with a high proportion of injuries located
in the upper extremity (Fig. 28-3).
Region-Specific Systems of Care
The first civilian trauma centers in Europe were Bergmannshell
in Bochum founded in 1890 and the Böhler-Clinic founded
297
 28  /  Scandinavia and Northern Europe 297.e1

ABSTRACT
In most Northern European countries, the incidence of
trauma is low; and the majority of vascular injuries are
iatrogenic, up to 79% in some countries. Vascular surgery
is an independent specialty or a subspecialty of general
surgery; and the vascular surgeon is the one who is mainly
responsible for the treatment of vascular injuries, except
for Germany and The Netherlands where trauma surgeons
perform the first-line surgery. Endovascular treatment
options are available in most countries, but mainly in large
academic centers. With increasing fragmentation of surgi-
cal training and with the growing potential of endovascular
treatment options, major challenges remain in both the
organization of emergency surgery care and the training of
a new generation of surgeons who are capable of working
in this new environment.

Key Words:  Scandinavia,

Europe,
vascular injury,
iatrogenic,
endovascular,
epidemiology
298 SECTION 5  /  INTERNATIONAL PERSPECTIVES

600 Iatrogenic trauma Thorax 5% Other 1%

Penetrating trauma Forearm 16%

Below knee 7%
500
Blunt trauma
293
400 241
Knee 12%
218
300
136
200 158 140
127
105
100
116 136
88 95
0
1987–1993 1994–1997 1998–2001 2002–2005
FIGURE 28-1  Etiology of vascular injuries in Sweden 1987-2005.
(From Rudstrom H, Bergqvist D, Ogren M, et al: Iatrogenic vascular inju- Upper arm
ries in Sweden. A nationwide study 1987-2005. Eur J Vasc Endovasc Surg 30%
35:131–138, 2008, with permission.) Thigh and groin
20%
Abdomen 5% Neck 4%
Thorax 2% Other 3% FIGURE 28-3  Sites of noniatrogenic arterial vascular injuries in
Forearm 3% Sweden 1987-2005. (From Rudstrom H, Bergqvist D, Ogren M, et al:
Below knee <1% Upper arm 8% Iatrogenic vascular injuries in Sweden. A nationwide study 1987-2005.
Knee 6% Eur J Vasc Endovasc Surg 35:131–138, 2008, with permission.)
Neck 3%

Abdomen 13% 2004 was 19 to 25 per 100,000 inhabitants.14 In the western

Thigh and groin,
left side
19%
Thigh and groin,
right side
43%
FIGURE 28-2  Sites of iatrogenic arterial vascular injuries in Sweden
1987-2005. (From Rudstrom H, Bergqvist D, Ogren M, et al: Iatrogenic
vascular injuries in Sweden. A nationwide study 1987-2005. Eur J Vasc
Endovasc Surg 35:131–138, 2008, with permission.)
in 1925, but it was another 50 years until the first trauma
system was established in Germany in 1972.13 Because of the
dominance of blunt trauma, general surgeons with additional
specialization in fracture management were mainly responsi-
ble for trauma care. Subsequently, two patterns of trauma care
evolved in Europe. In countries within the Austro-German
surgical tradition, orthopedic-oriented trauma surgeons were
trained to manage injuries in almost all body sites, including
visceral and vascular injuries. In contrast, in the Mediterra-
nean countries, Baltic States, and most of Western Europe,
general and visceral surgeons increasingly took over the man-
agement of nonskeletal injuries.13
In Northern Europe, and especially in the Nordic countries,
the incidence of trauma is low. According to a trauma audit
of Finnish hospitals, the annual incidence of severe trauma in
part of Norway, the incidence of severely injured patients
(Injury Severity Score [ISS] >15) was 30 per 100,000 inhabit-
ants.15 Considering that achieving the survival benefit of 15%
to 20% of a mature trauma system requires about 500 to 600
patients to be seen annually, organizing trauma care with a
purely trauma system–based concept as is not a viable option
in Northern Europe, with the exception of highly or densely
populated countries such as Germany or the Netherlands, or
major cities such as London. In countries with large land areas
and small populations, regionalization of all emergency
surgery services (combining trauma and nontrauma surgical
emergency care) seems to be the best option.16
Obviously, the regionalization of emergency surgery
requires corresponding changes in the training of future sur-
geons; and adoption of or enforcement of the acute care
surgery model currently implemented in the United States is
being considered in many Northern European countries.16 In
contrast to expanding a more generalized knowledge and skill
sets for emergency surgical care, elective surgery is becoming
more and more specialized, almost to the point of one-organ
surgery. To successfully combine the requirements of produc-
ing high-level and affordable elective and emergency surgical
services remains one of the most difficult surgical training
challenges for the near future.
Vascular surgery has become a specialty of its own with a
centralized European Board Fellowship Examination (ESBQ
Vasc or FEBV) in 2005.17 Centralization of services may be
beneficial by bringing larger volumes of patients to a center,
which means more experience. It also may mean subspecial-
ization within the specialty. Larger units can afford to have
more expensive and yet cost-effective infrastructure. In the
case of trauma surgery, it is vascular problems that may call
for very urgent management and expertise. In those situations,
there may not be time to send a patient to a tertiary hospital,
because a life or a limb may be lost in the process.
 28  /  Scandinavia and Northern Europe 299

Table 28-1 A Survey on Vascular Specialization and Vascular Trauma Care in Northern Europe
Vascular Surgery as an Specialty Mainly Managing Availability 24-7 of Endovascular
Independent Specialty Vascular Injuries Capability (Large Hospitals)
Finland Specialty Vascular Yes
Sweden Subspecialty Vascular Yes
Norway Subspecialty Vascular Yes
Denmark Specialty Vascular Yes
Iceland Subspecialty Vascular Yes
Estonia Specialty Vascular Yes
Latvia Specialty Vascular No
Lithuania Specialty Vascular Yes
Poland Subspecialty Vascular No
Germany Specialty Trauma Yes
The Netherlands Specialty Trauma Yes

Who, specifically cares for patients with vascular injuries?
According to an informal survey performed by the authors
with colleagues from Northern Europe, vascular surgery is
an independent surgical specialty in most countries with
the exception of some Scandinavian countries and Poland.
The majority of vascular injuries are managed by vascular
surgeons, except in Germany and The Netherlands where
trauma surgeons are responsible for the first-line treatment
(Table 28-1).
Due to centralization, vascular expertise is normally avail-
able in emergencies. However, all Scandinavian countries
(except for Denmark) have small populations in a geographi-
cally large country. The distances to vascular specialist units
can be long. Despite helicopter services, time can become a
factor, especially in the autumn or winter when helicopter
transportation of patients can be problematic.
Region-Specific Considerations
for Diagnosis
In many centers throughout the world, radiologists protect
their interests jealously and have at times initially even refused
to train surgeons in their units. Many cardiologists perform
peripheral vascular interventions as well. In Central Europe a
specialty called “angiology” exists, combining internal medi-
cine and radiology. These turf wars have been seen every-
where, but they are detrimental to patients, especially those
suffering from vascular trauma.
Smaller community hospitals in Scandinavia do not have
angioradiologists. As such, CT angiography, as well as digital
subtraction angiography, is available in all central hospitals;
and reliable diagnostics of vascular injuries is possible,
although there are fewer scanners in Europe than there are in
the United States (29 per 1,000,000 inhabitants in the United
States versus 13 to 17 per 1,000,000 in Scandinavia). A com-
parison of CT scanning actions shows that, while the rate of
CT scans per 1000 inhabitants is 185 in the United States, it is
70 to 90 per 1000 in Northern Europe.18 A similar pattern is
seen in the use of MRI examinations per 1000 inhabitants: 49
in the United States versus 29 in France. These technological
trends also show themselves in the annual health expenditure;
the United States spends a third more per capita than Scandi-
navian countries (U.S. $1263 versus U.S. $853).18 In Northern
Europe in general, an on-call vascular surgeon is available in
most central hospitals and in all university hospitals. Duplex
ultrasonography is not taught to all resident surgeons,
although the devices would be readily available. Vascular
surgery residents are expected to learn the basics of duplex
scanning, although it is not mandatory.
Region-Specific Treatment Strategies
The two essential components in managing major vascular
injuries are the control of bleeding (an endovascular approach
is often possible) and reconstruction of vessels (arteries and
veins).19,20 Even though most of the university hospitals in
Northern Europe have round–the-clock endovascular capabil-
ity (Table 28-1), interventional radiologists are not always
available in nonuniversity hospitals. Transportation of patients
to major centers is preferred; but, in regions such as Lapland
in northern Scandinavia, it can mean a distance of several
hundred kilometers in difficult weather conditions. Fixed-
wing aircraft is not used, although their use has been discussed
with the air force in many countries. Combining military pilot
training and patient transportation may be a possibility in
remote areas in the future, although financial constraints due
to recession are felt everywhere in the western world at the
moment.
Endovascular surgery has very strong proponents in the
Northern European surgical community, and it has been
included in the training of vascular surgeons early on.8,21
However, in large areas with small populations, keeping an
endovascular trauma unit active is difficult. Trauma work
takes a lot of imagination and creative thinking; but it also
requires a large stock of expendables (e.g., guidewires, covered
prostheses of different sizes), which make a realistic applica-
tion possible only in university hospitals.
Strategies to Sustain and Train
the Next Generation of
Trauma Surgeons
Centralization of services to large tertiary centers has improved
the results in many areas of vascular surgery,22 but it also
means lack of even basic vascular services in community hos-
pitals at times. The worrisome fragmentation in medical care
is seen in the management of vascular injuries as well. The
300 SECTION 5  /  INTERNATIONAL PERSPECTIVES
recruitment of trainees is problematic because vascular
surgery is not seen as a desirable option by most residents
these days.23
A European Vascular Examination called ESBQ-VASC has
been organized by the European Society of Vascular and
Endovascular Society since 1996. The title was changed to
Fellow of the European Board of Vascular Surgery (FEBVS) in
2005. Currently the FEBVS examination does not replace an
accreditation by national authorities, which still are recog-
nized by law by all member countries. Especially in Scandina-
via, all trainees are strongly encouraged to take the FEBVS
examination. Harmonization of various curricula would be
useful, but the conditions are quite different in European
countries, even within the European Union.
Fragmentation of the knowledge and skills of surgeons is
a problem all over the western world. True general surgery
hardly exists anymore. Even varicose veins tend to be managed
by vascular specialists and interventional radiologists—or
even dermatologists—but rarely by general surgeons, because
there is a growing demand for more-focused surgery where
the surgeon performs a duplex scan on the patient prior to
surgery. The emergence of endovascular techniques has made
it possible to treat up to 70% of abdominal aortic aneurysms
using intravascular stent prostheses.24 Does the diminishing
workload mean less experience and more difficulties, even for
the vascular specialist to treat the rare vena caval, aortic, or
other visceral arterial injuries in an open operation?
Training paradigms will have to change to reflect the needs
for changes in the delivery system of surgical emergency care.
Most Scandinavian countries have a common trunk type of
training (3 years). After that, trainee surgeons concentrate on
their own field of specialized (elective) surgery. That creates
the problem of how to provide those services in a smaller
(nonuniversity) hospital setting where many types of emer-
gency procedures are rare. On the other hand, similar services
are needed for problems related to chronic limb ischemia. A
study in the United States showed that the volume of open
vascular operations performed by trainees had not decreased
during the last decade. In fact, there had been an increase
driven by escalating endovascular procedure volume.25
Another approach would be to change the common trunk
training radically to reflect the needs of modern surgery;
perhaps it should have an emphasis on cavitary and intralu-
minal endoscopies, angiography, intensive care, and training
in emergency surgery for limb ischemia, intraabdominal inju-
ries, and other common surgical emergencies.
REFERENCES
1. Friedman SG: Early vascular repairs and anastomoses. In Friedman SG,
editor: A history of vascular surgery, Malden, MA, 2005, Blackwell Pub-
lishing, pp 14–30.
2. Carrel A: La technique operatoire des anastomoses vasculaires et de la
transplantation des visceres. Lyon Med 98:850, 1902.
3. Ligon BL: Biography: history of developments in imaging techniques:
egas Moniz and angiography. Semin Paediatr Infect Dis 14:173–181, 2003.
4. Berry D: History of cardiology: Werner Forssmann, MD. Circulation
113:F27–F28, 2006.
5. Hounsfield G: Computed medical imaging. Nobel lecture, December 8,
1979. J Comput Assist Tomogr 4:665–674, 1980.
6. Seldinger SI: Catheter replacement of the needle in percutaneous angiog-
raphy: a new technique. Acta Radiol 39:368–376, 1953.
7. Katzen B, Chang J: Percutaneous transluminal angioplasty with the Gru-
entzig balloon catheter. Radiology 130:622–626, 1979.
8. Schmidli J, Dick F: Specialisation within vascular surgery. Eur J Vasc
Endovasc Surg 39(Suppl 1):S15–S21, 2010.
9. Magee TR, Collin J, Hands LJ, et al: A ten year audit of surgery for vascular
trauma in a British teaching hospital. Eur J Vasc Endovasc Surg 12:424–
427, 1996.
10. Bhattacharya V, Stansby G: Postgraduate vascular surgery: the candidate’s
guide to the FRCS, Cambridge, 2011, Cambridge University Press.
11. Fingerhut A, Leppäniemi A, Androulakis A, et al: The European experi-
ence with vascular injuries. Surg Clin North Am 82:175–187, 2002.
12. Rudstrom H, Bergqvist D, Ogren M, et al: Iatrogenic vascular injuries in
Sweden. A nationwide study 1987-2005. Eur J Vasc Endovasc Surg 35:
131–138, 2008.
13. Leppäniemi A: A survey on trauma systems and education in Europe. Eur
J Trauma Emerg Surg 34:577–581, 2008.
14. Handolin L, Leppäniemi A, Vihtonen K, et al: Finnish trauma audit 2004:
current state of trauma management in Finnish hospitals. Injury 37:622–
625, 2006.
15. Hansen KS, Morild I, Engesater LB, et al: Epidemiology of severely and
fatally injured patients in western part of Norway. Scand J Surg 93:198–
203, 2004.
16. Leppäniemi A: Current status and future options for trauma and emer-
gency surgery in Europe. Turk J Trauma Emerg Surg 14:5–9, 2008.
17. Tsekouras N, Avgerinos ED, Moulakakis K, et al: Vascular surgery training
and its relationship to other surgical specialties. J Cardiovasc Surg
(Torino) 52:47–51, 2011.
18. OECD Health Data 2011. http://stats.oeced.org.
19. Karadimas EJ, Nicolson T, Kakagia DD, et al: Angiographic embolisation
of pelvic ring injuries. Treatment algorithm and review of the literature.
Int Orthop 35:1381–1389, 2011.
20. Katsanos K, Sabharwal T, Carrel T, et al: Peripheral endografts for the
treatment of traumatic arterial injuries. Emerg Radiol 16:175–184, 2009.
21. Hamilton G, Shearman C: Vascular surgical training. Ann R Coll Surg
Engl 90:95–96, 2008.
22. Laukontaus S, Aho P, Pettilä V, et al: Decrease of mortality of ruptured
aortic aneurysm after centralisation and in-hospital quality improvement
of vascular service. Ann Vasc Surg 21:580–585, 2007.
23. Currie S, Coughlin PA, Bhasker S, et al: Vascular surgery is an unattractive
career option for current basic surgical trainees: A regional perspective.
Ann R Coll Surg Engl 89:792–795, 2007.
24. Keefer A, Hislop S, Singh MJ, et al: The influence of aneurysm size on
anatomical suitability for endovascular repair. J Vasc Surg 52:873–877,
2010.
25. Schanzer A, Steppacher R, Eslami M, et al: Vascular surgery training
trends from 2001-2007: a substantial increase in total procedure volume
is driven by escalating endovascular procedure volume and stable open
procedure volume. J Vasc Surg 49:1339–1344, 2009.
Europe: Russia
IGOR M. SAMOKHVALOV, ALEXANDER A. PRONCHENKO,
AND VIKTOR A. REVA
Introduction
Russian surgeons have made significant contributions to vas-
cular surgery and the management of vascular trauma. The
thesis of Nikolai Pirogov, one of the founders of military
surgery, investigated the consequences of experimental liga-
tion of the abdominal aorta (1832); and he provided detailed
information concerning the diagnosis and surgical care of
major vascular injuries in his textbook “The Principles of War
Surgery” (1864).1,2 Nikolai Eck was the first surgeon to use
portocaval anastomosis in 1877; this technique was improved
on by the great physiologist Ivan Pavlov and is now known as
the Eck-Pavlov fistula.3 Alexander Jassinowsky proved that
arterial patency could be preserved after applying a lateral
suture to the artery (1889). During the Russo-Japanese War,
while studying the possibility of ligating arteries in cases of
aneurysm, Nikolai Korotkov invented a method of measuring
blood pressure by identifying “Korotkov sounds” (1905).4 In
1913, Yustin Janelidze was the first surgeon in the world to
suture a stab wound of the ascending aorta.5 In 1920, Sergei
Brukhonenko created the first artificial blood-circulation
device.6 During World War II, Soviet surgeons accumulated
vast experience in the treatment of vascular injuries; inclusive
of 1.4% reconstructive operations. Departments of vascular
injury care were established in military hospitals. In 1945,
Vasily Gudov and coauthors developed the vascular circular-
suturing device.7 After the war, vascular surgery in Russia
developed into a branch of definitive surgical care. Institutes
of cardiovascular surgery and cardiovascular units of hospi-
tals dedicated to caring for elective and emergency vascular
pathology (e.g., B.V. Petrovsky, P.A. Kupriyanov, A.A Shali-
mov, V.S. Savel’ev, A.V. Pokrovsky) were opened in large cities.
In 1987, professor Nikolai Volodos in Kharkov, Soviet Union
(now in Ukraine) first in the world performed an endovascu-
lar repair for a post-traumatic pseudoaneurysm in descend-
ing aorta.8
In recent decades, Russian military medics were among
those to provide care to the casualties of several conflicts,
emergency situations, and natural disasters, such as the Soviet
War in Afghanistan (1979-1989), the earthquake in Armenia
(1988), counterterrorist operations in the North Caucasus
region (1994-1996, 1999-2002), and the Georgian-Ossetian
conflict (2008). Important contributions to the treatment of
casualties were made by the personnel of Kirov Military
Medical Academy in Saint-Petersburg, especially by those of
the War Surgery Department, as well as by the staff of central
hospitals in Moscow, such as N.N. Burdenko General Military
29 
Hospital and A.A. Vishnevsky Central Military Hospital.
Equally important were the efforts of surgeons at district mili-
tary hospitals and garrison hospitals in frontier zones, as well
as those in forward medical units, such as medical companies,
separate medical battalions (similar to U.S. Level II forward
surgical teams and Level III combat surgical or theater hospi-
tals), and special-purpose medical teams.
The most significant progress in providing care to patients
with major vascular injuries occurred during the war in
Afghanistan and the armed conflicts in the North Caucasus.
The epidemiology of vascular injuries, the organizational
aspects of providing care, and the military trauma system all
differed significantly between the conflicts in Afghanistan and
the North Caucasus.
Afghanistan
Region-Specific Epidemiology
The rate of major vascular injuries occurring during the
Afghanistan war ranged from 2% to 8% of all injured combat-
ants (mean: 4.5%). The mean rate of combat-related injuries
to major arteries was 2.7%. Carotid artery injuries occurred
in 3.9%, and upper and lower extremity artery injuries
occurred in 30.8% and 60.6%, respectively. The remaining
4.7% were associated with major vascular injuries of the chest
and abdomen.
As for the mechanism of arterial wall injury, bullet wounds
prevailed at 53.5%. Fragment wounds and blast injuries were
found in 31.6% and 10.9%, respectively. Blunt arterial injury
occurred rather rarely (4%). Most injuries to major arteries
incurred during combat (64.2%) were accompanied by inju-
ries to the corresponding veins. Arterial injuries were some-
times associated with gunshot-induced bone fractures (42.6%)
and with peripheral nerve injuries (16.2%). Injuries to single
major veins were found in 0.8% of patients, with the iliac and
femoral veins being the most-frequently injured.
Patients with major vascular injuries belonged to a group
of severely injured patients. The majority of these who were
transported to the medical facilities were either in stable con-
dition (24.1%), in guarded or serious condition (36.4% and
28.3%, respectively), or in extremis (3.1%). Among patients
with vascular injuries, only 8.1% were judged to be in satisfac-
tory condition. Severe shock (systolic blood pressure less than
70 mm Hg) was recorded in 42.9% of patients. Massive blood
loss and severe associated injuries, specifically blast injuries,
were commonly accompanied by impaired consciousness. On
301
 29  /  Europe: Russia 301.e1

ABSTRACT
We present our experience in treating patients with vascu-
lar injuries during the Soviet War in Afghanistan (1979-
1989) and during the conflicts in the North Caucasus of
Russia (1994-1996; 1999-2002). The rate of vascular inju-
ries among all injured combatants in Afghanistan amounted
to 4.5%, and in the North Caucasus they amounted to 6%.
Surgical approaches to injured arteries of the extremities
were based on the type of acute ischemia. In the setting of
compensated ischemia, there are no indications for urgent
vascular reconstruction, as safe ligation of the artery is pos-
sible. Uncompensated ischemia requires the urgent restora-
tion of blood flow, or the extremity will undergo necrosis
in 6 to 8 hours. In irreversible ischemia, amputation is justi-
fied; because arterial reconstruction under field conditions
after this length of time without perfusion may lead to the
death from endotoxemia. In both conflicts, military sur-
geons in medical units near the point of injury carried out
damage control surgical tactics, such as temporary shunt-
ing of the injured arteries. Next, patients were evacuated
and underwent definitive vascular reconstruction by vascu-
lar surgeons at larger frontline military hospitals. The rate
of temporary shunting in primary vascular surgical opera-
tions amounted to 17.1% in Afghanistan and 25% and
16% in the first and second conflicts in the North Caucasus,
respectively. Among patients treated for vascular injuries in
Afghanistan, satisfactory outcomes were achieved in 43%
(33% of all patients with vascular injuries returned to duty),
45% were dismissed, and the mortality rate was 12%. In
the North Caucasus, 57% of patients returned to duty,
while the mortality rate was 9.4% in the first conflict and
7.6% in the second.

Key Words:  battlefield,

extremity injury,
vascular injury,
amputation,
trauma,
combat,
tactical medicine,
military trauma,
arterial repair,
ligation
302 SECTION 5  /  INTERNATIONAL PERSPECTIVES

FIGURE 29-1  Photograph of a divisional separate medical battalion FIGURE 29-2  The special set for percutaneous ligation of femoral
containing an operation room, a preoperative area, and an intensive vessels containing different needles with a stick. (From the Museum of
care unit. (From Afghanistan, Bagram, 1980.) Department of Operative Surgery, Kirov Military Medical Academy, Saint-
Petersburg, Russia.)

admission, 30% of patients had depressed consciousness; and

7% were unconscious, which made early and accurate diagno-
sis of vascular injuries difficult.
Region-Specific Systems of Care
Over the course of the armed conflict in Afghanistan, the fol-
lowing three-stage medical trauma system was formed: (1)
prehospital care (first aid, buddy aid, or combat lifesaver at
the scene and emergency medical care as preevacuation prepa-
ration); (2) advanced trauma management at forward medical
units, including augmented medical stations, medical compa-
nies, and separate medical battalions in Bagram (Fig. 29-1),
Kunduz, Feizabad, and Gelalabad; and (3) definitive surgical
care at the Army Multipurpose Military Hospital in Kabul. Femur
Over the years, 60% to 90% of patients were evacuated by
helicopter from the combat zone directly to advanced care.
During the war in Afghanistan, an evacuation system was
established, which allowed transport helicopters to fly without SFA
medical personnel (tactical evacuation) or which provided
for aeromedical evacuation by special “Bisectrix” helicopters SFV
staffed by medical personnel. These evacuations were followed
by aeromedical (interhospital) and strategic evacuation by
“IL-76 Scalpel” and “AN-26 Spasatel” military medical aircraft.
As a result, 90% of the wounded personnel with arterial inju-
ries were transported to a surgeon within 6 hours of injury.
Some 61.8% of vascular patients were delivered to the surgeon
within the first 3 hours after injury, which allowed for the wide
use of vascular reconstructive surgery and a reduction in the
FIGURE 29-3  Technique of percutaneous ligation of femoral vessels
primary amputation rate. in prehospital care. SFA, Superficial femoral artery; SFV, superficial
Among the medical supplies issued to individual service- femoral vein.
men before combat operations were first-aid kits containing
sterile field dressings and rubber tourniquets designated for
hemorrhage control. Combat medics were equipped with bags Nikolai Pirogov was a rarely used method of percutaneous
containing 15 to 20 field dressings, 4 to 5 tourniquets, 2 units ligation of the major artery in the middle of a thigh in case of
of crystalloid, and a 3-day supply of drugs. Additional units a distal arterial injury (Fig. 29-2). This technique consisted of
of crystalloid were carried by combat lifesavers. ligation of femoral vessels by pulling a sterile special long
During the war, the number of patients with vascular inju- curved needle through the muscles between the femur and
ries who did not receive prehospital care decreased from 14% vascular bundle making a knot over a stick until the arterial
to 3.2%. There were numerous improvements in prehospital flow stopped (Fig. 29-3). Possible venous bleeding from the
care, such as in-uniform tourniquet systems, tourniquets with wound can be controlled by tight bandage. This method of
graduated compression, and special needles for percutaneous hemorrhage control prolongs warm ischemia time without
ligation of the femoral artery. The last tool developed by any serious damage of arterial wall.9
 29  /  Europe: Russia 303

However, as in World War II, the main tool for temporary

hemorrhage control during the war in Afghanistan remained
the Esmarch-Langenbeck tourniquet—an elastic rubber band.
Among patients arriving at a surgical facility, the tourniquet
was used in over half of all cases of extremity artery injury
(51.1%). This led to many unsatisfactory results for these
patients; following tourniquet application, 44.5% later under-
went extremity amputation because of prolonged tourniquet
times.
Triage of patients transported from the battlefield to the
helicopter landing site or airdrome was conducted at the side
of the helicopter or aircraft. Patients requiring antishock mea-
sures and hemorrhage control were transferred immediately
to the operating room. Advanced trauma management was
provided in separate medical battalions, medical companies,
and even in independent medical platoons, which had been
deployed in wooden detachable modules since 1982. At the
beginning of the war, nearly all surgical facilities were in tents
with temperatures that ranged up to 60° C, making surgical
intervention difficult.
Due to a shortage of specialists trained in vascular surgery, FIGURE 29-4  Dr. Vadim Alexeevich Kornilov, Colonel, 1937-1993.
general surgeons provided care to vascular patients during the Professor at War Surgery Department, Kirov Military Medical Academy,
early years of the war in Afghanistan. A new stage in the provi- Saint-Petersburg. He has been recognized for his outstanding contri-
bution in vascular trauma.
sion of care to patients with major vascular injuries began in
1985 after the establishment of a group of vascular specialists
in the Army Hospital in Kabul. The group included 2 vascular
surgeons, an anesthesiologist, a nurse-anesthetist, and 2 scrub
nurses; and it played a major role in improving care and out- Table 29-1 Classification of Acute Limb
comes for patients with vascular injuries.10 Ischemia in Arterial Trauma
Severity of
Region-Specific Considerations   Ischemia Clinical Signs Surgical Approach
for Diagnosis
Compensated Active moves, pain, Arterial ligation is
The following clinical signs were considered key criteria in the and tactile sense possible and safe.
diagnosis of vascular injuries to an extremity: injury location are preserved.
in the projection of a major vessel (88.2% of patients), inten- Uncompensated Active moves, pain, Urgent arterial
sive external bleeding (83.7%), weak or absent arterial pulses and tactile sense reconstruction is
are absent. indicated (safe term
(73%), or large or growing hematoma in the wound region is 6 to 10 hrs).
(43.5%). Irreversible Ischemic muscle Limb amputation is
Fundamental to diagnosis and care of acute limb ischemia contracture mandatory.
is its classification according to Vadim Kornilov (1971) (Fig. (passive moves
29-4).11 This classification presented in the third edition of the are absent)
Soviet Great Medical Encyclopedia (1974-1988) in the Guide- (From V.A. Kornilov, 1971.)12
lines for War Surgery of the Russian Army (1988; 2000) is
extremely simple, explicit, and easy to use during the early
stages of military evacuation (Table 29-1). The main features
distinguishing it from classifications of ischemia in the setting exposure carried out. Indications for preoperative angiogra-
of artery thrombosis and embolism are the following: phy occurred more commonly in patients with multiple inju-
1. Arterial injuries are accompanied by massive bleeding, ries to major vessels and in those with blunt artery trauma.
which aggravates tissue ischemia. This diagnostic approach was applied in 16.7% of patients
2. There is no preceding chronic ischemia in extremities with extremity artery injuries. Under separate medical bat-
with a definite tissue adaptation to hypoxia. talion conditions, arteriography would preferably be per-
3. Vascular injuries occur more commonly in young males formed during surgery after exposure of the proximal segment
having large muscle bulk, and a pronounced endotoxi- of the artery. During definitive surgical care, 91% of patients
cosis can therefore accompany postischemic blood with injured lower extremity arteries underwent femoral
recirculation. artery catheterization using a Seldinger technique to perform
Among all admitted patients with injured arteries, signs of angiography following prolonged drug administration. (This
uncompensated ischemia were noted in 27.6% of cases. Com- approach allowed for a 2.5-fold decrease in the amputation
pensated ischemia (owing to collateral vessels) was reported rate.13) Owing to a lack of equipment, the informative method
in 63.6% of cases. Some 8.7% of admitted patients had irre- of duplex ultrasound examination was not used. Although by
versible ischemic changes in the extremities. Additional angi- the end of the war a portable ultrasonic device to study major
ography was used rather infrequently; only in the case of a vessel patency had been developed (unpublished data), it did
reasonably suspected major vascular injury was operative not find use in further conflicts in the North Caucasus.
304 SECTION 5  /  INTERNATIONAL PERSPECTIVES
Region-Specific Treatment Strategies
During combat in the Afghanistan war, the care of major
vascular injuries evolved. Military treatment facilities con-
sisted of physicians untrained in vascular surgery. In accor-
dance with “The Guidelines for War Surgery” (1970), advanced
trauma management had to include emergency surgery,
mainly in the form of vessel ligation or vessel suturing. At the
stage of definitive surgery, standard or mechanical vascular
suturing had to be carried out. During the first few months of
combat operations, it appeared that both ligations and
attempts to restore arteries in separate medical battalions or
in medical companies, particularly when combined with vein
grafting, led to many complications. In these circumstances,
the army surgeon Petr Zubarev worked out “The Guidelines
for Treatment of Major Vascular Injuries at the Military Treat-
ment Facilities” (1981). The most important vascular opera-
tion at the advanced trauma-management stage appeared to
be arterial ligation. Reconstructive vascular surgery was con-
sidered to be possible only when staff and facilities were not
overloaded with lifesaving operations. At the same time,
taking into account the many life-threatening and incapaci-
tating complications associated with permanent hemostasis
of major arteries in separate medical battalions, surgeons at
the advanced trauma-management stage were advised to
carry out temporary shunting (TS) with polyvinylchloride
tubes. These were taken from disposable 4.5-mm diameter
blood transfusion sets. Patients were evacuated to the Army
Military Hospital in Kabul or the 340th District Hospital in
Tashkent.
At that time, the practice of medical augmentation teams
and facilities with experienced surgeons during high-intensity
combat operations began. When the outcomes of vascular
operations performed by separate medical battalion general
surgeons were compared to those of the surgeons of the aug-
mentation teams, it appeared that reconstructive vascular
operations carried out by the surgeons of the augmentation
teams resulted in a twofold lower number of amputations and
a fourfold lower postoperative mortality rate compared to
separate medical battalions.14
All patients with significant blood loss and/or dehydration
underwent mandatory preoperative intensive care before
surgery on the injured vessels. In a number of cases, this care
led to the aggravation of extremity ischemia, yet attempts to
operate on unprepared patients, many of whom had associ-
ated injuries, resulted in death. Considering previous experi-
ence in World War II that demonstrated the high rate of
amputations accompanied by ligation of major arteries,15 as
well as a dramatic reduction in amputations (13.5%) while
restoring arterial patency during the Vietnam War,16 Soviet
surgeons in Afghanistan began to use primary restoration of
major artery patency more frequently (40.9%).
Eger et al17 published good results of TS of injured vessels
in combat settings, but it was in Afghanistan that this method
(now called “vascular damage control surgery”) was first used,
altogether being employed in 17.1% cases of primary opera-
tions on injured extremity arteries. This operation was recom-
mended for the advanced trauma-management stage and was
to be followed by definitive vascular reconstruction at the
definitive surgery stage.13 TS played a positive role in most
patients’ treatment outcomes; however, as general surgeons
gained experience, TS appeared to be a rather difficult and
prolonged intervention for them in most cases. TS took from
1 to 5 hours (mean 2.8 hours), and its duration sometimes
exceeded the time the same surgeons needed to apply lateral
sutures or end-to-end anastomosis. Besides, on average, 40%
or more of the polyvinylchloride tubes thrombosed during the
course of TS. These incidents were associated not only with
imperfections in the improvised prostheses but also with the
drawbacks of the method itself and technical errors in its
implementation. These incidents resulted in amputations in
37% of patients who had undergone TS, which exceeds the
amputation rate among all patients with major extremity-
artery injuries (18.4%).14 At the same time, when compared
with ligation, the results of TS look quite satisfactory. The
TS technique itself also varied as accomplished by different
surgeons during the war years. In most cases, the vascular
defect along the shortest line between its ends was the area
replaced by the prosthesis. Vessel walls were pulled over the
tube and fixed on both ends by two ligatures, which were
subsequently connected to each other and taken out to the
dermal wound. Temporary shunting with loop formation of
40 cm to 50 cm in length, drawn under the dressing, was
much more infrequently used, as it was accompanied by early
shunt thrombosis.
Considering our personal data on 64 patients with TS, we
can say that 27.8% of shunts thrombosed within 12 hours,
38.5% of shunts did so from 12 to 24 hours, and 50% of them
did so after exposure for more than 24 hours. Taking the
average rate of shunt thrombosis as 39.1%, this rate decreased
to 27% in superficial femoral artery injury, whereas it increased
up to 40% in brachial artery injury and up to 71% in popliteal
artery injury. In arterial injuries in adjacent regions, there was
no artery thrombosis. These differences are associated not
only with arterial diameter, but also with the specificity of
the wall structure, namely, the muscular walls of the brachial
and popliteal arteries. This finding leads us to conclude
that the technique is less expedient for use on peripheral arter-
ies. Thrombosis in TS and amputations in patients with the
injuries of the arteries of elastic type and distal arteries
of muscular type differed considerably: 17.6% and 22.2%,
respectively, in the first group, and 55.6% and 44.4% in the
second group (p < 0.01). Sterile polyvinylchloride tubes of
infusion sets were used in 83% of cases. Up to 40% of
the tubes thrombosed. Using specially made Silastic arterial
shunts, which were 4.5 mm in internal diameter, resulted in
better outcomes. The thrombosis rate was 25% with exposures
up to 120 hours. Intravenous injection of heparin after TS did
not significantly reduce thrombosis rates, nor did it influence
the amputation rate.
Simultaneous TS of both arteries and veins was carried out
in 16 cases, as well as in 6 cases of isolated venous injuries. Of
the total number of major-vein TS cases (22), only 3 patients
demonstrated shunt patency within 5, 16, and 18 hours. The
remainder of the shunts in this group of patients thrombosed
within 1 day.
Based on the lessons of the Afghanistan war, vascular TS
became a regular practice in Russian war surgery. In accor-
dance with “The Guidelines for War Surgery” (1988), an indi-
cation for TS at the advanced trauma-management stage is a
large arterial defect accompanied by uncompensated isch-
emia. Unjustified artery TS in patients with compensated
extremity ischemia resulted in an increased thrombosis rate
of up to 50%; and, in a number of cases, the severity of

ischemia increased due to simultaneous spasm of collateral
arterial branches.
Attitudes about ligation of major veins in combat trauma
also changed. The rate of vein ligation in a wound decreased
significantly from 86% to 57%. Important factors contribut-
ing to the success of vascular injury care were débridement,
early fasciotomy (which was performed in 40% of vascular
reconstructions), prophylactic antibiotics, adequate fluid
resuscitation, and a controlled use of anticoagulants. (Only
unfractionated heparin was used, and it was under the control
of plasma recalcification time.)
In gunshot-induced fractures accompanying vascular inju-
ries, immobilization was commonly achieved with a plaster
bandage (93.8%), while skeletal traction was rarely used
(3.8%). External fixation or intramedullary nailing was even
less frequently used (1.2%).10 Primary neural suture was
applied in 13% of patients who had vascular injuries accom-
panied by peripheral nerve injuries. The total amputation
rate following reconstructive operations at the advanced
trauma-management stage reached 18.4%. These high indexes
could be explained by the presence of severe injury to soft
tissues of the extremities in the setting of blunt trauma and
associated injuries, as well as by inadequate training of the
general surgeons providing care at forward military treatment
facilities.
In the definitive surgery of patients who had previously
undergone temporary hemorrhage control, definitive hemo-
stasis was performed by applying lateral sutures, by creating
an end-to-end anastomosis, by conducting autologous vein
grafting, or when indicated, by artery ligation or extremity
amputation. In the Army Military Hospital, indications for TS
differed from those at the advanced trauma-management
stage units. These indications were to reduce the duration of
extremity ischemia during injury débridement and fracture
stabilization, as well as to provide a “damage control” option
in cases where vascular reconstruction had to be delayed due
to the severe patient’s condition.10,13 Repaired vessels devel-
oped thrombosis in 17% of cases. Nearly half of all vascular
patients developed wound infection. As a result of damage
control surgery for combat-sustained major arterial injuries
in Afghanistan, 88% of patients survived. Among injured ser-
vicemen, 33% returned to duty, while 43% of patients dem-
onstrated either good or satisfactory results.
Strategies to Sustain and Train the Next
Generation of Trauma Surgeons
Since 1979, the specialists of Kirov Military Medical Academy
in Saint-Petersburg have been directly involved in the coordi-
nation of surgical care in Afghanistan, holding positions as
chief surgeons of the 40th Army. All of them—P.N. Zubarev,
E.V. Chernov, I.D. Kosachev, G.A. Kostjuk, and A.V. Nizovoj—
paid special attention to patients with extremity vascular inju-
ries. It was under their supervision that guidelines for the care
of casualties with vascular injury were prepared and textbooks
on TS of injured arteries were published.
The training of surgeons in war surgery, specifically in
vascular trauma, was obviously inadequate. At the beginning
of the Afghanistan war, most surgeons had not served in a
specialty for more than 1 to 5 years, and their average age was
29. Up to 85% of surgeons needed continuous surgical support
from senior colleagues. In addition, young surgeons lacked
psychological training and knowledge of basic triage princi-
29  /  Europe: Russia 305
ples. These shortcomings were manifested during mass casu-
alty situations. During combat, simultaneous admissions
exceeded 25 to 30 patients.
Due to extra training, surgeons eventually improved.
Before being assigned to Afghanistan, the physicians were
trained in an internship in Turkestan Military District (Tash-
kent) and in an internship for medical personnel of the
40th Army Hospital (Kabul). In addition, during the war,
experienced surgeons from the Military Medical Academy
and central military hospitals were commonly delegated to
Afghanistan. These older surgeons improved training in
combat pathology while teaching younger surgeons serving in
separate medical battalions and garrison military hospitals.
As with all contract servicemen of the 40th Army, turnover
occurred every 2 years. Top-ranked specialists in combat vas-
cular trauma were trained in the operating rooms of separate
medical battalions and military hospitals. Lessons learned
during vascular injury care were reviewed and subsequently
used extensively in the training of medical officers in the Mili-
tary Medical Academy and military medical institutes. In sub-
sequent years, these officers were sent to combat settings to
provide patient care.
The North Caucasus
Region-Specific Epidemiology
Due to similar combat operations, the main characteristics of
the wounded during two internal conflicts in the North Cau-
casus (1994-1996 and 1999-2002) did not significantly differ.
The rate of combat vascular injury during the armed con-
flicts in this region amounted to 6%. During combat opera-
tions, especially during the 1999-2002 period characterized by
“mine war,” the share of blast vascular injuries significantly
increased (from 29.2% in the earlier conflict to 40% in the
second). This change reflects the specifics of combat activities.
By contrast, in Afghanistan, the share of blast trauma did not
exceed 11% among vascular injuries.
A considerable percentage of all extremity artery injuries
(50.1%) were accompanied by injuries to concomitant veins.
Gunshot fractures of bones of the extremities were observed
in 48.4% of all cases. Injuries of lower-extremity arteries pre-
vailed. As a rule, patients with major artery injury were
deemed to be in severe condition. In particular, a significant
increase in the rate of popliteal artery injury in the second
conflict (from 8.6% to 22.2%) stands out in this list, reflecting
the increased number of mine-blast injuries. Compared with
the Afghanistan war, the share of severe abdominal vascular
injuries increased fourfold (8.3%), while the rate of vascular
injuries to the neck fell to 2.9%.
Region-Specific Systems of Care
Individual medical supplies for servicemen participating in
combat operations included a sterile field dressing and a
rubber tourniquet (one for two servicemen). A physician, a
paramedic, and four combat medics were assigned to each
battalion. Augmentation teams (2 surgeons, an anesthesiolo-
gist, and a scrub nurse) were assigned to each medical station
and medical company.16
More advanced training of those physicians stationed at
medical stations and medical companies resulted in improved
care for external hemorrhage. Tourniquets were used less
306 SECTION 5  /  INTERNATIONAL PERSPECTIVES
commonly in the first and the second conflict (32.1% and
22.2%, respectively) compared to Afghanistan (51.1%). Com-
pressive bandages (33.3%), tight tamponade (9.5%), retroclu-
sion in the wound (4.8%), and vessel clamping (3.2%) were
the main procedures used to control external hemorrhage.18
Armored vehicles evacuated patients from the battlefield to
medical stations and transferred medical companies to the
front lines. Further tactical evacuation to a military hospital
was mostly via helicopter (90%). Road transport used in only
10% of cases.
The conditions and nature of combat in the North Cauca-
sus conflicts were significantly different from those in the
Afghanistan war. Further reduction in the number of treat-
ment stages in some of the severely injured soldiers became
possible. A two-stage organization of military treatment facili-
ties, wherein patients are immediately evacuated to definitive
surgical care after receiving first aid, is considered optimal and
reduces the overall mortality by 3 times.19
However, providing advanced surgery remains important
during frequent evacuation delays. One feature of advanced
surgery organization in the North Caucasus was the use of
four Special-Purpose Medical Teams (Fig. 29-5). Created by
the district military hospitals, these mobile medical units were
on constant alert and were ready to provide disaster support;
and, during these conflicts, they were deployed under combat
conditions for the first time.
All medical facilities providing definitive surgical care were
grouped into three echelons. The first echelon (Mozdok and
Vladikavkaz military hospitals) was located near the combat
zone. These frontline military hospitals were provided with
appropriately equipped medical augmentation teams from the
Military Medical Academy and central military hospitals,
thereby turning them into multipurpose hospitals similar to
peacetime Level II trauma centers. The second echelon con-
sisted of district and garrison military hospitals in the North
Caucasus Military District and in other regions of Russia. The
third echelon was comprised the central military hospitals and
clinics of the Military Medical Academy.20
Region-Specific Considerations for Diagnosis
Diagnosis of major vascular injuries at the advanced trauma-
management stage did not change significantly compared to
FIGURE 29-5  Movement of casualties from the Special-Purpose
Medical Team deployed in the outskirts of Grozny, a capital of Chech-
nya. (Russia, the North Caucasus, 1995, courtesy Dr. Michail Rogachev.)
the Afghanistan war. The use of duplex ultrasound examina-
tion appeared possible at the definitive surgery stage; for
instance, 5 of 29 soldiers with neck wounds underwent duplex
scanning.21 Computed tomography angiography (CTA) was
not performed. Conventional angiography remained the
most frequently used instrumental method of diagnosing vas-
cular injuries. Despite this property, clinical examination,
especially in case of suspected injury, was the main diagnostic
method, as it was in the Afghanistan war. Where there were
associated injuries, patients were rapidly examined by consul-
tant specialists.
The severity of limb ischemia in cases of major artery
injury was estimated according to V.A. Kornilov’s classifica-
tion. Half of the patients (52.7%) had compensated ischemia,
34.4% had uncompensated ischemia, and 12.9% had irrevers-
ible ischemia. The surgical approach was determined in accor-
dance with the above grades.
Region-Specific Treatment Strategies
The average evacuation time of vascular patients to the
advanced trauma-management stage (Special-Purpose Medi-
cal Teams or separate medical battalions) did not exceed 2.7
hours. At the definitive surgical-care stage, all major vascular
interventions were performed by general surgeons; vascular
surgeons did not provide care. The rate of ligature surgery
decreased (16% compared to 31% in the Afghanistan war).
This finding reflects surgeons’ preference for performing
reconstructive operations in cases of vascular injury. However,
arterial ligation is justified in patients with compensated isch-
emia, especially if there are severe associated injuries.
The share of primary limb amputations among vascular
injury interventions increased twofold compared to Afghani-
stan War (Table 29-2). That was due to a significant share of
blast injuries among vascular patients in the North Caucasus
and a two- to threefold decrease in evacuation time that led
to arrival of the patients with more severe trauma.
Improvised TS of the arteries continued to see frequent use
(16% to 25%).22 Temporary shunting of vessels at the defini-
tive surgical-care stage was used intraoperatively for definitive
restoration of blood flow in patients with prolonged uncom-
pensated ischemia. Such delays occurred either during periods
of injury débridement and bone external fixation in bone
vascular injuries or in the setting of multiple urgent opera-
tions. Reinforced siliconized tubes were used more frequently,
Table 29-2 Percentage Distribution of Primary
Surgical Operations Performed for
Major Artery Injuries in Advanced
Trauma-Management Facilities
The North Caucasus
Afghanistan Conflicts
Type of War
Operation 1979-1989 1994-1996 1999-2002
Ligation 31.0 15.9 16.1
Arterial repair 34.0 22.7 29.3
Temporary 17.0 25.0 16.0
shunting
Primary 18.0 36.4 38.6
amputation
Total 100.0 100.0 100.0

FIGURE 29-6 Unilateral external fixation frame (KST-1) and tempo-
rary shunts (reinforced siliconized tubes) used during the conflicts in
the North Caucasus (1994-1996; 1999-2002). KST, Komplekt dlja
sochetannyh travm (associated trauma kit).
as well as bone external fixation using original KST frame
(Fig. 29-6).22 All these resulted in a two fold lower number
of amputations after TS (15.0% compared to 35.1% in the
Afghanistan War).
The share of definitive artery reconstruction was high
(23% to 29%). Lateral sutures prevailed (43.8%), while end-
to-end anastomosis was used more rarely (31.2%), and autol-
ogous vein grafting was used in 25.0% of cases. There were no
immediate postoperative extremity amputations or fatalities
at the advanced trauma-management stage. On average, all
patients were evacuated to definitive surgical care in 1.3 ± 0.1
days. Therefore, the importance of advanced trauma manage-
ment to urgent intervention in vascular injury remains high,
making basic vascular surgical training for military surgeons
a necessity.
In the first-echelon military hospitals in which patients
typically underwent surgery by vascular surgeons of the aug-
mentation teams from the Military Medical Academy and the
central hospitals, definitive arterial restoration prevailed at a
rate of 40% to 66%. Among definitive vascular surgeries,
autologous vein grafting was the procedure most frequently
performed (60%), while end-to-end anastomosis (35%) and
lateral sutures (5%) were used less frequently. Ligation of
major arteries was performed in 14% of cases with compen-
sated limb ischemia, mainly when one of the paired arteries
of the forearm or lower leg was injured.
Compared with the advanced trauma-management stage,
according to primary indications, the share of limb amputa-
tions was reduced to 8%; the definitive surgical-care stage
offers a number of possibilities for medical rehabilitation.
During both Caucasus conflicts, the rate of postoperative
amputations in first-echelon hospitals at the definitive
surgical-care stage did not exceed 4% to 5%. Infectious com-
plications occurred in 12.4% of patients with vascular injuries.
In cases of vascular injury, total mortality amounted to 9.4%
in the first Caucasus conflict and 7.6% in the second. Among
patients with gunshot wounds to extremity vessels, 35% were
discharged from the armed forces. More than half of all vas-
cular patients (57.4%) returned to duty. Considering the
29  /  Europe: Russia 307
results of vascular injury care in Afghanistan (33% returned
to duty), we can state that there has been an improvement in
immediate outcomes for patients with combat vascular
trauma.
Strategies to Sustain and Train the Next
Generation of Trauma Surgeons
Significant contributions to both clinical care and scientific
research were made by medical augmentation teams of the
Military Medical Academy and by central hospitals that
worked in concert with frontline military hospitals (Vladika-
vkaz, Mozdok) under the supervision of specialists from the
War Surgery Department. During the conflict, these military
hospitals became affiliated branches of the Academy. This
allowed for the training of a large group of surgeons under
combat conditions, and new methods of diagnosis and
treatment of contemporary combat pathology substantially
improved patient outcomes.
Several specialized teams provided vascular surgical care.
These teams turned over every 3 months, as they were a part
of the medical augmentation teams. The assignment of vas-
cular surgeons to frontline medical facilities during the con-
flicts led to a new generation of surgeons skilled in the care of
combat vascular injury. This last development allowed the
organization of a major vascular-trauma training course for
surgeons at the War Surgery Department of the Military
Medical Academy in Saint-Petersburg.
Conclusion
Improvements in the quality of care for vascular patients have
grown from the experiences of both Russian (N.I. Pirogov,
V.A. Oppel, B.V. Petrovsky, V.A. Kornilov) and foreign (M.
DeBakey, C. Hughes, N. Rich) vascular military surgeons.
However, actual experience in treating vascular patients under
combat conditions underscores the importance not only of
surgical skills but also of all elements of the trauma system,
as follows: optimal organization, availability of medical
treatment facilities, staff training, and improvements in staff
endurance and competence. Unfortunately, it was impossible
to make extensive use of high-tech methods of vascular injury
diagnosis (such as CT and magnetic resonance angiography
[MRA]), as well as make use of endovascular treatment in
frontline hospitals during these conflicts. Despite the lack of
advanced technology, highly qualified surgeons and a well-
established trauma system allowed a reduction in mortality
among patients with major vascular injuries from 12% during
the Afghanistan War to 7.6% in the North Caucasus. Other
factors that led to improved outcomes include improvements
in prehospital care, the use of damage control surgery, reduc-
tion in evacuation time of severely injured patients to military
hospitals, and early definitive care in frontline hospitals for
vascular patients by specialists trained in the Afghanistan War
and in trauma centers during peacetime.
Databases were compiled by the staff of the War Surgery
Department of the Military Medical Academy into a Registry
of Vascular Trauma that includes comprehensive data on the
care of 755 patients. These surgical experiences, gained at a
heavy cost, allowed for improvements in medical care for civil-
ians. Duplex ultrasound and CTA are now widely used in the
diagnosis of injuries, while endovascular treatment of vascular
injuries is gradually being adopted in the care of these patients.
308 SECTION 5  /  INTERNATIONAL PERSPECTIVES
Despite progress in visual diagnosis of injuries and in high-
tech vascular surgery, we believe that the above-mentioned
experiences of providing medical care to combat vascular
injury patients using rapid diagnosis based on clinical signs
and an active surgical approach will be of value to surgeons
who have yet to treat combat vascular trauma in the 21st
century.
REFERENCES
1. Blair JS: Nikolai Ivanovich Pirogov (1810-1881). J R Army Med Corps
148(3):303, 2002.
2. Samohvalov I, Fomin N, Reva V, et al: Sõjakirurg Nikolai Pirogov. Eesti
Arst 90(2):84–88, 2011.
3. Zubarev PN: Nikolaĭ Vladimirovich Ekk (1849-1908). Vestn Khir Im I I
Grek 159(4):9–11, 2000.
4. O’Rourke MF, Seward JB: Central arterial pressure and arterial pressure
pulse: new views entering the second century after Korotkov. Mayo Clin
Proc 81(8):1057–1068, 2006.
5. Dzhanelidze IuIu: Wounds of the heart and their surgical treatment. 1927
(excerpts from the book). Vestn Khir Im I I Grek 157(3):107–110, 1998.
6. Konstantinov IE, Alexi-Meskishvili VV, Sergei S: Brukhonenko: the devel-
opment of the first heart-lung machine for total body perfusion. Ann
Thorac Surg 69(3):962–966, 2000.
7. Gudov VF: Technic in mechanical application of a vascular suture.
Khirurgiia (Mosk) 12:58–60, 1950.
8. Volodos NL, Karpovich IP, Shekhanin VE, et al: A case of distant trans-
femoral endoprosthesis of the thoracic artery using a self-fixing synthetic
prosthesis in traumatic aneurysm. Grudn Khir 6:84–86, 1988.
9. Fomin NF: An anatomicophysiological evaluation of the percutaneous
ligation of the femoral vessels as a method for temporary hemostasis in
trauma of the lower extremities. Voen Med Zh 7:32–34, 1994.
10. Makhlin IA, Khomutov VP: The organization of the delivery of special-
ized vascular trauma care for victims (1). Voen Med Zh 8:18–22, 1991.
11. Kornilov VA: On restoration on injuries of major arteries of the limb in
acute ischemia. Khirurgiia (Mosk) 45(6):30–35, 1969.
12. Kornilov VA: Surgical tactics and techniques in major vascular injuries in
terms of staged treatment of the wounded, Leningrad, 1971, Dissertation,
Military Medical Academy, p 154.
13. Makhlin IA, Khomutov VP: The organization of the delivery of special-
ized vascular trauma care for victims (2). Voen Med Zh 1:35–38, 1992.
14. Eriukhin IA, Kornilov VA, Samokhvalov IM: The diagnostic and treat-
ment characteristics of modern combat trauma to the blood vessels. Voen
Med Zh 8:22–24, 1991.
15. DeBakey ME, Simeone FA: Battle injuries of the arteries in World War II;
an analysis of 2,471 cases. Ann Surg 123:534–579, 1946.
16. Rich NM, Baugh JH, Hughes CW: Acute arterial injuries in Vietnam:
1,000 cases. J Trauma 10(5):359–369, 1970.
17. Eger M, Glocman L, Goldstein A, et al: The use of temporary shunt in
the management of arterial vascular injuries. Surg Gynecol Obstet 132:
67–70, 1971.
18. Gumanenko EK, Samokhvalov IM, Trusov AA, et al: Surgical care ren-
dered to the wounded in the antiterrorist operations on the Northern
Caucasus: premedical and initial medical care in the combat zone (Report
II). Voen Med Zh 326(3):4–13, 2005.
19. Gumanenko EK, Samokhvalov IM, Trusov AA, et al: Principles of surgical
care organization and structural characteristics of wounded in counter-
terrorist operations in the Northern Caucasus (Report I). Voen Med Zh
326(1):4–13, 2005.
20. Gumanenko EK, Samokhvalov IM, Trusov AA, et al: Organization and
contents of the specialized surgical care in multiprofile military hospitals
of the 1st level during counter-terrorist operations on the northern Cau-
casus (report V). Voen Med Zh 327(3):7–18, 2006.
21. Reva VA, Pronchenko AA, Samokhvalov IM: Operative management of
penetrating carotid artery injuries. Europ J Vasc Endovasc Surg 42(1):16–
20, 2011.
22. Samokhvalov IM, Zavrazhanov AA, Kornilov EA: Results of usage of
temporary prosthetics in cases of combat injuries of extremities. Voen
Med Zh 327(9):29–33, 2006.
Europe: Serbia
LAZAR B. DAVIDOVIC
Region-Specific Epidemiology
The development of surgery has always been connected with
wars. A. Pare once said, “The only people who gain from
warfare are young surgeons.”1 This was particularly the case
in the Balkans where the great leaders’ interests collided for
almost a thousand years. Small nations with long traditions,
but different economies, culture, language, and religion, tried
to create and preserve independent countries; but they were
part of greater territories for hundreds of years, which also
affected the development of medicine. Industry, traffic, and
the urban way of life were the key factors in the etiology of
vascular injury in the 20th Century in Europe; while in the
Balkans, the driving factor was often war.
The history of the surgical management of vascular trauma
in the Balkans began during the Balkan Wars (1912-1913).
Vojislav Subotic, a Serbian surgeon, reported the experience
of surgeons at the Belgrade Military Hospital during these
wars in a study published in The Lancet in 1913.2 Of a total
of 77 patients who developed false traumatic aneurysms and
arteriovenous fistulas (AVF), reconstruction was performed in
42% of cases (19 direct arterial suture repairs, 11 arterial end-
to-end anastomoses, and 13 vein repairs). Discussing that
report, Rudolph Matas spoke about Soubbotitch with great
praise.3 Later, Dr. Norman M. Rich stated that Soubbotitch’s
technique and results were not surpassed until 40 years later,
during the Korean Conflict.4 At the end of the 20th century,
the former Yugoslavia experienced civil war, and this unpleas-
ant fact gave a generation of surgeons (including this author)
an oportunity to treat a significant number of war injuries.
In developed European countries, industrial and traffic
accidents provided most of the mechanisms causing vascular
trauma. It is commonly held that the presentation and
management of vascular injuries is fundamentally different
between wartime and civilian circumstance as the causes of
vascular trauma are significantly different in countries facing
ongoing war than they are in those countries that exist
peacefully.5
Over the past 20 years in the former Yugoslavia, the number
of treated civilian and war arterial injuries markedly increased
to reach epidemic proportions.6-17 However, the actual inci-
dence of vascular trauma in most Balkan countries, including
Serbia, is unknown. One of the reasons for this is that these
injuries are not always treated by vascular surgeons. In the
absence of national registers, the most reliable data on inci-
dence, epidemiology, diagnostics, and vascular injury treat-
ment can be found in the database of the Clinic for Vascular
30 
and Endovascular Surgery of the Serbian Clinical Centre. This
is the oldest and largest vascular institution in the whole ter-
ritory of the former Yugoslavia, which deals with urgent vas-
cular cases on a daily basis, as well as with elective surgery.
The database of that clinic contains records from patients
with 590 peripheral arterial injuries sustained between 1992
and 2001. Of these injuries, 140 were war-related and 273
occurred in the civilian setting.17 Also, 142 iatrogenic vascular
injuries were documented in the period between 1992 and
2007. Demographics, injury modality distribution, mecha-
nism, type, and anatomic site of injury are presented in
Table 30-1.
In the noniatrogenic groups, the majority of patients were
male (war: M:  = 132 : 8; civilian: M : F = 237 : 36), while in the
group having sustained iatrogenic injury there was no signifi-
cant difference between the male and female ratio (M : F =
84 : 58). The most frequent cause of war-related vascular
trauma was an explosive mechanism (53%), and these injuries
were most commonly penetrating in nature. In contrast,
motor vehicle crashes and industrial accidents (the most
common causes of vascular injury in the civilian setting)
caused blunt injury. Three quarters of the iatrogenic injuries
resulted after diagnostic, catheter-based angiography, while
26% followed actual interventional cardiac or vascular proce-
dures. Vessel transection was the most frequent type of arterial
injury in both the war-related (37%) and the civilian trauma
(38%) cohorts. False aneurysm was the most common form
of vascular trauma (34%) in the iatrogenic injury group. The
most frequently injured vessel was the femoral artery (war:
38%; civilian: 34%; iatrogenic: 68%). The incidence of popli-
teal artery injury was also relatively high representing 31% of
injuries in the war-related group and 30% in the civilian
trauma group.
Region-Specific Systems of Care
The treatment of vascular trauma in Serbia and the West
Balkans is associated with two main problems. The first one
is slow and inefficient transportation of the injured, especially
during war conditions. In 1918, when the defeated Austro-
Hungarian and German troops were returning from the Thes-
saloniki front to Belgrade, Geza de Takach, the main surgeon
of the Austro Hungarian Army, described the condition of
injured soldiers who were not treated in a timely manner:
“Arriving on the Balkan front from Salonika to Belgrade
through narrow mountain roads, harassed by guerrilla troops
watching from the mountain tops, I still hear the creaky wheels
309
 30  /  Europe: Serbia 309.e1

ABSTRACT
At the beginning of the second decade of the 20th century,
Serbian surgeon V. Soubbotitch reported his experience
with the treatment of vascular injuries from Balkan Wars
(1912-1913). And, at the end of the 20th century, the
former Yugoslavia experienced civil war; and thanks to this
unpleasant fact, the author’s generation of vascular sur-
geons had an oportunity to treat a significant number of
war vascular injuries. In the absence of national registers,
the most reliable data about vascular injury in Serbia can
be found in the database of the Clinic for Vascular and
Endovascular Surgery of the Serbian Clinical Centre. That
database collected 590 peripheral arterial injuries (140 war,
273 civil, and 142 iatrogenic vascular injuries). Those data
showed that the treatment of vascular injury in the region
of the Western Balkans is associated with two main prob-
lems. The first one is inefficient transportation of the
injured; the second is the lack of qualified vascular sur-
geons, followed by a significant number of redo procedures
and by poor functionality following vascular trauma. In the
majority of cases with vascular injuries, an open surgical
repair is most commonly necessary. On the other hand, in
most developed countries, residents and young vascular
surgeons do not have any experience in the treatment of
vascular trauma; and education and training in open vas-
cular surgery is essential. Young vascular surgeons and resi-
dents in Serbia do not lack this training.

Key Words:  vascular trauma treatment,

Serbia,
Western Balkans
310 SECTION 5  /  INTERNATIONAL PERSPECTIVES

Table 30-1 Demographics, Injury Modality However, during the Yugoslavian Civil War, the transport time
Distribution, Mechanism of Injury, was again prolonged and as much as 12 hours. The prolonged
Type of Arterial Injury, and evacuation time in this conflict existed in part because of the
Anatomic Site of Arterial Injury uncertainty of who and where the enemy was located.6-12,14,15,17
Due to unfavorable traffic conditions and the limited number
War Civil Iatrogenic of ambulance services in the Western Balkan countries, the
Injuries Injuries Injuries transportation of persons with vascular trauma is not efficient
No. (%) No. (%) No. (%) even in peacetime. According to the results of one of our
Total injuries 140 273 142
studies, the amputation rate in patients treated more than 12
hours after injury is significantly higher than in those operated
Demographics
within the first 6 hours.17
Male 132 (94. 29) 237 (86.81) 84 (59.2)
The other challenge with the treatment of vascular trauma
Female 8 (5.71) 36 (13.19) 58 (40.8)
in Serbia and the majority of the Western Balkan countries is
Average age 34.3 years 34.7 years 55.6 years
the lack of qualified vascular surgeons. It was the case during
Injury Modality Distribution the Yugoslavian Civil War and unfortunately remains the case
Isolated arterial 65 (46.43) 148 (54.1) 135 (95.7) during peacetime that vascular injuries are most often treated
Arterial plus 75 (53.57) 115 (45.9) 7 (4.93) by less-experienced general surgeons. This phenomenon was
venous
the main reason for a number of secondary procedures after
Associated 91 (65.00) 160 (58.61) 0 (0.00)
nonvascular
unsuccessful operations performed by less-experienced sur-
injury geons on patients with war-related vascular injury.6-12,14,15,17
Mechanism of Injury
Having less-experienced surgeons with limited vascular expe-
Gunshot injury 66 (47.14) 99 (36.26) 0 (0.00)
rience manage complex war-related trauma was felt to con-
Explosive injury 74 (52.86) 10 (3.66) 0 (0.00)
tribute to the higher amputation rate (19%) in some studies
Blunt injury* 0 (0.00) 102 (37.36) 0 (0.00)
from this region.6-12,14,15,17 In the fourth part of this chapter,
Stab injury† 0 (0.00) 62 (22.42) 0 (0.00)
some of the shortfalls associated with inadequate primary
Diagnostic 0 (0.00) 0 (0.00) 90 (73.8)
procedures during the management of vascular trauma will
procedure be presented.
Therapeutic 0 (0.00) 0 (0.00) 32 (26.2)
procedure Region-Specific Considerations
Type of Arterial Injury for Diagnosis
Laceration 29 (19.46) 62 (20.74) 42 (29.58)
Transection 55 (36.91) 115 (38.46) 3 (2.11) One challenge that both general and vascular surgeons
Contusion 30 (20.13) 70 (23.41) 0 (0.00) encounter is how to recognize and diagnose vascular trauma
False aneurysm 18 (12.1) 29 (9.7) 49 (34.5) in the absence of the so called “hard signs” of injured vessels.
AVF [pe] 17 (11.41) 23 (7.7) 7 (4.93) As an example, a significant vascular injury can often hide
Dissection 0 (0.00) 0 (0.00) 3 (2.11) underneath what appears to be a minor surface wound (Fig.
Thrombosis 0 (0.00) 0 (0.00) 36 (25.35) 30-1). The diagnostic algorithm shown in Figure 30-2 is used
Foreign body 0 (0.00) 0 (0.00) 9 (6.33) to assess penetrating extremity wounds in our region. Within
Anatomic Site of Arterial Injury
this algorithm, contrast angiography and duplex ultrasonog-
Carotid 0 (0.00) 0 (0.00) 4 (2.8)
raphy are used commonly in cases with “soft signs” of vascular
Vertebral 0 (0.00) 0 (0.00) 2 (1.4)
injury.21 In this context, soft signs are as follows: history of
Subclavian 0 (0.00) 1 (0.37) 0 (0.00)
significant bleeding, diminished distal pulses, small nonex-
Axillar/Brachial 27 (18.75) 70 (25.64) 14 (9.8)
panding hematoma, injury to anatomically related nerve, and
Radial/Ulnar 3 (2.09) 16 (5.86) 2 (1.4)
anatomic proximity of wound to a major vessels. Patients who
Iliac 0 (0.00) 0 (0.00) 18 (12.7)
are hypotensive and have “hard signs” of vascular injury
Femoral 54 (37.5) 94 (34.43) 97 (68.3)
require immediate surgical exploration without additional
Popliteal 45 (31.25) 82 (30.04) 2 (1.4)
diagnostic procedures. In this context, hard signs are as
Crural 15 (10.42) 12 (4.4) 0 (0.00)
follows: acute limb ischemia, absent distal pulses, arterial
bleeding, expanding hematoma, and the presence of a thrill or
AVF, Arteriovenous fistula. murmur.21 It is the author’s preference to perform angiogra-
*Includes traffic and industrial trauma. phy in stable patients with “hard signs” of vascular injury if
†
Includes cut injuries and bite injuries.
they are hemodynamically normal (Fig. 30-2).
Angiography confirms the presence of vascular injury, but
it also provides useful details about the injury location, sever-
of the wagon and the neighing of horses and still smell the ity, and complexity. The angiographic finding, which is some-
stench of gangrenous limbs.”18 times unusual and interesting, may also help guide the
During the 20th century, the transport of the injured has operative approach and type of vascular repair (Fig. 30-3). The
significantly improved in terms of speed and efficiency, from more sophisticated diagnostic procedures such as computed
around 12 hours during the World War II, to only 1 or 2 hours tomography (CT) with or without contrast and magnetic
in Vietnam.19 In the most developed countries with good resonance imaging (MRI) are used sparingly in Serbia and the
emergency services practicing “scoop and run” tactics, the Western Balkans and are typically reserved for complex cases
transportation of the injured is now only 30 to 45 minutes.20 in stabile patients.
 30  /  Europe: Serbia 311

FIGURE 30-1  What appears to

be (A) a minor surface gunshot
wound to the thigh (arrow) is
hiding (B) an arteriovenous fistula
between the common femoral A B
artery and vein.

Penetrating wound of the extremities

“Hard signs” of “Soft signs” of

vascular injury26 vascular injury26

Hemodynamically Hemodynamically
stable patient unstable patient Duplex or angiography

Angiography With vascular Without vascular

inury inury

Vascular Immediate surgical Vascular Observation

reconstruction exploration reconstruction

FIGURE 30-2  Algorithm guiding investigation and management of the patient with a penetrating injury and possible vascular involvement.22

Region-Specific Treatment Strategies Table 30-2 Method or Type of Arterial

Analysis of the study of 448 peripheral arterial injuries pro- Reconstruction
vides insight regarding the most common operative proce- War Civil Iatrogenic
dures for vascular trauma in our region Table 30-2).17 Primary Injuries Injuries Injuries
amputation was performed in only 3% of cases, most com- No. (%) No. (%) No. (%)
monly due to irreversible ischemia or extensive tissue damage.
Total injuries 140 273 142
Interposition or bypass graft replacement of the injured arte-
rial segment was the most common reconstructive procedure Type of Arterial Reconstruction
in both the wartime (68%) and the civilian (60%) cohorts. On Suture/patch 18 (12.85) 39 (14. 29) 85 (59.86)
the other hand, the majority of iatrogenic arterial injuries End-to-end 20 (14.28) 56 (20.51) 4 (2.82)
anastomosis
(60%) were repaired with direct or primary suture closure or
Graft 95 (67.86) 163 (59.7) 26 (15.49)
with patch angioplasty. Generally, repair of wartime and civil- interposition;
ian injuries required more complex procedures compared to bypass
those needed for iatrogenic injuries. Ligature 7 (5.00) 17 (6.23) 5 (3.52)
In the cases in which vascular conduit was required, autolo- Thrombectomy 0 (0.00) 0 (0.00) 22 (15.5)
gous vein graft (preferably contralateral saphenous vein) was Early Results
used in 54% of cases. In contrast, prosthetic conduit such as Mortality rate 1 (0.7) 10 (3.7) 8 (5.7)
Dacron or polytetrafluoroethylene (PTFE) was used in only Amputation rate 25 (17.9) 20 (7.3) 2 (1.75)
7% of wartime and civilian injury cases. Arterial ligature was
312 SECTION 5  /  INTERNATIONAL PERSPECTIVES

FIGURE 30-3  A, The hemodynamically significant steno-

sis (arrows) after injured superficial femoral artery repair
with saphenous vein graft. B, The remaining distal arterial
A B thrombosis (arrow) after adequately performed proximal
reconstruction of the injured popliteal artery.

also uncommon (5% of war-related injuries; 6% of civilian Table 30-3 Statistical Analysis of Factors
injuries; 4% of iatrogenic injuries) and performed only in Associated With Limb Loss
cases of injury to the deep femoral artery, to its branches, or
to the tibial (crural) arteries. In cases in which ligation was Univariate Multivariate
Variable Analysis* (p) Analysis† (p)
performed, the extremity was assessed before and after the
procedure to make sure there were minor signs or no signs of Failed revascularization <0.01 0.0000
limb ischemia (Fig. 30-2). Other important variables one Associated injuries <0.01 0.0013
should consider in relation to repair of vascular trauma Secondary operation <0.01 0.0075
include the duration of limb ischemia, the choice of vascular Explosive injury <0.01 NS
reconstruction and conduit, and the treatment of any associ- War injury <0.01 NS
ated vein injury. Arterial contusion <0.05 NS
The common nature of motor vehicle crashes in Serbia and Popliteal artery injury <0.05 NS
other Western Balkan countries combined with the limitations Surgery >6 hours from injury <0.05 NS
of local and regional ambulance services resulted in delayed
From Mubarak SJ, Hargens AR: Acute compartment syndromes. Surg
transfer, evaluation, and revascularization of many extremity Clin North Am 63:539–565, 1983.
vascular injuries. If revascularization was pursued in these NS, Nonsignificant.
cases, it often resulted in reperfusion injury including necrosis *Chi-square test and one-way ANOVA on 54 variables.
†
of skeletal muscle and peripheral nerve. Like others, the Logistic regression analysis on eight variables.
authors observe that reperfusion of an extremity following a
prolonged period of ischemia (greater than 6 hours) often
leads to compartment syndrome, regional pain syndrome, dis- injuries to result in debilitating joint contractures or signifi-
abling efferent neuralgia, and in some cases amputation.23 Leg cant edema. The treatment of such conditions is challenging
fasciotomy to prevent or treat compartment syndrome was and includes orthopedic procedures and other long-term
performed in 30% of the war and civilian vascular injuries postoperative physical therapy strategies, along with manage-
managed in the author’s experience.17 In vascular reconstruc- ment of the vascular injury itself.
tions performed outside of specialized centers, the fasciotomy Table 30-3 shows an analysis of factors associated with limb
was often inadequate and did not release all four compart- loss after surgical repair of 448 war-related and civilian vascu-
ments of the leg.23 Another phenomenon observed in the lar injuries.17 In this report 54 preoperative and perioperative
weeks and months after a traumatic extremity injury is chronic variables were analyzed. Univariate analysis identified the fol-
false aneurysms (i.e., traumatic pseudoaneurysms) and/or lowing eight factors associated with a higher risk of amputa-
arteriovenous fistula. These vascular injuries were initiated at tion: (1) failed revascularization, (2) associated injuries, (3)
the time of the trauma but did not manifest until later. In secondary operation, (4) explosive mechanism, (5) wartime
some cases, the author has observed these chronic vascular setting, (6) arterial contusion and thrombosis on exploration,

(7) popliteal artery injury, and (8) an operation performed
more than 6 hours after injury. However, the only variables
identified as independent risk factors for amputation on mul-
tivariate analysis were failed revascularization, associated inju-
ries, and secondary operation.17 Further analysis in this study
described the various challenges associated with managing
vascular trauma in Serbia and the West Balkan region.
Explosive and high velocity bullet injuries were often
associated with bone fracture as well as with vascular
damage.8-10,24-26 The treatment of complex injuries requires
combined and often multidisciplinary procedures (e.g.,
general, orthopedic, and vascular surgery). A clinical scenario
that presents several questions or challenges is that of an
extremity with a combined long bone and vascular injury. In
this case, what should be repaired first—the injured artery or
the fractured bone? If one opts for preventing hemorrhage
and prolonged ischemia, the artery should be repaired first.
However, it is acknowledged that secondary movement
of bone fragments and placing the extremity in traction
might compromise or even disrupt any preceding vascular
repair.6-10,12,14,17 Like others around the world, the authors have
found utility in the use of temporary vascular shunts in this
scenario to reduce the ischemic time.22 Using this approach,
the temporary intraluminal shunt is placed after proximal and
distal control of the injured vascular segment is gained, allow-
ing for restoration of perfusion. With the shunt in place, the
extremity is formally reduced and the fracture is repaired.
Once this is accomplished, the injured vascular segment is
again explored, the shunt is removed, and the vascular repair
is performed.
The best choice for vascular repair is the simplest method
that can be used to achieve a technically excellent result. In
cases where the injury is limited and where there has been no
loss of vessel length, lateral suture repair or an end-to-end
anastomosis may be best. However, these simple methods can
be used only in cases when the defect in the vessel is minor.
For instance, the ends of the injured common and superficial
femoral arteries can be mobilized only for a length of 1 cm to
2 cm. As such, lateral repair or primary end-to-end anastomo-
sis of this and similar vascular segments is rarely possible after
complex injuries.6-15,17,19,23-29 In more complex injuries, or in
those in which some amount of length has been lost in the
injured vascular segment, the use of an interposition or bypass
conduit will be necessary.6-15,17,19,23-29 Many technical problems
or complications have been observed after attempts at primary
repair to a vessel with too severe an injury, often due to a flow-
limiting stenosis that results in thrombosis. Primary repair is
especially difficult if the vessel is small or where there is vaso-
spasm from the injury. To reduce the chances of complica-
tions, it is imperative that the surgeon is able to clearly see the
vessel wall and the spatial relationship of the segment(s). The
author suggests using the well-known Carell triangulated
suture or oblique technique to improve visualization and
suture spacing during the repair of smaller vessels.30
The author has also found it important to be mindful of
and to remove distal arterial thrombi before performing
reconstruction of an injured vascular segment. Failure to
perform proximal and distal thrombectomy compromises
inflow and outflow and ultimately leads to failure of the vas-
cular repair.10,12,17 To prevent this, the author uses a Fogarty
thromboembolectomy catheter to remove the clot after
proximal and distal control have been gained on the injured
30  /  Europe: Serbia 313
segment, and then again before flow is restored at the end of
the vascular repair. Back-bleeding from the distal arterial
segment and vigorous inflow from the proximal segment indi-
cate successful technique. Inadequate débridement of an
injured arterial segment before repair can also lead to compli-
cations such as thrombosis or anastomotic disruption. The
author has found that abundant resection of the vessel is
necessary in cases of complex or extensive injury, to ensure
that the suture repair is placed on normal and uninjured
vessel. Incorporation of an unresected portion of contused or
injured artery into the repair has been the origin of failure in
many cases (Fig. 30-3).12,17
In cases of highly contaminated or complex soft-tissue
wounds an in-situ or anatomic reconstruction of an injured
artery may not be advisable. In this scenario, repair of the
injured vessel with primary techniques—or an interposition
or bypass conduit—may even be dangerous because infection
can lead to disruption of the repair. Anastomotic disruption
and hemorrhage resulting from a contaminated or infected
wound is a devastating complication and is associated with
high rates of amputation and even mortality.10,12,17 Using a
conduit routed out of the zone of injury in an extraanatomic
fashion is best for these select complex cases of upper and
lower extremity vascular trauma (Fig. 30-4).
The repair of associated vein injuries is controversial.
Venous repair improves the patency of repaired artery and also
minimizes swelling of the extremity, compartment syndrome,
and potential long-term complications related to venous
outflow obstruction. The only proven benefit of venous liga-
tion is reduced operating time. For these reasons, the author
pursues a strategy of selective vein repair. When possible and
when the patient has good physiology and is hemodynami-
cally normal, larger or proximal veins in watershed areas such
as the popliteal, common femoral, and iliac locations should
be repaired.10-12,14,15,17 Large and midsized veins may be repaired
with panel or spiral venous grafts, or with interposition grafts
with autologous nonreversed saphenous vein according to
vessel caliber.31
The type of material used to repair vascular trauma can be
autologous or prosthetic. The author’s preferred conduit is
autologous saphenous vein from the uninjured lower extrem-
ity. The author does not prefer to use synthetic grafts such
as PTFE or Dacron in the setting of trauma because of con-
cerns for a higher incidence of infection associated with their
use.10-12,14,17,25 However, prosthetic grafts may be necessary in
some select cases if there is no saphenous vein available or if
there is no time to harvest the saphenous vein. Prosthetic
grafts are suitable for extraanatomic bypass outside of the
zone of injury and crossover reconstruction of an injured iliac
vessel. According to the literature and the author’s experience,
the incidence of infection following repair of vascular trauma
is higher in the wartime scenario than with civilian or iatro-
genic trauma.5-17 In the author’s experience, these historic
trends may not hold true today as many civilian vascular
injuries are associated with significant soft-tissue loss and may
be followed by infection. As referenced earlier, the develop-
ment of an infection in an area where there is a patent vascular
repair increases the risk of amputation.12 Because of this, steps
to reduce the likelihood of infection (i.e., prevention) are very
important and include adequate débridement and irrigation
of the soft-tissue wound and avoiding primary skin closure in
cases of soft-tissue loss or contamination.
314 SECTION 5  /  INTERNATIONAL PERSPECTIVES
A B
Endovascular Repair
of Vascular Trauma
Regarding endovascular treatment of vascular trauma in
Serbia, there are three different problems and questions. The
first (not only for Serbia) is that there are no long-term results
to show efficacy and durability of endovascular therapy of
vascular injuries. The second challenge relates to the relatively
late uptake of endovascular techniques—the Serbia program
begun in 200732—caused by fact that the Yugoslavian Civil
War and the political and economic crises that it spawned
happened during the same decade or more that the endovas-
cular revolution occurred around the rest of the world. The
third challenge is specific for all developing countries. Cur-
rently 9% of the gross domestic product (GDP) of Serbia is
invested in our National Health Care System, a figure compa-
rable to developed countries. However, the GDP in Serbia is
lower than that of developed European countries; and, because
of that, innovative and costly medical procedures—including
endovascular surgery—are being taken up slowly in Serbia.
The organization of the health system in Serbia also limits the
development of endovascular therapy because it is universal
in nature and publicly funded by general taxation. While this
provides universal coverage to all members of society it does
not easily accommodate costly techniques and devices with yet
unproven long-term efficacy.
Because of these facts, endovascular therapy for vascular
trauma in Serbia is used only for select, critically injured
patients with certain complex injuries. For example, endovas-
cular therapy for blunt aortic injury is possible in some cases.
In these instances, guidelines are used to determine whether
or not endografting should be considered. Most commonly,
hemodynamically stable patients each with an isolated aortic
FIGURE 30-4  A, The in-situ bypass performed due to a complex
popliteal artery injury. B, An extra-anatomic procedure at the
upper limb at patient with injured brachial artery with massive
soft-tissue damage and lost.
injury and who are younger than 65 and who are candidates
for open surgery will receive traditional open repair. In con-
trast, patients with polytrauma, those who are older than 65
(i.e., poor candidates for open operation), or those who are
hemodynamically unstable will be considered for treatment
with a thoracic aortic stent-graft.32 Aside from blunt aortic
injury the vast majority of vascular trauma cases require an
open surgical approach. Although the number of different
endovascular procedures is increasing, it remains very impor-
tant for young surgeons to gain and to maintain experiences
in open procedures for vascular trauma.
In Belgrade, education in vascular surgery is now an inde-
pendent specialization that lasts 6 years. Out of those years, 2
are spent in general-surgery training and 4 in vascular-surgery
training. The vascular component consists of 3 years of open
vascular surgery training, while 1 year is spent focusing on
catheter-based endovascular approaches. Furthermore, due to
the previously mentioned limited budget, 75% of the vascular
procedures in Serbia are performed using open methods,
whereas only 25% are performed using endovascular
approaches. While this ratio may seem paradoxical in this
modern endovascular era, young vascular surgeons in Serbia
have no issues or limitations in performing open vascular
procedures, including those required to manage vascular
trauma.
REFERENCES
1. Schwartz A: The historical development of methods of hemostasis.
Surgery 44:604, 1958.
2. Subbotitc V: Military experiences of traumatic aneurysms. Lancet 2:720–
721, 1913.
3. Matas R: The surgery of the arterial system. In International congress of
medicine, section VII: surgery, part II, 1913-1914, London, 1914, Oxford
University Press.

4. Rich N, Clagett P, Salander JM, et al: The Matas/Soubbotitch connection.
Surgery 93(1):17–19, 1983.
5. Fingerhut A, Lappaniemi A, Androulakis G, et al: The European experi-
ence with vascular injuries. Surg Clin North Am 82(1):175–188, 2002.
6. Lovrić Z: Reconstruction of major arteries of extremity war injuries.
J Cardiovasc Surg (Torino) 34(1):33–37, 1993.
7. Lovrić Z, Wertheimer B, Candrić K, et al: War injuries of major extremity
vessels. J Trauma 36:248–251, 1994.
8. Radonic V, Baric D, Petricevic A, et al: Military injuries to the popliteal
vessels in Croatia. J Cardiovasc Surg (Torino) 35:27–32, 1994.
9. Radonic V, Baric D, Petricevic A, et al: War injuries of crural arteries.
Br J Surg 82:777–783, 1995.
10. Davidovic L, Lotina S, Kostic D, et al: Popliteal artery war injuries. Car-
diovasc Surg 5:37–41, 1997.
11. Davidovic L, Lotina S, Vojnovic B, et al: Post-traumatic AV fistulas and
pseudoaneurysms. J Cardiovasc Surg (Torino) 38:645–651, 1997.
12. Velinovic M, Davidovic L, Lotina S, et al: Complications of operative
treatment of injuries of peripheral arteries. Cardiovasc Surg 8:256–264,
2000.
13. Ilijevski N, Radak D, Radević B, et al: Emergency surgery of acute trau-
matic arteriovenous fistulas. Cardiovasc Surg 8(3):181–185, 2000.
14. Dragas M, Davidovic L, Kostic D, et al: Upper extremity arterial injuries:
factors influencing treatment outcome. Injury 40(8):815–819, 2008.
15. Marković M, Davidović L, Kuzmanović I, et al: Giant postraumatic pseu-
doaneurysm of the peroneal artery with arteriovenous fistula and fibular
notch. Am Surg 75(7):627–629, 2009.
16. Davidovic LB, Banzic I, Rich N, et al: False traumatic aneurysms and
arteriovenous fistulas: retrospective analysis. World J Surg 35(6):1378–
1386, 2011.
17. Davidovic L, Cinara I, Ille T, et al: Civil and war peripheral arterial
trauma: review of risk factors associated with limb loss. Vascular 13(3):
141–147, 2005.
30  /  Europe: Serbia 315
18. De Takats G: Vascular surgery in the war. War Med 3:291–296, 1943.
19. Neel S: Army aeromedical evacuation procedures in Vietnam. JAMA
204:99–103, 1968.
20. Demetriades D, Theodoru D, Murray J, et al: Mortality and prognostic
factors in penetrating injuries of the aorta. J Trauma 40:761–763, 1996.
21. Feliciano DV, Herskowitz K, O’Gorman RB, et al: Management of vascu-
lar injuries in the lower extremities. J Trauma 28:319, 1988.
22. Reber PU, Patel AG, Sapio NL, et al: Selective use of temporary intravas-
cular shunts in coincident vascular and orthopedic upper and lower limb
trauma. J Trauma 47:72, 1999.
23. Mubarak SJ, Hargens AR: Acute compartment syndromes. Surg Clin
North Am 63:539–565, 1983.
24. Fasal R, Irvine S, Zilla P: Vascular injuries caused by anti-personnel mines.
J Cardiovasc Surg (Torino) 30(1):467–472, 1989.
25. Sfeir RE, Khoury GS, Haddad FF, et al: The injury of the popliteal vessels:
the Lebanese War experience. World J Surg 16(6):1156–1159, 1992.
26. Sherif A: Vascular injuries: experience during the Afghanistan War. Int
Surg 77:114–117, 1992.
27. Frykberg ER: Popliteal vascular injuries. Surg Clin North Am 82(1):67–
89, 2002.
28. Clouse WD, Rasmussen TE, Perlstein J, et al: Upper Extremity vascular
injury: a current in-theater wartime report from Operation Iraqi
Freedom. Ann Vasc Surg 20:429–434, 2006.
29. Zellweger R, Hess F, Nicol A, et al: An analysis of 124 surgically managed
brachial artery injuries. Am J Surg 188:240–245, 2004.
30. Carrel A: The surgery of blood vessels. Johns Hopkins Med J 18:18, 1907.
31. Rich N, Baugh J, Hughes C: Acute arterial injuries in Vietnam:1000 cases.
J Trauma 10:359–369, 1970.
32. Davidović L, Končar I, Marković D, et al: Povrede grudne aorte i njenih
grana. Vojnosanit Pregl 68(3):257–265, 2011.
31  Vascular Trauma in Israel
AARON HOFFMAN, TONY KARRAM, AND SAMY NITECKI
Epidemiologic Considerations
Vascular trauma in Israel includes the usual myriad of causes
for vascular trauma as in other western societies. These include
blunt and penetrating mechanisms, road traffic accidents,
long bone fractures, and falls. Of note, more cases of iatro-
genic vascular trauma are recently being encountered. Para-
doxically, some of these are related to an increased use of
“minimally-invasive” and laparoscopic techniques and the
liberal use of angiography. On the other hand, vascular trauma
caused by criminal acts is less frequent in Israel than in some
western societies; but this type of trauma also seems to be
increasing recently. Above all of the regular civilian causes of
vascular trauma in Israel is the country’s great experience with
combat-related injury.
Israel is a small-sized western country of 7 million citizens
with a special geopolitical status (Fig. 31-1). It is surrounded
by hostile neighbors and constantly threatened by close and
remote enemies. Israel is actively engaged in daily defense acts
and periodic wars of small or large magnitude an average of
every 6 to 10 years. In the short period of time since the begin-
ning of the 21st century, Israel has suffered the wave of ter-
rorism of the Second Intifada of 2000-2005, the 2006 Lebanon
War, and the Cast Lead event of 2008, as well as multiple ter-
rorist attacks in between. In total, these clashes have caused
about 1500 deaths and 8000 casualties, mostly civilian. The
rate of vascular trauma among these casualties is relatively
high. Unfortunately, in the absence of peace agreements and
in the wake of major political changes now taking place in the
Middle East, more such events are expected.
During these types of hostilities, even civilian medical
centers (themselves treating casualties) have been targeted
both by suicide bombers and by short- and medium-range
rockets. In fact, all major Israeli hospitals are within the range
of missiles and rockets that are readily available to the sur-
rounding conflict countries and terrorist groups. Also, public
venues, buses, restaurants, and hotels are purposely targeted
by attackers to maximize casualties. Weapons are also designed
to increase destruction by using rockets containing high
explosives covered by thousands of pellets and other types of
fragments (Fig. 31-2). These rockets are mostly inaccurate but
may prove highly lethal if they happen to fall amid a crowd.
In one case in a railroad station, 8 civilians bled to death; and,
in another, 12 soldiers died mainly from bleeding vascular
injuries. Altogether Northern Israel was attacked by more than
4000 rockets from Lebanon in the 2006 war, and Southern
Israel was attacked by 2000 rockets from Gaza.
316
The threats to the security of the public are now so severe,
and the potential for use of weapons of mass destruction so
high, that Israel is preparing for more casualties in the future
including building shelters for mass casualties and building
underground fortified hospitals. A 1000-bed underground
emergency hospital has been built in the city of Tel Aviv, and
a 2000 bed sheltered hospital is being completed in Rambam
Health Care Center in the city of Haifa (Fig. 31-3). More such
facilities will be built in the future and integrated military and
civilian medical drills are conducted periodically to increase
preparedness.
Another consideration for the field of vascular trauma is
that the distances from the peripheral regions and front lines
to major hospitals are relatively short, and evacuations by
designated helicopters are preferred (Fig. 31-4). For example,
Rambam Health Care Center is less than 50 km from the
Lebanese border and less than 80 km from the Syrian border
(Fig. 31-1). These facts result in relatively brief evacuation
times and contribute to decreasing mortality and limb loss
from vascular trauma.
Incidence of Vascular Trauma
Vascular injuries are relatively uncommon but vary widely in
the civilian trauma experience, ranging from 0.6% of all
patients to 30% in specific injuries such as posterior knee
dislocation.1 In battlefield trauma, the reported incidence of
vascular injuries has been historically low with a range of only
0.2% to 4% of all injuries.2,3 This low incidence was probably
due, in part, to excessive mortality of vascular patients during
prolonged evacuation time and to limited treatment options.
In more-recent reports from the Iraq War this incidence
increased to 6.8%4,5 due to improved immediate resuscitation
and quick evacuation from the battleground. Even more so, in
our recent experience of the 2006 Lebanon War, the rate of
vascular trauma increased to 7.6% of all casualties and 10.8%
in the subgroup of soldiers only.6 Vascular injuries are mostly
caused by penetrating trauma due to penetrating fragments,
high-velocity bullets, and pellets (Fig. 31-2). Less frequently,
blunt trauma is the cause of vascular trauma. In modern
armies better torso protection of soldiers by advanced ceramic
armored vests is afforded. The use of torso body armor may
have increased the frequency of survivable extremity vascular
injury and may have led to recognition of what are referred to
as junctional vascular injuries (i.e., those between the torso
and the extremities). Almost half (46%) of all combat-related
vascular injuries affect the lower extremities, and almost a
 31  /  Vascular Trauma in Israel 316.e1

ABSTRACT
Vascular trauma is common in Israel, as it is in other western
societies; and it includes a variety of etiologies such as
traffic accidents, extremity fractures, falls, gunshot wounds
and, increasingly, iatrogenic causes. However, in addition
to the regular civilian pattern of vascular injuries, Israel is
involved in frequent armed conflicts; the civilian vascular
community has to care for military-type injuries, such as
penetrating wounds from bullets, from ball bearings, and
from other fragments and foreign bodies from explosive
devices. The Israeli experience in vascular trauma shows
that injuries may be caused by blunt trauma; but more
often they are the result of penetrating injuries and are the
main causes of severe bleeding, ischemia, disabilities,
amputations, and death. Vascular injuries take first priority
in treatment paradigms since shortening of the time of
bleeding and the time of ischemia are of paramount impor-
tance in saving limbs and lives of the injured. Identification
of the specific injured arteries and veins allows accurate
control of blood loss and allows appropriate repair of
vessels. Use of fasciotomies in this setting should be liberal
to prevent compartment syndrome and to improve func-
tional outcome. To lessen the risk of infection and throm-
bosis, primary repair of vessels and use of autologous vein
are preferred over the use of synthetic conduits. In the
battlefield and during evacuation, rubber and improvised
tourniquets are used to stop life-threatening bleeding; but
in the setting of the operating room these should be
removed as soon as possible to prevent continued ischemia
of nerves and other soft tissues. In the modern specialized
vascular facilities of Israel, the rate of success in repairs of
vascular injuries is high; and the amputation rate is low and
constantly continues to decrease. The mortality rate of
those who reach a surgical facility is near zero.

Key Words:  vascular trauma,

vascular surgery,
endovascular,
hemorrhage control,
shunt
 31  /  Vascular Trauma in Israel 317

Lebanon

Syria

10 20
Miles Haifa

Mediterranean Sea Israel

Jordan
Tel Aviv
Jerusalem
A

Gaza

Beer Sheva

Egypt

FIGURE 31-1  Map of Israel and its borders and surroundings. Level
I trauma and vascular centers are marked (Blue Star of David). Note
the limited distances from the frontlines to the major centers.
B
quarter affect the upper limbs. All grades of vascular injuries
are now encountered, better diagnosed, and better treated.
These range from small intimal flaps that do not require
immediate interventions, to bleeding sources that may be
stopped by catheter-based embolization, to complete transec-
tion of large vessels that are life threatening.
Evacuation Methods of Vascular Injuries
Rapid evacuation from the arena of injury to the nearest surgi-
cal facility is of utmost importance in vascular trauma. The
time factor is important both in reducing continued bleeding
and in reducing tissue ischemic time of the injured limb when
tourniquets are applied. Emergency evacuation should be
ordered otherwise mortality may ensue. Evacuation by heli-
copter is the most rapid method when the vascular facility is C
remote. However, ground vehicles may prove to be faster when
the arena is close.13 FIGURE 31-2  Shrapnel and pellets from a Grad-type rocket shot at
Rambam Health Care Campus from Lebanon during the 2006 Lebanon
War. Each rocket warhead contains thousands of pellets to maximize
Israeli Vascular System of Care injuries. A, Shrapnel. B, A road sign. C, A shelled hospital.

The organization of the area of vascular trauma in Israel

should be put in the complex context as described earlier.
Specialized vascular units and trained vascular surgeons are
present in almost all public hospitals in Israel, and all are ready
to provide 24-7 immediate vascular care as part of their daily
routine. However, at times of major armed conflicts most
evacuations are designated to go to Level I trauma and vascu-
lar centers. There is one such center in the north of Israel,
three in the populated center of the country, one in Jerusalem,
and one in the south (Fig. 31-1). During such events military
medical officers, using mainly airborne evacuation, take
responsibility for organizing and setting priorities of evacua-
tion (Fig. 31-4).
There is close contact and good collaboration between
trauma and vascular specialists within these Level I trauma
centers to allow the best approach and outcome for those with
vascular injury. This collaboration is of utmost importance in
318 SECTION 5  /  INTERNATIONAL PERSPECTIVES

B
FIGURE 31-4  Evacuation of casualties from the frontlines to Rambam
B Health Care Center during armed conflicts. A, The airborne transpor-
tation by helicopters to a landing pad on the seashore is a well-
FIGURE 31-3  Rambam Health Care Center and Technion Faculty of organized routine. B, Ambulances are usually used for evacuation of
Medicine under fire. Three rockets are seen hitting the water near closer locations.
campus (red circles). Altogether 60 rockets hit within a short distance
of the hospital. A, The shelled campus. B, The shelled Faculty of
Medicine building.

complex cases of shock, multiple system injuries, and mangled

extremities. Vascular repairs are always done by a qualified
vascular surgeon (Fig. 31-5).

Considerations for Diagnosis

Physical examination is the mainstay for the diagnosis of vas-
cular injuries. Classical “hard signs” include active hemor-
rhage; large, expanding, or pulsatile hematoma; palpable thrill
or audible bruit; and distal ischemia (with the well-known 6
Ps: pain, paralysis, paresthesias, pallor, pulselessness, and poi-
kilothermy). Precise identification of vascular trauma is of
utmost importance for the success of treatment. However, in
complex modern vascular injuries with multiple penetrating
wounds, the exact extent, severity, and location of the injury
are not always straightforward. High quality vascular imaging
helps to identify such injuries (Fig. 31-6). In other cases,
imaging may exclude significant injuries, especially in patients FIGURE 31-5  A multidisciplinary team works on a near-amputation
with hypovolemic shock, large hematomas, and large bone injury. Vascular surgeons, together with orthopedic and plastic sur-
fractures. In these cases an unnecessary exploration may be geons, managed to save this limb.
 31  /  Vascular Trauma in Israel 319

A B
FIGURE 31-6  Hundreds of penetrating shrapnel and pellet injuries in one patient. CT angiography (CTA) identifies with accuracy the location
of a single vascular injury in the left superficial femoral artery. A, Skin artery penetrations. B, A shrapnel shower.

A B
FIGURE 31-7  A carotid artery injury by a ball pellet. A large pseudoaneurysm compressing the trachea identified in a peripheral hospital by
CTA and 3-D reconstruction. A, Neck CTA. B, Neck reconstruction.

avoided. Vascular duplex scanning in trauma is seldom used
in Israel since this modality is observer dependent, has low
specificity, and is time consuming.
The routine use of old gold-standard angiography is no
longer indicated because of its time consumption, which may
spans hours; its risks; and its inherent inaccuracies, including
a 15% false negative rate.7,8 Instead, multislice CT angiography
(CTA) with rapid reconstruction is our preferred method of
imaging in all cases of vascular trauma.9,10 CTA is rapid, accu-
rate, and provides additional information such as size of
hematoma, presence of unexpected periarterial hematoma,
bone fragment compression, additional injuries, proximity of
penetrating fragments, and additional detail (Fig. 31-7). All
vascular centers in Israel are well equipped with modern mul-
tislice CT scanners. The use of angiography in vascular trauma
is reserved for only therapeutic interventions like emboliza-
tion, use of covered stents when indicated, and closure of
traumatic arteriovenous fistulas.
Treatment Strategies
In vascular trauma the goal of treatment is twofold: first, to
stop continued bleeding to prevent possible mortality; then,
second, to restore flow to and to revascularize ischemic tissues.
Speed is an important factor since irreversible damage may
result within 6 hours or less in the setting of shock.
Hemorrhage Control
Patients with limb vascular trauma are frequently saved from
exsanguination by liberal use of rubber tourniquets that are
available to all paramedics and to almost every soldier in the
battlefield. Improvised tourniquets are seldom needed (Fig.
31-8). Local prolonged hand pressure to stop bleeding is used
only temporarily until a tourniquet can be applied. Specialized
compression devices are under investigation but are not yet in
practice. The liberal use of tourniquets and prompt removal
on arrival at the hospital seem to save lives without the serious
side effects of secondary ischemia or nerve injury.
Extremity vascular injuries were associated with an approx-
imate 9% to 10% mortality rate due to exsanguination. Tour-
niquets are the basic equipment of every medical team in
Israel to control both civilian and battlefield hemorrhage.
Proper use of tourniquets may indeed save lives. However,
unnecessary or prolonged use may result in limb ischemia and
paralysis, which may lead to amputation. Moreover, improper
use may not stop the bleeding. Tourniquets were utilized in
320 SECTION 5  /  INTERNATIONAL PERSPECTIVES
FIGURE 31-8  Tourniquets and compression dressings are used fre-
quently in the field to stop bleeding. These should be placed close to
the injury site and should be removed as soon as possible to minimize
secondary ischemic damage.
3% to 8% of extremity injuries in Iraq. In the Israeli Defense
Force every soldier has access to a tourniquet that can be used
when necessary, even without the presence of a medical team.
In our 2006 Lebanon War experience, tourniquets were liber-
ally used in 39% of extremity vascular injuries and were
removed only in the operating room.6 Tourniquets were ben-
eficial in 11 patients and overused (abused) in 2 patients
without adverse effects. In a recent publication, 8 tourniquets
were used at Kandahar Airfield Base: 5 saved lives, 1 was
misused, and 1 overused.11 Prehospital tourniquet use in
Operation Iraqi Freedom was associated with improved hem-
orrhage control without adverse outcomes related to its use.12
These findings support liberal use of tourniquets and refute
the policy of their utilization as a last-resort option.
Triage in the Emergency Room
Vascular injuries take priority in treatment paradigms since
shortening the time of bleeding and ischemia are of para-
mount importance in saving lives and limbs of the injured.
When a vascular injury is identified, the patient is rushed to
the operating room without delay. When such injuries are
suspected by physical examination but are not certain, then
vascular imaging is required. A simple hand-held Doppler
apparatus is very helpful in identifying arterial flow in the
dorsalis pedis or the tibialis posterior arteries, especially in
patients with vasospasm from hypothermia or reduced blood
pressure. Sophisticated duplex ultrasound machines have yet
to prove efficacy in the treatment algorithm of the suspected
vascular injury.
Priority in the Operating Room
The first priority in the operating room is controlling blood
loss. If tourniquets are still applied, they should be released as
soon as possible under controlled conditions. If bleeding
resumes, direct pressure is applied on the point of bleeding;
and proximal control of the artery is gained. Distal control is
also required to reduce bleeding. Then the injured segment of
the vessel is approached and repair is started by standard
vascular methods. If the patient is successfully stabilized with
Suture Graft Anastomosis
B
FIGURE 31-9  Methods of vascular repair. A, Minimal débridement
and clean, simple sutures without tension or strictures allow fast
revascularization. When end-to-end anastomoses or interposition
grafts are used, care should be taken to avoid constriction. B, Consider
leaving a “growth factor”—bringing down the ties a short distance
from the wall to allow adaptation and dilation to the proper diameter.
no more bleeding, we use intravenous heparin to avoid sec-
ondary thrombosis of the injured blood vessels. Only after
bleeding is stopped and revascularization is secured are other
necessary fixations and repairs undertaken. Intensive care unit
is recommended for 24 hours following surgery due to hypo-
volemic shock, reperfusion injury, hypothermia, and bleeding
diathesis.
Methods of Vascular Repair Employed
Simple repair of injured blood vessels is preferred (Fig. 31-9).
Lateral suture and end-to-end anastomosis when possible are
rapid and effective with few complications. Venous interposi-
tions and bypasses are used when a longer arterial segment is
injured. Synthetic bypasses should be avoided if possible. All
vascular repairs should be well covered by viable clean tissue
to prevent late infection and bleeding. In our recent experi-
ence, interposition venous grafts were used in 38% of cases,
end-to-end anastomosis in 23%, and lateral repair or patch in
16%; whereas primary ligation was reserved for small arteries
and for veins (8%). Extraanatomic bypasses are rarely required
(Fig. 31-10).
Endovascular Methods
Endovascular repairs of arterial injuries by covered stents are
sometimes abused as simple repairs may be as effective and
less likely to be complicated by infection. However, in one
specific type of injury, namely thoracic aortic injury, stent-
grafts seem to be superior to open repair (Fig. 31-11). The use
of endovascular methods in combat injuries is still rare
although more cases were treated in recent combat events. In

our experience, an open approach to extremity vascular injury
is more direct, expeditious, and effective than any endovascu-
lar treatments. In contrast, select patterns of torso vascular
injury may be better treated with endovascular methods if
they are available. Covered stents are seldom used except in
relatively inaccessible segments such as the descending tho-
racic aorta and the subclavian artery. In the recent 2006 con-
flict, we used covered stents for limb vascular trauma only in
one subclavian artery injury (Fig. 31-12). In 13% of recent
cases we used endovascular methods for hemorrhage control,
either embolization or balloon occlusion. We have used other
endovascular methods selectively in vessels such as the iliac
arteries and veins (Fig. 31-13).
Compartment Syndrome and Fasciotomy
Four compartment fasciotomy of the leg proved to be effective
in limb salvage after ischemia reperfusion (Fig. 31-14). When
in doubt, prophylactic fasciotomy should be performed every
time. Exact measurement of the compartment pressure is
seldom helpful. Classic indications for prophylactic fasciot-
FIGURE 31-10  Complex vascular repairs may include venous inter-
position grafts to arteries and veins, as well as repair of nerves when
necessary. Immediate reconstructions of neurovascular injuries proved
effective in saving many limbs.
A B
FIGURE 31-12  Right subclavian artery blast injury treated endovascularly by a covered stent. This method was preferred here because of the
relative inaccessibility of this artery.
31  /  Vascular Trauma in Israel 321
omy are prolonged limb ischemic time (more than 6 hours),
a combined arterial and venous injury, and a massive soft
tissue injury (i.e., crush).14-16 However, compartment syn-
drome may also develop even after short periods of ischemia,
especially in patients with a venous injury or in those having
undergone a large fluid resuscitation. Clinical judgment is
preferred and in most cases there is no need to measure
compartment pressures. The aim is to prevent compartment
syndrome from happening rather than to treat it once it is
diagnosed, resulting in an irreversible neuronal damage.14 If
fasciotomy is not done immediately, treatment with intrave-
nous hypertonic mannitol is often considered to prevent the
later development of a compartment syndrome.17,18
Fasciotomy as a treatment for compartment syndrome
should be performed on the following clinical grounds: pain,
FIGURE 31-11  Aortic wall tear distal to the origin of the left subcla-
vian artery caused by deceleration mechanism. Simple tube stent-
grafts in this specific position proved to be superior to complex open
repair.
322 SECTION 5  /  INTERNATIONAL PERSPECTIVES

edema, and paresthesia. Once compartment syndrome is

diagnosed, fasciotomy is an urgent procedure for limb
salvage.14-16 It should be noted that 78% of our patients with
combat-sustained extremity vascular trauma underwent fas-
ciotomy, similar to the results of the U.S. and U.K. militaries
in Iraq.6
Venous Injury
Arterial injuries of the extremities are manifested by life-
threatening hemorrhage or ischemia resulting in limb loss. In
sharp contrast, severe venous trauma is manifested by hemor-
rhage but not ischemia. Bleeding may be internal or external
and rarely may lead to hypovolemic shock. Unlike arterial
injury, repair of major extremity veins has been a subject of
controversy18-20 and the current teaching is to avoid venous
repair in an unstable or multitrauma patient. Our experience
in the 2006 Lebanon War leads to preference of venous repair
over ligation, even when an interposition graft rather than
simple repair is needed.21 In the past, distal arteriovenous
fistulae were added to increase flow but their benefits have not
FIGURE 31-13  Bilateral iliac artery to iliac vein arteriovenous fistulas been proven. The thrombosis rate of injured veins may be
caused by pellets. These were sequentially treated by a combination high, but secondary interventions are seldom indicated.
of embolization methods and glues using simultaneous artery and
vein access.
Rather, prolonged anticoagulation may be considered and
postphlebitic syndromes expected in the future.
External Temporary Shunt
The use of temporary vascular shunts is still controversial in
the literature. Eger et al from Israel were among the first
reporting on the use of temporary vascular shunts in the
Anterior compartment modern era.22 Although ischemia to an extremity has a lower
treatment priority than massive hemorrhage, a temporary
shunt may be inserted quickly. The shunt serves for temporary
Tibia revascularization by restoring blood flow to the leg, thereby
Incision
reducing the ischemic time until the shunt can be removed at
the time of definitive vascular repair. Recent studies in animal
Incision
models have confirmed a physiologic beneficial effect of tem-
Lateral
compartment porary vascular shunts.23-27 Early shunting protects the extrem-
ity from further ischemic insult and reduces circulating
Fibula markers of tissue injury. In our experience, shunts were used
Deep mainly in very unstable fractures and in complex injuries
compartment requiring multidisciplinary teamwork for reconstructions.
A Posterior compartment Amputation
Among the major vascular risk factors for limb amputation
are Injury Severity Score (ISS), Mangled Extremity Severity
Score (MESS), and ischemia of longer than 6 hours. In our
experience, amputation rates may reach 50% in rare cases
when the ischemia time is 12 hours or more or in cases of a
combined injury of both the popliteal artery and vein with
failed vascular reconstruction. Amputation rates due to vas-
cular injuries have decreased over time: from 60% in World
War II, to 12% in Vietnam, to 9% in Iraq, to 5% in Ireland,
and to only 2% in Israel.21 The continued improvement of
results seem to be due to multiple factors like a high index of
suspicion for vascular injury, better imaging techniques, and
a quick and meticulous intervention that is performed by
experienced vascular specialists in a multidisciplinary team.
B
Late Complications
FIGURE 31-14 Large, open fasciotomies are done as the first steps
of operations on traumatized ischemic limbs to prevent additional
Longer-term complications after vascular trauma are rare.
damage from compartment syndrome. Plastic surgery or skin graft to Thrombotic occlusions of autologous vascular repairs are
close the wound is done within a week. almost unseen but occlusions of repairs using synthetic grafts

do occur. In our experience these events are responsive to
thrombolytic therapies, similar to occluded bypasses per-
formed for age-related peripheral vascular disease. Late
detected pseudoaneurysms and arteriovenous fistulas can be
successfully treated by the usual repertoire of surgical or endo-
vascular methods. Late or secondary amputations of previ-
ously traumatized extremities with vascular repair can happen
and are usually performed for neurologic reasons such as
intractable pain or a denervated, functionless limb.
Mortality from Vascular Injuries
The real mortality rate due to vascular trauma in the field is
unknown since postmortem studies are rarely performed in
Israel. However, the mortality of those patients who survive
to reach Level I trauma centers is now very low. In the 1982
Lebanon War casualties, the mortality rate was 1%; and in the
2006 Lebanon War, the mortality was 0%.6
Prospects for the Future
There seems to be a disturbing gap between the expected
numbers of vascular casualties in the future and the number
of available trained vascular surgeons. Recently there has been
a decline in the numbers of applicants for training in vascular
surgery in Israel, in spite of major changes in requirements for
specialization. These changes include shortening of the surgi-
cal training period to only 6 years, shortening of the time
spent in general surgery, the addition of time in endovascular
training, and less on-call time. If this trend continues, a dan-
gerous shortage of vascular surgeons in the country may
ensue. Solutions for this problem are urgently needed.
Conclusions
In the recent Israeli vascular experience, a high rate of patient
and limb salvage has been achieved, in spite of prolonged
evacuation time. A high index of suspicion and awareness for
possible vascular injuries, a liberal use of CTA for diagnosis,
and quick and meticulous definite vascular intervention
within a multidisciplinary team allow these good results.
REFERENCES
1. Barmparas G, Inaba K, et al: Pediatric vs adult vascular trauma: a national
trauma databank review. J Pediatr Surg 45:1404–1412, 2010.
2. DeBakey ME, Simeone FA: Battle injuries in World War II: an analysis of
2,471 cases. Ann Surg 123:534–579, 1946.
3. Rich NM, Hughes CW: Vietnam vascular registry: a preliminary report.
Surgery 62:218–226, 1969.
4. Clouse WD, Rasmussen TE, Peck MA, et al: In-theater management of
vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg
204:625–632, 2007.
31  /  Vascular Trauma in Israel 323
5. Starnes BW, Beekley AC, Sebesta JA, et al: Extremity injuries on the battle-
field: tips for surgeons deploying to war. J Trauma 60:432–442, 2006.
6. Nitecki SS, Karram T, Ofer A, et al: Vascular injuries in an urban combat
setting: experience from the 2006 Lebanon War. Vascular 18:1–8, 2010.
7. Miller-Thomas MM, West OC, Cohen AM: Diagnosing traumatic arterial
injury in the extremities with CT angiography: pearls and pitfalls. Radio-
graphics (Suppl 1):S133–S142, 2005.
8. Fleiter TR, Mervis S: The role of 3D-CTA in the assessment of peripheral
vascular lesion in trauma patients. Eur J Radiol 64:92–102, 2007.
9. Ofer A, Nitecki S, Braun J, et al: CT angiography of the carotid arteries
in trauma to the neck. Eur J Vasc Endovasc Surg 21(5):401–407, 2001.
10. Ofer A, Nitecki S, Lin S, et al: Multidetector CT angiography of peripheral
vascular disease: a prospective comparison with intraarterial digital sub-
traction angiography. Am J Roentgen 180:719–724, 2003.
11. Beekley AC, Sebesta JA, Blackbourne LH, et al: 31st Combat Support
Hospital Research Group, Prehospital tourniquet use in Operation
Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma
64(2 Suppl):S28–S37, discussion S37, 2008.
12. Tien HC, Jung V, Rizoli SB, et al: An evaluation of tactical combat casualty
care interventions in a combat environment. J Am Coll Surg 207(2):174–
178, 2008.
13. Fox CJ, Starnes BW: Vascular surgery on the modern battlefield. Surg Clin
North Am 87:1193–1211, 2007.
14. Arató E, Kürthy M, Sínay L, et al: Pathology and diagnostic options of
lower limb compartment syndrome. Clin Hemorheol Microcirc 41(1):1–
8, 2009.
15. Dente CJ, Feliciano DV, Rozycki GS, et al: A review of upper extremity
fasciotomies in a Level I trauma center. Am Surg 70(12):1088–1093. 2004.
16. Misovic S, Ignjatovic D, Jevtic M, et al: Extended ankle and foot fasciot-
omy as an enhancement to the surgical treatment of patients with pro-
longed ischemia of the lower extremities. Vojnosanit Pregl 62(4):323–327,
2005, [Serbian].
17. Fox CJ, Gillespie DL, O’Donnell SD, et al: Contemporary management of
wartime vascular trauma. J Vasc Surg 41:638–644, 2005.
18. Oredsson S, Plate G, Qvarfordt P: The effect of mannitol on reperfusion
injury in skeletal muscle. Eur J Vasc Surg 8(3):326–331, 1994.
19. Mullins RJ, Lucas CE, Ledgerwood AM: The natural history following
venous ligation for civilian injuries. J Trauma 20:737–743, 1980.
20. Rich NM, Hughes CW, Baugh JH: Management of venous injuries. Ann
Surg 171:724–730, 1970.
21. Nitecki SS, Karram T, Hoffman A, et al: Venous trauma in the Lebanon
War–2006. Interact Cardiovasc Thorac Surg 6(5):647–650, 2007.
22. Eger M, Golcman L, Goldstein A, et al: The use of a temporary shunt in
the management of arterial vascular injuries. Surg Gynecol Obstet 132:
67–70, 1971.
23. Gifford SM, Eliason JL, Clouse WD, et al: Early versus delayed restoration
of flow with temporary vascular shunt reduces circulating markers of
injury in a porcine model. J Trauma 67:259–265, 2009.
24. Chambers LW, Green DJ, Sample K, et al: Tactical surgical intervention
with temporary shunting of peripheral vascular trauma sustained during
Operation Iraqi Freedom: one unit’s experience. J Trauma 61:824–830,
2006.
25. Rasmussen TE, Clouse WD, Jenkins DH, et al: The use of temporary
vascular shunts as a damage control adjunct in the management of
wartime vascular injury. J Trauma 61:8–12, 2006.
26. Subramanian A, Vercruysse G, Dente C, et al: A decade’s experience with
temporary intravascular shunts at a civilian Level I trauma center.
J Trauma 65:316–324, 2008.
27. Taller J, Kamdar JP, Greene JA, et al: Temporary vascular shunts as initial
treatment of proximal extremity vascular injuries during combat opera-
tions: the new standard of care at Echelon II facilities? J Trauma 65:595–
603, 2008.
32  South Africa
KENNETH BOFFARD
Region-Specific Epidemiology
South Africa is a large country (1,200,000 sq km2), with a
population of about 50 million. Of these, half live in the urban
environment and half live in the rural environment. There is
inevitably a wide difference in the availability of general and
specialized medical care as a result.
For many years, South Africa has had a background of
violence. Some of this can be attributed to the political and
other difficulties of the Apartheid era, but a significant pro-
portion was both criminal and tribal in origin. The trauma
registry at Johannesburg hospital, which has been in existence
since 1984, reflects that in 1984 of the 1000 major resuscita-
tions per annum (injury severity score [ISS] >15) some 300
injuries were penetrating in nature. In the 1980s, these were
predominantly due to stab wounds and usually associated
with alcohol.
Around the time of the advent of full democracy in 1994,
there was initially an upsurge in interpersonal violence, partly
due to the relatively free availability of firearms and partly due
to some initial instability in the political system before the
democratic elections. At that time, not only was there an
upsurge in the number of gunshot wounds; but also a signifi-
cant proportion in both rural and urban environments were
due to wounds from assault-rifle (AK-47) ammunition. By
1994, of the 2000 resuscitations at Johannesburg hospital,
1000 were penetrating; and, by 1999, there were 2500 resusci-
tations of which 2000 were penetrating, the majority of which
were gunshots. By 1999, at the two major teaching hospitals
in Johannesburg (Chris Hani Baragwanath Hospital in Soweto
and Johannesburg Hospital in central Johannesburg [Fig.
32-1]), the incidence of penetrating trauma was approxi-
mately 85% of all trauma victims. Of these, 70% were second-
ary to gunshot injuries. The majority of the remaining injuries
were due to stabbing.
Since 1994, government focus has been on bringing primary
health care to poorer people, especially in rural areas. The
money has had to come from somewhere; and, despite dra-
matic increases in total budget, famous urban hospitals like
Baragwanath, and Groote Schuur in Cape Town fell into
neglect while hundreds and thousands of rural dwellers
received some medical attention, many for the first time in
their lives.
The last 10 years has seen a decline in the homicide rate
across the country, and stringent firearm laws have seen a
significant reduction in the use of firearms. There has been a
slight increase in the number of stabbings; but overall, par-
ticularly in the Johannesburg area, both the homicide rate and
the incidence of penetrating injury has dropped in some cases
324
by up to half. In 2011, the same trauma registry showed 1700
cases, of which 800 were penetrating. The incidence of gunshot
injuries in the Cape Town area has not shown such a dramatic
falloff, but this may be partly due to increased use of firearms
secondary to an increased gang culture and drug culture.
A substantial number of vascular injuries seen in the South
African context present late, with other competing injuries;
and patients are in hypovolemic shock. The patients’ outcome
may also be compromised by the high prevalence of AIDS.
The common mechanisms of injury in blunt trauma are
similar to other countries and are related to long bone frac-
tures, direct blows to the neck, and compression injuries.
South Africa has a very high incidence of pedestrian injuries
from motor vehicles, with associated pelvic, femoral, and
lower limb fractures, many of which are associated with vas-
cular injury as well.
Other injuries seen include strangulation, animal bites
(beyond the area of penetrating injury), ejection from motor
vehicles, and an association between high cervical fractures
and fractures involving the foramen transversarium, associ-
ated with blunt internal carotid artery injury.
In penetrating trauma, currently 50% of vascular injuries
are gunshot-wound related and are particularly common in
the torso, with transmediastinal injury, transabdominal injury,
and injury to the femoral vessels. The bulk of stab wounds
causing vascular injury are to be found in the neck, particu-
larly zone I and zone II (in association with aerodigestive
injuries).1-4
A relatively large number of patients with stab wounds to
the heart survive to reach the hospital; and our experience,
like similar series from elsewhere, has been that, if they survive
to reach hospital alive, they are likely to leave the hospital alive
(Fig. 32-2).
Finally, South Africa has a significant gold and coal mining
industry. The deepest mines are found about 50 miles (80 kilo-
meters) to the west of Johannesburg in the West Wits Gold-
field (Tau Tona and Mponeng mine). Active mining takes
place at up to 17,000 feet (about 5000 miles) below ground
level. At this depth, the uncooled temperature of the rock can
reach 60° C, and the air pressure can reach more than twice
that at sea level. Rock movement is common. The mining
industry has an excellent safety record, but the challenges of
the injuries caused include rock falls causing crush and com-
partment syndromes, often complicated by the long periods
(up to 2 hours) to reach the surface.
Reliable follow-up is often difficult in South Africa, and
treating minimal injury conservatively (nonoperatively) is not
always either feasible or possible. There is an associated short-
age of high-care beds, so many injuries that would no longer
 32  /  South Africa 324.e1

ABSTRACT
Vascular injuries can occur due to a wide variety of causes.
They can arise from blunt injuries, as well as penetrating
injuries. Across South Africa, there has been a gradual
reduction in the amount of interpersonal trauma, with the
result that there are fewer penetrating injuries; and most
hospitals are now seeing the majority of vascular injuries as
a result of blunt trauma, which presents secondary to auto-
mobile accidents, mining accidents, and industry. There is
a great dichotomy in the quality of health care between
urban and rural environments, with long distances and
frequent delays in transfer to hospitals that have specialist
vascular services. The management of the vascular injuries
themselves follows internationally recognized guidelines,
and most techniques that are practiced elsewhere are prac-
ticed in South Africa as well.

Key Words:  South Africa,

vascular,
injury,
hemostasis,
endovascular,
shunts

FIGURE 32-1  Emergency Medical Services (EMS) helicopter flying
past Charlotte Maxeke Johannesburg Academic Hospital and metro-
politan Johannesburg.
FIGURE 32-2  A penetrating injury to the chest.
be operated on elsewhere are dealt with surgically, including
with the use of endovascular techniques. Long-term follow-up
is difficult in institutions in South Africa, particularly after
trauma, mainly because of socioeconomic factors. It is
expected that only approximately one third of patients will
return to clinic visits within 2 months of discharge.
Region-Specific Systems of Care
There is approximately 1 physician for 25,000 patients in the
rural areas, and 1 physician per 700 patients in the urban areas
of South Africa. There are 43 registered subspecialist vascular
surgeons and 25 registered subspecialist trauma surgeons for
the country, almost all concentrated in the urban areas, and
most in Academic centers.5 There are some 800 practicing
general surgeons nationwide, mostly in the major centers; and
it is they who bear the brunt of the vascular trauma load.
Currently there are 8 medical schools in South Africa, pro-
ducing 1500 graduates per annum. Unfortunately 700 doctors
leave the country each year primarily to Canada and Australia,
many of whom have already trained as specialists, including
surgery. Thus, there is a significant shortfall of medical prac-
titioners in general and a shortfall of surgeons, in particular.
While qualified general surgeons provide the full range of
trauma care in most instances, select cases requiring subspe-
cialty care or techniques (e.g., endovascular stent-grafts) may
be referred to subspecialty vascular or trauma centers. By its
32  /  South Africa 325
very nature and urgency, a good deal of trauma is dealt with
by general surgeons in regional or district hospitals.
There is a thriving private health sector, which inevitably
spends considerably more of the national health dollar per
patient than the state sector. In general, private facilities are
better equipped and staffed; and many centers are capable of
advanced surgery (e.g., stereotactic neurosurgery, cardiac
and lung transplantation). Diagnostic imaging is usually far
superior and more accessible at these private facilities, as is
endovascular and minimally invasive surgery. A substantial
proportion of the population (up to one third) are covered by
private health insurance, by a gasoline tax if the victim is
injured in an automobile accident, and by a workman’s com-
pensation insurance scheme. Thus a significant amount of
trauma will be dealt with by the private sector; and, indeed,
the first two Level I trauma centers accredited by the Trauma
Society of South Africa are fully privately funded.
Much rural surgery, both basic surgery and obstetric
surgery, is performed by general practitioners. Although there
is a mix of public and private facilities across the country,
the reality is that most trauma, particularly outside the major
city centers, is dealt with in the public sector hospitals by
government-employed doctors, many of whom are quite
junior and lack senior backup, adequate infrastructure, and
appropriate training.
As with many other developing countries, prehospital care
in the major cities is good in parts, with a combination of
public and private ambulance services, paramedics, linked
road and air ambulances, and an integrated system of care;
however in the rural areas, the level of training is often poor,
the vehicles are ill equipped, and the distances long, resulting
in interhospital transport times of up to 8 hours. Similar to
Australia, many parts of the country are served by a rural
flying doctor service, though sometimes during daylight hours
only.
Techniques of Care
There is considerable emphasis on short courses to upgrade
trauma care and the recognition of vascular injury. The
Advanced Trauma Life Support program (ATLS) of the Amer-
ican College of Surgeons has been in place for 20 years, and
over 30,000 physicians have been trained. In addition to the
specialist fellowships such as surgery, and subspecialty fellow-
ships such as vascular surgery, and trauma surgery, with
trauma critical care, the College of Medicine of South Africa
also offers a 2-year Higher Surgical Diploma to provide extra
preparation and support for rural doctors involved in basic
general surgery, including life-saving surgery such as damage
control surgery.
The Definitive Surgical Trauma Care (DSTC) Course of the
International Association for Trauma Surgery and Intensive
Care (IATSIC) has been very popular, with some 500 surgeons
and surgical medical officers now trained in advanced emer-
gency surgical life and limb-saving techniques, including
damage control, vascular shunting, and basic vascular repair.6
Management of Acute Vascular Hemorrhage
There is emphasis on arresting hemorrhage with conventional
techniques and sometimes with tamponade, using adjuncts
such as the Foley catheter.7 This technique has proven useful
especially in stab wounds of zone I of the neck, allowing
transfer to a more appropriate center. The surgical tourniquet
326 SECTION 5  /  INTERNATIONAL PERSPECTIVES
FIGURE 32-3  Patient with a stab wound of the neck showing the
use of the Foley catheter for tamponade.
(perhaps because South Africa does not have the recent
combat experience of the Middle East and Afghanistan) is not
in frequent use. The penetrating wounds are generally low-
energy gunshot wounds or stab wounds, and almost all can be
controlled by direct pressure or by the use of a blood pressure
cuff (Fig. 32-3).
Management of Acute Ischemia
Failure to recognize acute ischemia, especially in blunt inju-
ries, remains a challenge; and limb ablation as a result of
delays in both recognition and patient transfer remains a real
issue. Rehabilitation facilities in the state sector are often
rudimentary.
Region-Specific Considerations
for Diagnosis
Many of the same considerations referred to above in training
and care delivery also apply to diagnostic imaging. In major
urban hospitals the computer tomography angiogram (CTA)
is usually the diagnostic method of choice, often associated
with simplex or duplex Doppler imaging. Magnetic resonance
angiography (MRA) is generally available as well. Interven-
tional angiography is less readily available. The technique of
emergency room angiography, although well described, is
practiced by very few centers.8
The use of the low dose X-ray unit (Lodox Statscan,
www.lodox.com) (Fig. 32-4), a South African-developed unit
originally created for detection of swallowed diamonds in the
mining industry, is very fast and effective.9 The Statscan is
capable of producing a high-quality digital whole-body X-ray
in as little as 13 seconds, at an ultralow-radiation dose (Fig.
32-5). The use of the Statscan has halved total resuscitation
times; and at our center it is installed in the resuscitation unit,
so that all X-rays are complete within 120 seconds of arrival,
and no further X-rays are routinely required.
Particularly with the use of the Lodox Statscan unit, emer-
gency room angiography using a contrast dose of as little as
20 mL over the same period allows high-quality limb angio-
grams (Fig. 32-6).
However in the rural areas, even 24-hour general X-rays
are not always available, not even a hand-held Doppler unit is
readily available, and therefore diagnosis is primarily clinical
with transfer to the nearest appropriate center. These transfers
FIGURE 32-4  Photograph of the Lodox Statscan unit.
are frequently associated with delays and subsequent limb loss.
Rehabilitation facilities are few and far between; and, although
available to the mining and private sector, they are not com-
monly available to indigent patients.
Region-Specific Treatment Strategies
The treatment of vascular injuries follows the same tech-
niques, using the same equipment, as in most Western
countries, including primary repair, vein patching, and inter-
position grafts using either vein or synthetic graft. Commer-
cially available self-expanding stent-graft is a logical choice
where there is incomplete arterial disruption and separation,
and where the angiographic capabilities and endovascular
grafts are available.
Neck
Management of penetrating wounds of the neck has favored
selective conservatism in Johannesburg for at least 2 decades
although one incentive for pursuit of a nonoperative policy is
the heavy trauma load presenting in our hospitals, together
with comparatively limited resources. Of those patients
observed with penetrating neck wounds, 6% to 9% had
delayed surgery within 24 hours for missed injuries, usually
esophageal or laryngeal injuries. Duplex Doppler is used to
follow up minor carotid injuries, identified angiographically,
that are not operated on. It is generally agreed that surgical
intervention should be reserved for unstable patients with
zone I and zone III injuries, patients with ongoing bleeding,
and patients requiring exploration for other injuries. With
other cases they are treated noninvasively or with endovascu-
lar techniques.10,11
Cervicomediastinal Injuries
Cervicomediastinal venous trauma can be very difficult to
control.12-14 In a series of 49 patients, 45% of whom presented
in hypovolemic shock, Nair et al showed that ligation is an
acceptable form of treatment in the presence of hemodynamic
instability.15
Transmediastinal or Transabdominal  
Torso Injuries
Most patients with intrathoracic or intraabdominal aortic
injury die before they reach the hospital. Where possible,

FIGURE 32-5  A Lodox whole-
body scan and scans showing
details of the skull, abdomen, and
pelvis, following explosion of a
gas cylinder.
FIGURE 32-6  Photograph showing a limb arteriogram performed on
the Lodox Statscan.
endovascular stenting has become the treatment of choice.
With transtorso gunshot wounds, there is a much higher inci-
dence of associated injuries (e.g., the esophagus).
Blunt thoracic aortic dissection is generally diagnosed on
the basis of the CT scan rather than an angiography; the
32  /  South Africa 327
causes are similar to those in other countries. The treatment
is generally regarded as similar, as well, and endovascular
stenting as the treatment of choice.
Cardiac Injuries
Most penetrating cardiac injuries do not survive to reach the
hospital; however, of those that do, most have a good
outcome.16,17 Most South African residents will have com-
pleted a number of emergency room thoracotomies (ERTs)
with both anterolateral and sternotomy approached before
completion of their residencies. The repair techniques are
similar to those practiced elsewhere. An interesting challenge
is the patient who presents with a second stab wound to the
heart, having had a previous injury repaired on another occa-
sion. A different approach is often required, especially if there
has been a pre­vious sternotomy with repair or closure per-
formed using steel wires!
Strategies to Sustain and to Train
the Next Generation of
Trauma Surgeons
Medical training in South Africa is normally 5 to 6 years, fol-
lowed by a 2-year internship period and a further year doing
compulsory community medical service, usually in a rural or
community hospital. This is performed before any approved
specialty training program.
General surgical training (which includes at least 3 to 6
months of specific critical care training) consists of a 5-year
training period similar to that in many Western countries; and
it is possible to do a further 2-year subspecialty fellowship in
vascular surgery or trauma surgery, including trauma critical
care, and completion of the relevant fellowship, resulting in
an independent subspecialist qualification.
328 SECTION 5  /  INTERNATIONAL PERSPECTIVES
As part of their general surgical training, most general sur-
gical trainees will spend at least 1 year out of their 5 years
dealing primarily with trauma cases from within a dedicated
trauma center. Acute care surgery as practiced in the United
States does not exist in South Africa, as all acute surgery cases
are dealt with by the same trainees and surgeons who would
deal with the general surgery and trauma emergencies in addi-
tion to their time spent in dedicated burns, trauma, or inten-
sive care settings. Many specialist centers, especially those
associated with an academic institution will have a separate
emergency vascular service. The volume of both acute care
surgical cases and trauma cases that require operative inter-
vention is high enough that surgical skills are retained.
Both trauma and emergency medicine are young special-
ties with an enthusiastic following, and those going into
trauma as a career will practice critical care as well. Nonethe-
less, most vascular trauma will continue to be dealt with by
general surgeons as part of their greater practice.
REFERENCES
1. Plani F: Vascular trauma. In Nicol A, Steyn E, editors: Handbook of
trauma for Southern Africa, ed 3, Oxford, 2010, Oxford University Press,
pp 258–272.
2. Veller MG, Pillai J: Vascular injuries. In Adeloye A, Adekunle OO, Awojobi
A, editors: Davey’s companion to surgery in Africa, ed 3, Uruwa Nigeria,
2009, Acecool Medical Publishers, pp 33–40.
3. Degiannis E, Levy RD, Sofianos C, et al: Arterial gunshot injuries of the
extremities: a South African experience. J Trauma 9:570–575, 1995.
4. Franklin J, Hatzitheophilou C, Pantanowitz D: Vascular trauma. In Pan-
tanowitz D, editor: Modern surgery in Africa: the Baragwanath experi-
ence, Johannesburg, 1988, Southern Book Publishers.
5. Bowley DMG, Degiannis E, Goosen J, et al: Penetrating vascular trauma
in Johannesburg, South Africa. Surg Clin North Am 82(1):221–235, 2002.
6. Boffard KD, editor: Manual of Definitive Surgical Trauma Care (DSTC),
London, 2011, Hodder.
7. Navsaria P, Thoma M, Nicol A: Foley catheter balloon tamponade for life
threatening haemorrhage in penetrating neck trauma. World Journal of
Surg 30(7):1265–1268, 2006.
8. MacFarlane C, Saadia R, Boffard KD: Emergency Room Arteriography: a
useful technique in the assessment of peripheral vascular injuries. J Roy
Col Surg Edin 34:310–313, 1989.
9. Boffard KD, Goosen J, Plani F, et al: The use of low dosage X-ray (Lodox/
Statscan) in major trauma: a comparison between low dose X-ray and
conventional X-ray techniques. J Trauma 60(6):1175–1181, discussion
1181–1183, 2006.
10. Veller MG, Le Roux D: Carotid, jugular and vertebral blood vessel inju-
ries. In Velmahos GC, Degiannis E, Doll D, editors: Penetrating trauma.
Heidelberg, 2012, Springer, pp 229–238.
11. Demetriades D, Stewart M: Penetrating injuries of the neck. Annals R Coll
Surg Engl 67:71–73, 1985.
12. Robbs J, Baker LW, Human R, et al: Cervico-mediastinal arterial injuries.
Arch Surg 116:663–668, 1981.
13. Du Toit DF: Penetrating trauma to the subclavian vessels. In Velmahos
GC, Degiannis E, Doll D, editors: Penetrating trauma. Heidelberg, 2012,
Springer, pp 229–238.
14. Robbs J, Baker LW: Subclavian and axillary artery injury. S Afr Med J
51:227–231, 1977.
15. Nair R, Robbs JV, Muckart DJ: Management of penetrating cervico-
mediastinal venous trauma. Eur J Vasc Endovasc Surg 19:65–69, 2000.
16. Robbs J, Baker LW: Cardiovascular trauma. Curr Prob Surg 21:7–87, 1984.
17. Degiannis E, Loogna P, Doll D, et al: Penetrating cardiac injuries: recent
experience in South Africa. World J Surg 30(7):1258–1286, 2006.
Vascular Trauma in
Latin America
LUIS A. MORENO, OSWALDO BORRAEZ, AND JORGE H. ULLOA
Epidemiology
Approximately 5 million people die annually worldwide as the
result of trauma or injury. Death from trauma represents 9%
of the global mortality; and 90% of these deaths occur in
developing countries, creating a public health problem. In
nearly all countries, trauma or injury is the leading cause of
death among people between 15 and 44 years of age.1-4 From
1996 to 2010 in Latin America, trauma was the third leading
cause of death in all age groups following cardiovascular
disease and malignancy. Homicide was the most common
cause (60%) of traumatic death in Latin America followed by
motor vehicle accidents (19%), suicide (6%), and injury
during combat operations (6%) (Fig. 33-1).5-6 While less com-
monly resulting in death, injury of the femoral vessels during
performance of catheter-based, endovascular procedures has
been an increasingly common cause of vascular trauma over
the past decade.7 The largest trauma registries in Latin America
are in Colombia and Brazil, while other countries do not have
organized repositories because of limited resources or lack of
political will. In aggregate, the morbidity and mortality from
trauma in Latin America are similar to those of developed
countries around the world.8,9,10,11
In the context of all trauma admissions, recorded or docu-
mented vascular injuries are relatively rare. Vascular trauma
in civilian centers in Latin America represents 0.65% to 1.14%
of all trauma admission and is much more common in men
(88%) than women (gender proportion of 12: 1). Almost three
quarters of vascular injuries (71% of patients) in Latin
America occur in those between the ages of 15 and 45 years.
Penetrating trauma is responsible for 88% of cases of vascular
injury with gunshot wounds most prevalent (60% of penetrat-
ing cases). Stab wounds account for about 28% of the pene-
trating vascular trauma cases and only about 8% of the
vascular trauma in Latin America results from nonpenetrating
causes. A small percentage of vascular trauma results from
iatrogenic causes such as vascular access for endovascular
procedures.9 Day-by-day violence is responsible for most cases
of vascular trauma in Columbia and Latin America and most
of this is in urban, civilian areas (78%). Vascular trauma
during official military operations has represented only a
small percentage (5%) of the region’s experience in the recent
past.12-13
Similar to other experiences with vascular trauma around
the world, the extremities have a higher preponderance for
injury than the torso and cervical regions. Almost two thirds
of all vascular injury (62%) in Columbia and Latin America
occurs in the extremities (33% lower and 29% upper).
Abdominal and pelvic vascular trauma accounts for 17% of
33 
vascular injury followed by lesions in the thorax (12%) and
cervical regions (9%). The majority of vascular trauma (62%)
is arterial in nature although nearly a quarter of cases (22%)
have multiple vascular injuries. Documented venous injury is
present in 10% of cases of vascular trauma, and there is a
preponderance of venous injury in the abdomen and pelvis
compared to other anatomic locations (Table 33-1).9,10 The
amputation rate following extremity vascular injury is approx-
imately 5% although long-term follow-up is difficult to
achieve in Columbia and other parts of Latin America. Injury
patterns associated with higher amputations rates and mortal-
ity include blunt popliteal artery trauma and penetrating inju-
ries with a combined arterial and venous component. Early
amputation rates in these more-complex injury patterns have
been recorded to be 4% to 12% in different studies.9,10,11
Specific Systems of Care
in the Region
In most hospitals in Columbia and Latin America, vascular
trauma is managed by a general surgeon who is well suited
due the wide range of injury patterns in the region. Like many
other parts of the world, it is impractical to have a specialty-
trained vascular surgeon in the emergency department (ED)
24 hours a day, 7 days a week for vascular trauma call.14 None-
theless, with the advent of a new breed of vascular surgeons
interested in trauma and an increase in specialized centers,
specialty-trained vascular surgeons are becoming more
involved in vascular injury in many locations. These types of
centers have multidisciplinary teams composed of general and
vascular surgeons as well as interventional radiologists and
vascular technologists that provide more prompt and thor-
ough diagnosis and treatment of vascular injury.
Regional Considerations for the
Diagnosis and Management of
Vascular Trauma
About 70% of patients with vascular trauma in Columbia and
Latin American manifest some degree of hemodynamic shock.
Two thirds (65%) of these patients are taken immediately to
an operating room after the initial clinical assessment.8,9,10 The
remaining patients undergo some form of imaging, most
commonly computed tomography (CT) or contrast angiogra-
phy. Even in the operating room, angiographic capability
exists in more advanced medical centers in the form of a
C-arm fluoroscopy unit. In such facilities, intraoperative angi-
ography allows for the diagnosis of vascular trauma and
329
 33  /  Vascular Trauma in Latin America 329.e1

ABSTRACT
In Latin America, interpersonal violence is the most-
common cause of trauma mortality. Vascular trauma
accounts for 0.65% to 1.14% of all trauma admissions
and is usually due to penetrating mechanisms. Iatrogenic
damage from percutaneous vascular access is becoming
notable. The majority of injury is to the extremities. Prehos-
pital times are usually short but may be much longer given
the geographical challenges. Larger hospitals have access
to computed tomography (CT) and digital fluoroscopy, but
hand-held Doppler is a valued tool for the assessment of
peripheral vascular trauma outside of these facilities. Shunt-
ing and early fasciotomy is an established technique; endo-
vascular therapy is emerging as an alternative to open
surgery in certain cases. The amputation rate is 5%, and
the overall mortality rate is 7.5%. To reduce the mortality
and morbidity of this complex injury pattern, Latin Ameri-
can countries would benefit from the development of
regional or country-specific trauma registries, the dissemi-
nation of appropriate endovascular techniques, and the
training of selected trauma surgeons in these therapies.

Key Words:  trauma,

vascular,
Latin America,
Bogota bag
330 SECTION 5  /  INTERNATIONAL PERSPECTIVES

Undetermined the setting of trauma. In patients who have normal hemody-

violent namic measures, the Doppler may be used to calculate an
deaths
9%
injured extremity index (IEI) or ankle brachial index (ABI),
which is more than adequate to assess for flow-limiting arte-
rial injuries in a limb. The Doppler examination may need to
War be repeated in patients who are hypotensive or hypothermic
6% as these conditions tend to reduce peripheral perfusion and
may skew the ABI measurement. In some centers in Latin
Suicides America, patients with a question of vascular trauma undergo
6% duplex ultrasound as a noninvasive diagnostic measure. This
modality is more sensitive than simple Doppler and is com-
monly performed by a vascular surgeon or vascular technolo-
gist under the supervision of a vascular surgeon. In most
facilities patients who meet criteria for an angiogram will
undergo this procedure in the initial 48 hours following the
injury. In recent years select patterns of vascular injury such
as pseudoaneurysm and arteriovenous fistulae may be repaired
using catheter-based endovascular techniques such as place-
Motor vehicle
ment of a covered stent.15,16 Some specialized centers in Latin
Homicide America have the capability to perform contrast-enhanced CT
accidents 60%
(MVAs) angiography, which has been shown to have a sensitivity of
19% 95% in the setting of trauma.17,25
FIGURE 33-1  Distribution of trauma in Latin America from 1996 to Most trauma in the authors’ geographic region occurs in
2010. the civilian setting; and thus the time from injury to surgical
evaluation is relatively short, occurring within 3 hours of
injury in 80% of cases.10 The improved trend in reducing
Table 33-1 Variables of Vascular Trauma prehospital times demonstrates the increased training and
Variable Percentage (%)
preparedness of first responders and ambulance crews in
many cities in Latin America. It should be noted that prehos-
Gender pital times vary widely with some more remote or less devel-
  Male 88 oped areas having prehospital times that exceed 3 hours and
  Female 12 in rare cases may even extend to 12 to 24 hours. In some Latin
Age 27 years American countries, the movement of patients from the point
Mechanism of Injury of injury to the hospital emergency department is performed
  Penetrating 88 by local police or law enforcement personnel.
  Blunt 8 In general, first responders and ambulance crews in Latin
  Other causes 4 America do not use tourniquets for extremity injuries. Instead
  Gunshot wounds 60 first responders are mostly taught techniques for direct com-
  Stab wounds 28 pression, and use of dressings for bleeding injuries and tour-
Localization niquets are used only on select bases. In hospital hemorrhage,
  Upper limbs 29 control of torso bleeding is pursued with expedited laparot-
  Lower limbs 33 omy, thoracotomy, or reduction of complex pelvic fractures
  Cervical 9 with a sheet or external fixation. Resuscitative aortic occlusion
  Thoracic 12 via thoracotomy and clamping is used as a last resort in
  Abdominal and pelvic 17 patients in cardiovascular collapse. The use of resuscitative
Surgical Treatment endovascular balloon occlusion of the aorta (REBOA) is yet
  Primary repair 30 to be used widely in Latin America, although interest is
  Vein graft 55 growing as efficacy is demonstrated in other parts of the
  Prosthetic graft 10 world. Needless to say, resuscitation with whole blood or
  Ligation 5 blood products is very much a part of these maneuvers to
Amputation 5 control hemorrhage from vascular trauma and is often accom-
Mortality 7.5 plished with use of auto-transfusion and cell-saver devices.
Patients with major vascular injury and concomitant
physiologic compromise (i.e., hypothermia, severe acidosis,
endovascular treatment in some cases. More remote or lesser shock) are often managed with the use of improvised or
established medical centers in Latin America do not have homemade temporary vascular shunts. In the authors’ experi-
C-arm fluoroscopic capability in the operating room; and, in ence, restoration of flow across a major vascular injury has
these facilities, surgeons must rely on clinical examination and been accomplished most commonly using nasogastric tubes
operative exploration to diagnose vascular trauma. or small-caliber chest tubes (Fig. 33-2). In these cases, the
The continuous-wave Doppler machine is more commonly improvised shunt is secured to each vessel end using free ties
available in hospital settings in Columbia and Latin America to allow for stabilization and eventual removal of the device
and is a useful and more-basic way to assess limb perfusion in at the time of formal vascular reconstruction.
 33  /  Vascular Trauma in Latin America 331

Chest tube

FIGURE 33-2  Small-caliber chest tube serves as a vascular shunt in FIGURE 33-3  Vessel-loop shoelace technique.
an iliac artery injury.

If use of a temporary vascular shunt is not possible, ligation

of the artery may be necessary as a recognized damage control
option. This maneuver may be especially necessary in cases
where the patient has other life-threatening injuries or severely
compromised physiology. In the authors’ experience, arterial
reconstruction using saphenous vein has been completed in
50% of cases following initial ligation. Cases of delayed arte-
rial reconstruction have typically occurred at an interval time
period (usually several hours to 1 day) after the patient has
been resuscitated and any wound contamination controlled.
In the authors’ experience 27% of vein injuries are ligated at
the initial operation with no subsequent reconstruction of
venous outflow. In rare cases arterial transposition may be
used as a form of autologous reconstruction (e.g., external to
distal internal carotid transposition for proximal internal
carotid artery injury).
Synthetic conduits or grafts such as expanded polytetra- FIGURE 33-4  Free Bogota (Borraez) bag in the abdominal cavity
under the fascia and above the intestine.
fluoroethylene (ePTFE) are used as last resorts (less than 10%
of the vascular reconstructions) in cases where autologous
saphenous vein is not able to be harvested. Extremity com- perform this as soon as possible (usually within 1 to 3 days)
partment syndrome has been shown to be present in 7% of to avoid physical limitations.
patients with vascular injury and is most commonly diag- Damage control laparotomy with temporary abdominal
nosed by thorough physical examination. In the authors’ expe- closure (i.e., Bogota bag) was first described by the author in
rience, approximately one third (30%) of patients undergo a 1995 and has continued to be used in cases of significant
preventive or prophylactic four-compartment fasciotomy of intraabdominal contamination and/or massive resuscitation
the leg following severe extremity injury with a vascular com- with resultant concerns for the development of intraabdomi-
ponent. Fasciotomy is especially important in the setting of a nal hypertension. In these scenarios, the author has described
combined arterial and venous injury or in cases of complex constructing the Bogota bag using two ViaFlex bags opened
fracture or crush injury. The authors also advocate for liberal and placed above the abdomen and below the fascia, in
use of fasciotomy if there has been arterial reconstruction after order to decrease the formation of adherences between organs
a prolonged ischemic period (i.e., 4 to 6 hours or longer) or and the abdominal wall. During abbreviated laparotomy, this
in patients who have had large-volume resuscitation.18 For the step facilitates eventual definitive fascial closure in the days
closure of leg fasciotomy wounds or even delayed primary following major trauma and resuscitation (Figs. 33-4 and
closure of abdominal wounds, the authors frequently use a 33-5).20-21
reapproximation maneuver that include Silastic (i.e., rubber) Endovascular therapy to manage vascular trauma and
vessel loops which gradually pull the skin edges together as severe shock is not widely accepted or used, but it continues
edema resolves (Fig. 33-3). Using this approach, the authors to evolve in Columbia and Latin America. At this early stage,
are able to achieve delayed primary closure in the majority of when endovascular methods are considered for vascular
cases, avoiding the need of skin grafts.19 When it appears that trauma, they are generally used in patients who are hemody-
delayed primary closure of leg fasciotomy or abdominal namically normal and in scenarios where appropriate time can
midline wounds may be possible, the authors attempt to be taken to prepare for the case. The interest in expanding use
332 SECTION 5  /  INTERNATIONAL PERSPECTIVES
FIGURE 33-5  Bogota bag fixed to the skin with a running suture.
of endovascular technologies in the management of trauma is
reflected by the completion of translational research, includ-
ing one published animal trail in this area.22 Most cases of
vascular trauma in which an endovascular approach is now
considered are arteriovenous fistula, stable pseudoaneurysm,
or limited arterial dissections. A growing experience is being
achieved using endovascular coil embolization to control
bleeding from vertebral and pelvic vessels and from solid
organ injuries.15 In rare cases, endovascular approaches to
extremity vascular trauma have been described even suggest-
ing the benefit of decreased recovery time compared to open
operation.23 As in many countries around the world, the great
potential for endovascular methods to be effective and poten-
tially lifesaving in the setting of vascular trauma and end-stage
shock is recognized in Latin America. However, like many
countries in the world, the full utility of endovascular
approaches has not been realized at the present time.
Strategies to Train the Next
Generation of Trauma Surgeons
The most important aspect of vascular trauma in Columbia
and Latin America is recognizing its status as a public health
problem with social, economic, familial and working implica-
tions. A trauma registry (not yet developed in Latin America)
is required to fully understand and communicate the burden
of morbidity and mortality from this challenging injury
pattern and to promote mitigating strategies. It is imperative
that such a national and possibly regional registry be con-
structed and maintained.
In Columbia and Latin America, vascular trauma is most
effectively managed when the general or trauma surgeon
works closely with the vascular surgeon. It may be that now
and in the future optimal management of vascular trauma will
require that a surgeon extend his or her skill set and work to
the prehospital setting. Because of the implications of vascular
trauma and hemorrhage, lifesaving strategies will need to be
aimed at hemorrhage control and prompt transportation to
capable medical facilities. Once at the hospital, a clinical prac-
tice algorithm to diagnose and manage vascular trauma while
initiating appropriate resuscitation is likely to increase patient
survival. It is the authors’ perspective that training a number
of trauma surgeons (some but not all) to be facile with the use
of duplex ultrasound, fluoroscopy, basic endovascular skills,
and even CT imaging would allow for a better diagnostic and
treatment approaches to vascular trauma in the acute setting.
In this context, translating a basic endovascular skill set to
general and trauma surgeons to allow them improved dexter-
ity with these tools in the acute setting should be a priority.
To lower the morbidity and mortality from vascular trauma
in Columbia and Latin America, it is a goal of the authors to
advocate for the training of a work force that is knowledgeable
about the prevention, control, management, and rehabilita-
tion of patients having sustained this complex injury pattern.
REFERENCES
1. World Health Organization: Global burden of disease: 2004 update,
Geneva (Switzerland), 2008, World Health Organization. Krug EG, Mercy
JA, Dahlberg LL, et al: The world report on violence and health. Geneva
(Switzerland): World Health Organization; 2002.
2. WHO: Global burden of disease attributable to injuries, 2000 estimates.
In World Health Report, Geneva, 2001, World Health Organization.
3. Krug EG, et al, editors: World report on violence and health, Geneva,
2002, World Health Organization.
4. Health Situation in the Americas: Basic Indicators, Washington, 2005, Pan
American Health Organization.
5. Gonzalez G: Epidemiología del Trauma: Trauma. Editorial Universidad
de Antioquia. In Morales CH, Isaza LF, editors: Medellín, Colombia, 2004,
pp 3–12.
6. Health Situation in the Americas: Basic Indicators, Washington, 2006, Pan
American Health Organization.
7. Griswold ME, Landry GE, Taylor LM, et al: Iatrogenic arterial injury is
an increasingly important cause of arterial trauma. J Am Surg 187:590–
592, 2004.
8. Morales CH, Sanabria A: Vascular trauma in Colombia. Experience of a
Level I trauma center in Medellin. Surg Clin North Am 82(1):2002.
9. Sonneborn R, Andrade R, Bello F, et al: Vascular trauma in Latin America.
A regional survey. Surg Clin North Am 82(1):2002.
10. Costa-Val R: Reflexões sobre o trauma cardiovascular civil a partir de um
estudo prospectivo de 1000 casos atendidos em um centro de trauma de
nível I: a prospective study from 1000 cases. Rev Col Bras Cir 35(3):162–
167, 2008. ISSN 0100-6991; [online].
11. Quiroz F, Garcia A: Trauma vascular periférico revisión de 577 lesiones
vasculares. Rev Colomb Cir 13(2):100–103, 1998.
12. World Health Organization: Global burden of disease: 2004 update,
Geneva (Switzerland), 2008, World Health Organization.
13. Forensis 2010: Forensis datos para la vida. Herramienta para la interpre-
tación, intervención y prevención de lesiones de causa externa en Colom-
bia 12(1):2011. ISSN 2145-0250.
14. Espinoza R, Dietz P: Trauma arterial de extremidades: resultados del
manejo por el cirujano no especialista. Rev Chilena de Cirugía 54(3):225–
230, 2002.
15. Angotti Furtado C: Endovascular management of extremity arterial
trauma. J Vasc Bras 7(1):56–61, 2008.
16. Cerezo M, Cuacci O: Utilization of endovascular proceeding for vascular
trauma treatment. Actas Cardiovasc 10(2):99–111, 1999.
17. Morales CH, Ochoa M, Suarez T: Multidetector CT (MDCT) angiogra-
phy: new gold standard for the diagnosis in vascular injuries in the
extremities? Iatreia 20(4):2007.
18. Gomez J, Morales C: Fasciotomía profiláctica y síndrome compartimental
de extremidades: ¿existen indicaciones justificables? Rev Colomb Cir 26:
101–110, 2011.
19. Reyes A, Siegel S: Afrontamiento primario con elásticos vasculares en el
manejo del cierre progresivo de fasciotomías. Rev Chilena de Cirugía
62(4):377–381, 2010.
20. Feliciano D, Moore E, Mattox K: Trauma Damage Control. 5a. Edición.
21. Borráez O: Abdomen Abierto. Utilización del Polivinilo. Rev Colomb
Cirugía 16:1, 2001.
22. Belczak S, Erasmo I: Endovascular treatment of peripheral arterial injury
with covered stents: an experimental study in pigs. Clinics 66(8):1425–
1430, 2011.
23. Soto JA, Múnera F, Morales CH, et al: Focal arterial injuries of the proxi-
mal extremities: helical CT arteriography as the initial method of diag-
nosis. Radiology 218:188–194, 2001.
Implications of Vascular
Trauma in Brazil
ROSSI MURILO AND RINA PORTA
Introduction
Like elsewhere in the world, vascular trauma is the most chal-
lenging aspect of care in the multiply injured patient in
Brazil. The breadth and complexity of vascular injury, includ-
ing its propensity to result in shock or profound ischemia
and its tendency to be associated with injuries to other tissues
or organs, requires a multidisciplinary approach focused on
life- and limb-saving maneuvers. Further complicating the
landscape of vascular-injury management in this region of
the world are rapidly evolving diagnostic and therapeutic
options, including noninvasive computed tomography (CT)
imaging and less-invasive endovascular interventions. New
concepts related to damage control vascular surgery are also
evolving and together with advances in resuscitation provide
the opportunity for better survival following this complex
injury pattern. It’s the premise of these authors that, amid
all the changing paradigms in vascular trauma, management
of the injury pattern should remain focused on the patient
and the physiology and not simply focused on the anatomy
of the vascular disruption. The objective of this review is to
provide insight into the epidemiology of trauma in Brazil
and the implications of vascular injury in that spectrum.
In this chapter, the authors also describe some regionally
unique aspects of diagnosis and treatment of this injury
pattern (Fig. 34-1).
Epidemiology
The epidemiology of trauma in Brazil has its roots in both the
military and the civilian settings. Currently, urban violence,
automobile crashes, and work-related accidents are responsi-
ble for most injuries in Brazil; a notable amount of those
injuries are to major vascular structures.1-3 Concomitant with
this experience, better lifesaving interventions and early resus-
citation strategies have been established in many of the larger
emergency rooms in Brazil. As in other countries, there is a
disparity of capacity to manage vascular trauma between the
larger, better-equipped centers and those in more remote or
austere locations. Additionally, a full understanding of the
epidemiology of vascular trauma is hampered by the lack of
standardized data retrieval and archiving mechanisms or
databases.1-3
Trauma in Brazil
According to Brazil’s Institute of Geography and Statistics, just
over 190 million people live in Brazil. Until the most recent
34 
decade (2000 to 2010), there were increasing levels of violence
and trauma within certain urban areas and regional locations
in Brazil (Table 34-1). This trend has lessened recently as the
rate of violent crimes including homicide have remained
steady or declined in proportion to population growth. In
Brazil, since 2003, there has been a decrease in the death rate
from homicide; and, since 2005, the rate of homicide has
fluctuated around a level of 26 per 100,000 people.1-3
Urban Conflicts
Like other areas of the world, the mechanism of vascular
trauma in Brazil differs widely depending on whether the
injury occurs in a military setting or as a result of urban vio-
lence.4,5 Subsequently, the severity of vascular trauma also
varies; injuries stemming from military- or combat-related
munitions generally cause more extensive damage. In the
absence of a recent major war, the broad-scale experience of
Brazilian surgeons dealing with severe injury caused by mili-
tary munitions including those from explosive devices has
been practically nonexistent. The sporadic use of military-
type weapons in the urban setting is a regrettable but new
reality that is not unique to Brazil. Knowledge of the type of
weaponry that is responsible for a particular type of injury can
provide information regarding the velocity and type of pro-
jectiles or munition. Although uncommon, vascular trauma
resulting from weapons such as the AR-15, AK-47, M16, and
even grenades does occur on a sporadic basis in some areas of
Brazil (Fig. 34-2).
The importance or relevance of injury from military type
weaponry in Brazil was described in injury data collected from
the Hospital Municipal Souza Aguiar (1995 to 2000). During
the study period, it was found that services provided to
patients who were victims of high-velocity munitions declined
by nearly 50%. While the decreased rate was encouraging, it
was made during a time when the overall crime rate was
decreasing in the region but the homicide rate was increasing.
These somewhat conflicting statistics suggested that high-
velocity munitions remained a significant cause of trauma
including lethal injury to major vascular structures. In an
encouraging and more-recent trend, the rate of violence and
the number of high-velocity gunshot wounds currently tended
to in the state has plummeted.1-3
The Rural Setting
The incidence of vascular trauma in the rural setting of Brazil
is difficult to measure because of vastly isolated and austere
conditions and limitations in data recording and record
keeping. However, it has been reported that between 1% and
333
 34  /  Implications of Vascular Trauma in Brazil 333.e1

ABSTRACT
Like elsewhere in the world, vascular trauma is the most
challenging aspect of care in the multiply injured patient
in Brazil, a country of approximately 190 million people.
The complexity of vascular injury, including its propensity
to result in shock or ischemia and its tendency to be associ-
ated with injuries to other tissues or organs, requires a
multidisciplinary approach focused on life- and limb-saving
maneuvers. In Brazil, urban violence, automobile crashes,
and work-related accidents are responsible for most
instances of vascular injury. In the recent decade, injury
from urban violence has plateaued or decreased when con-
sidered in the context of continued population growth. The
evaluation, diagnosis, and management of vascular trauma
in Brazil varies widely depending on whether or not the
patient is treated in a remote rural setting or in a better
equipped urban medical center. In the metropolitan areas
of Brazil, the triage, diagnosis, and management of vascular
injury is similar to that in other developed countries of the
world. In these settings, modern imaging modalities such
as multislice contrast CT scanning and contrast angiogra-
phy are useful adjuncts to the physical examination. For
organizational and teaching purposes, vascular trauma in
this international perspective essay is considered in the fol-
lowing anatomic distributions, each with slightly different
diagnostic and management considerations: (1) cervical or
carotid, (2) axillo-subclavian, (3) thoracic, (4) abdominal,
and (5) extremity. Whereas the majority of vascular injury
is managed via an open operative approach, the use of
endovascular techniques is common in the metropolitan
centers throughout the country. In these instances, stent
grafts are often used to treat or “seal” vascular disruption
in anatomically challenging areas to reach vessels such as
those in the thorax and thoracic outlet. In Brazil, challenges
exist as to the “best training paradigms” to prepare trauma
and vascular surgeons. However, a number of Brazilian
medical centers and emergency medical systems, along
with meetings and courses offered by professional societies
such as the Brazilian trauma society Sociedade Brasileira de
Atendimento Integrado ao Politraumatizado (SBAIT), have
led to an increased emphasis on the importance of all
aspects of trauma care in the country.

Key Words:  Brazil,

trauma,
South America,
vascular injury,
hemorrhage
334 SECTION 5  /  INTERNATIONAL PERSPECTIVES

FIGURE 34-1  State Institute of Cardiology Aloísio de Castro (IECAC)

in Rio de Janeiro, which is the primary medical center of the authors
FIGURE 34-2  Left lower extremity saphenous vein interposition graft
of this international perspective.
following a high-velocity gunshot wound. The extensive soft-tissue
injury is indicative of wounding with a military-like munition, in this
case an AR-15 rifle.
Table 34-1 Ranking of States by Homicide
Rates (per 100,000). Brazil
2000/2010 upper extremity vascular injury is often confined to the radial
2000 2010* artery (34% of cases) or the ulnar artery (36% of cases), either
of which frequently can be managed by ligation instead of
State Rate Position Rate Position
repair or reconstruction.
Alagoas 25,6 11° 66,8 1°
Espirito Santo 46,8 3° 50,1 2° Automobile Crashes
Pará 13,0 21° 45,9 3° Figures presented by the World Health Organization (WHO)
Pernambuco 54,0 1° 38,8 4° regarding automobile accidents in Brazil are startling and sug-
Amapá 32,5 9° 38,7 5° gestive of national health urgency. Specifically, the WHO esti-
Paraíba 15,1 20° 38,6 6° mates that by 2020 nearly 2 million deaths in Brazil could be
Bahia 9,4 23° 37,7 7° attributable to automobile crashes. Automobile crashes, which
Rondônia 33,8 8° 34,6 8° are also prevalent in urban settings, are the third leading cause
Paraná 18,5 16° 34,4 9° of death in Brazilians between the ages of 30 and 44 years, the
Distrito Federal 37,5 7° 34,2 10° second leading cause of death in those 4 to 14 years, and the
Sergipe 23,3 12° 33,3 11° leading cause of death in the 15- to 29-year-old age bracket.
Mato Grosso 39,8 5° 31,7 12° In 2010, nearly two-thirds of traffic victims were pedestrians,
Amazonas 19,8 14° 30,6 13° cyclists, and/or motorcyclists; however, in the last decade,
Ceará 16,5 17° 29,7 14° national trends are evolving with fewer automobile versus
Goiás 20,2 13° 29,4 15° pedestrian accidents and slightly lower mortality. During this
Roraima 39,5 6° 27,3 16° same time there has been an increase in deaths related to
Rio de Janeiro 51,0 2° 26,2 17° cycling and more significant increases in the mortality rates
Mato Grosso do Sul 31,0 10° 25,8 18° associated with motorcycle crashes.
Mato Grosso do Norte 9,0 24° 22,9 19°
Tocantins 15,5 19° 22,5 20° Evaluation and Diagnosis of Vascular
Maranhão 6,1 27° 22,5 21°
Acre 19,4 15° 19,6 22°
Injury in Brazil
Rio Grande do Sul 16,3 18° 19,3 23° There is wide disparity in the resources available to trauma
Minas Gerais 11,5 22° 18,1 24° patients in the more remote and smaller towns of Brazil and
São Paulo 12,2 4° 13,9 25° the resources available to patients in the larger urban medical
Piauí 8,2 25° 13,7 26° centers. In the metropolitan areas of Brazil, the routine triage,
Santa Catarina 7,9 26° 12,9 27° evaluation, and diagnosis of vascular injury is similar to that
Source: SIM/SVS/MS.
in other developed countries of the world. A detailed summary
*2010: preliminary data. of the discrepancy of resources between rural and urban
medical centers in Brazil is beyond the scope of this review.
As such, this report focuses on the diagnosis and management
4% of injuries in the more remote areas of Brazil have a vas- of vascular injury in Rio de Janeiro, which has a population
cular component. In the rural setting, lower extremity traumas of more than 6 million people and is the second largest city
usually result from automobile crashes, whereas upper extrem- in Brazil. In this setting, the prehospital evaluation of the
ity injuries typically occur as result of factory or industrial trauma victim is divided into four phases, all made by the Fire
accidents, agricultural mishaps, or domestic disputes (i.e., Department (emergency physicians):
knife or glass lacerations). In the case of domestic disputes 1. Rapid assessment: Completed in a matter of minutes,
where knife and lacerations from glass are more common, this phase aims to diagnose and treat conditions that are

life-threatening and to evaluate whether a patient is
critical.
2. Critical intervention and transportation: Transportation
to the one of seven trauma referral centers in Rio de
Janeiro should occur immediately after stabilization
procedures are completed.
3. Nonessential procedures: These are deferred until after
the patient is transported to a trauma referral center.
4. Detailed examination: This examination is to diagnose
injuries that were not observed during the rapid assess-
ment. For critical patients, this phase must be performed
during transportation; whereas, for stable patients, it
can be performed on the scene in less than 5 minutes.
Referral trauma centers in the city of Rio de Janeiro are
able to use modern resuscitation rooms, which are accessible
to the prehospital emergency vehicle(s) and providers with
ample space for a multidisciplinary team to quickly triage and
perform a range of diagnostic and resuscitative maneuvers.
These resuscitation rooms are equipped with radiography and
ultrasound equipment to perform diagnostic imaging and
assist with vascular access, as well as operative equipment to
facilitate resuscitation (i.e., transfusion), fracture stabilization
and immediate lifesaving interventions. Depending on the
injury, as soon as the initial survey is complete and any life-
saving maneuvers are performed, the patient is usually trans-
ferred to one of three locations: radiology for additional
imaging, the intensive care unit for monitoring and resuscita-
tion, or the operating room for resuscitation and repair. In
most cases of significant vascular trauma, patients are trans-
ferred from the resuscitation room to the operating room
where additional imaging and repair can be performed as
needed while resuscitation is ongoing.
Region-Specific Treatment Strategies
(Acute Vascular Hemorrhage and
Acute Ischemia)
A retrospective study from the Municipal Hospital Souza
Aguiar (one of the largest emergency centers in Latin America)
between 1998 and 2008 reported 1478 vascular injuries in
1236 patients. Like other regions of the world, findings from
this study revealed that vascular trauma in Brazil occurs most
commonly in men (73% of the cohort) under 40 years of age
(69% of the cohort). The main mechanism of vascular injury
in this study was gunshot wound (73%) with low-velocity
projectiles being more common than those with high velocity
(83% and 17%, respectively). The most common anatomic
location of vascular injury was the lower extremities followed
by the upper extremities (54% and 33%, respectively). Approx-
imately 5% of the vascular injuries were in the cervical region
with a similarly small percentage in the abdomen (5%) and
the thorax (3%). Surgical management of vascular injury in
this retrospective series consisted of primary anastomosis
(39%), graft reconstruction (21%), ligation (16%), and suture
repair (12%). Primary amputation was reported in only 1.5%
of the cases of extremity vascular trauma. The main conduit
used as vascular substitute was autologous vein, with synthetic
grafts used in only 5% of the reconstructions. In instances in
which an autologous conduit was used, the vast majority of
the time (90%) that conduit was great saphenous vein (Fig.
34-3). Of note, arm cephalic vein was used as a conduit in a
34  /  Implications of Vascular Trauma in Brazil 335
FIGURE 34-3  Arterial reconstitution using superficial femoral vein in
pediatric trauma.
few instances (1.3%) of autologous reconstructions. Not sur-
prisingly (and like other regions of the world) patients who
had the misfortune of having vascular and nonvascular trauma
(i.e., polytrauma) had the highest rates of mortality in the
review. The highest mortality existed in those patients with
vascular trauma and concomitant cranial and/or thoracic
injury.
Specific Vascular-Injury Patterns
A complete rundown of all anatomic locations of vascular
trauma managed in Brazil would be redundant of other mate-
rial in this book and beyond the scope of this review. However,
for completeness sake, the following are brief mentions of
various injury patterns with one or two points based on the
authors’ experience. Suffice it to mention that, like other areas
of the world, endovascular technologies (i.e., balloons, stents,
and stent-grafts) have played increasingly important roles in
managing some patterns of vascular trauma, especially in the
larger and better-equipped tertiary trauma centers in Brazil
(Fig. 34-4). In general, endovascular stent-graft management
of vascular trauma is reserved for central vascular injuries of
the aorta and its proximal branch vessels, such as the subcla-
vian, intrathoracic carotid, and even occasionally a mesenteric
vascular injury.
Carotid Injuries
Lesions of the common and internal carotid artery may cause
thrombosis and/or hemorrhage, especially when the wound is
lateral or in the intimal lesion, which may go unnoticed and
cause future problems (i.e., pseudoaneurysm). It has been the
authors’ experience that an open arterial reconstitution has
been the best procedure, even in patients with neurologic
symptoms. A neurological assessment of the patient before
and after the operation is essential to outline the best thera-
peutic course and to assess its outcome. For injuries to the
external carotid artery and its branches, endovascular embo-
lization has been useful with good results for these authors.
Subclavian Injuries
Like others, the authors recognize that there is a significant
difference in the surgical approach to the three distinct
336 SECTION 5  /  INTERNATIONAL PERSPECTIVES
A1 A2
B1 B2
FIGURE 34-4  Endovascular treatment (arteriography and emboliza-
tion of bleeding) of vascular trauma resulting from pelvic fracture.
segments of the subclavian artery. The intrathoracic segment
of the subclavian artery is typically approached using a high
anterolateral thoracotomy with or without a separate supra-
clavicular exposure of the more distal artery. Because of the
challenges associated with exposing and controlling the intra-
thoracic subclavian artery, the authors have found this injury
location particularly well suited for treatment using an endo-
vascular covered stent. The more distal subclavian artery seg-
ments behind and distal to the first rib can be exposed with a
supraclavicular incision often combined with an infraclavicu-
lar approach of the axillary artery. Like the intrathoracic
segment, the authors have found endovascular repair of the
more distal subclavian and even proximal axillary artery
favorable in some cases.
Thoracic Vascular Trauma
Given the prevalence of automobile crashes in Brazil, experi-
ence with blunt thoracic aortic injuries is considerable. Like
other developed regions of the world, diagnosis of this injury
is now almost solely based on contrast-enhanced CT imaging
and/or magnetic resonance imaging (MRI). Contrast angiog-
raphy is typically reserved for the time of stent-graft repair of
blunt aortic injury, which has quickly become the approach
of choice for the majority of these types of injuries. The
authors have observed that endovascular stent-graft repair of
blunt descending thoracic aortic injuries has greatly reduced
the morbidity and mortality associated with this pattern of
vascular trauma. Like other areas of the world in which there
is a wide discrepancy between medical capabilities in urban
versus rural areas, the greatest challenge in Brazil is making
this type of approach and repair available to a wider range of
patients.
Abdominal Vascular Trauma
Injury to the abdominal aorta typically results in the onset of
retroperitoneal bleeding or occasionally free bleeding into the
abdominal cavity. Unlike blunt injuries to the descending tho-
racic aorta, the authors prefer an open approach (i.e., lapa-
rotomy) to abdominal aortic injuries (blunt or penetrating).
Because of the propensity for large resuscitation and damage
to hollow viscus or solid organs, principles of damage control
laparotomy are espoused by the authors. Like elsewhere in the
world, this approach to abbreviated operating focuses mostly
on patient physiology and resuscitation while controlling
hemorrhage and contamination with a willingness to return
to the operating room at a later time for more definitive repair.
Extremity Vascular Trauma
Penetrating injury to the extremities, resulting in tissue
destruction and vascular disruption, often requires a multidis-
ciplinary approach that includes vascular, trauma, and ortho-
pedic surgeons. Like other anatomic areas of vascular injury,
the priorities in the extremities are to control hemorrhage and
to restore perfusion. However, unlike other anatomic areas,
consideration of fracture reduction and stabilization is often
necessary in extremity trauma. Following hemorrhage control,
fracture reduction and alignment is usually accomplished. If
fracture fixation (internal or external) is necessary and pre-
dicted to take some length of time, the authors typically
proceed with reestablishing perfusion to the limb first. This
can be accomplished with a formal vascular reconstruction or
with the use of temporary vascular shunts. If shunts are used,
they are removed and vascular repair performed after the frac-
ture fixation has been completed. Another important consid-
eration is adequate soft-tissue coverage of the vascular repair.
If tissue destruction is such that this cannot be accomplished
with the vascular graft routed in the normal or in-situ posi-
tion, the authors favor routing the conduit in an extraana-
tomic location (i.e., extraanatomic bypass) to reduce the risk
of infection and disruption. Difficulties in acquiring suitable
prosthetics and rehabilitation for amputees in the reference
centers in Brazil emphasize the need for surgical teams to
maximize efforts at limb salvage in patients with extremity
vascular injury (Fig. 34-3).
Regional Strategies to Sustain and
Train the Next Generation of
Trauma Surgeons
Learning from our own experiences and mindful of military
experience and reports from around the world, trauma centers
and systems in Brazil have been formed in two different
manners.6-8 The first group arose mostly out of academic

interest as hospitals attached to medical schools already
received trauma patients. In the other group was a larger col-
lection of hospitals, mostly public, that had a long experience
in caring for trauma victims, but with fewer propensities for
formal academics or study in the field of trauma surgery. To
become a general surgeon in Brazil, the doctor must always
perform a minimum of 2 years of general surgery. By law in
Brazil, with 2 years of general surgery residency, one can be
certified as a general surgeon and practice acute care surgery.
In an attempt to correct this problem, some residency pro-
grams have divided the general surgery residency into two
sections: basic general surgery for 2 years and advanced
general surgery for an additional 2 years. All other surgical
specialties require 2 years of general surgery and 2 or 3 years
of the specialty (i.e., vascular surgery). Specialist surgeons in
Brazil have two titles: general surgeon and another title that
reflects their specialty.
In Brazil, there are 55 vacancies for medical residency pro-
grams in trauma surgery, distributed in 9 states. These resi-
dency programs consist of 2 years of general surgery plus 1
year of training in trauma. There is still a deficiency in the
teaching of trauma, due to the complexity of this specialty.
However, trauma and emergency surgeries are significant
problems in the health-care system in Brazil because the
trauma and emergency surgeries are usually performed by
surgeons with only 2 years of general surgery training or are
performed by specialists with 2 years of general surgery and a
further 2 or 3 years of any specialty training. To address some
of these challenges, professional societies such as the Brazilian
trauma society Sociedade Brasileira de Atendimento Inte-
grado ao Politraumatizado (SBAIT), created in 1984, have
been offering annual meetings and many courses for all
health-care providers in trauma.
34  /  Implications of Vascular Trauma in Brazil 337
In conclusion, it is the authors’ viewpoint that the future
of vascular surgery, specifically vascular trauma, is very prom-
ising in Brazil. It is a good sign for the country and region that
the overall indices of urban violence are decreasing and that
the number of established and capable trauma centers is
increasing. Challenges remain as to the “best training para-
digms” for trauma and vascular surgery; however, with the
emergence of improved methods of damage control and
resuscitation and with the rapid acceptance of catheter-based,
endovascular techniques to treat some forms of vascular
injury, patients with this challenging injury pattern stand to
have improved outcomes.
REFERENCES
1. Araujo GR, Mathias SB, Junior GF: Dados epidemiológicos (Epidemiol-
ogy). In Rossi M, editor: Trauma Vascular, Revinter, 2006, Rio de Janeiro,
pp 74–82.
2. Waiselfisz JJ: Novos padrões da violência homicida no Brasil, São Paulo,
2011, Mapa da Violência. Instituto Sangari.
3. Rossi M, Loureiro E, Villas-Boas R: Traumatismo Vascular (Vascular
Trauma). In Brito: cirurgia vascular, Revinter, 2013, Rio de Janeiro,
pp 1651–1688.
4. Stannard A, Brown K, Benson C, et al: Outcome after vascular trauma in
a deployed military trauma system. Br J Surg 98(2):228–234, 2011.
5. White JM, Stannard A, Burkhardt GE, et al: The epidemiology of vascular
injury in the wars in Iraq and Afghanistan. Ann Surg 253(6):1184–1189,
2011.
6. Eastridge BJ, Mabry RL, Seguin P, et al: Death on the battlefield (2001-
2011): implications for the future of combat casualty care. J Trauma Acute
Care Surg 73(6 Suppl 5):S431–S437, 2012.
7. Rasmussen TE, Gross KR, Baer DG: Where do we go from here? J Trauma
Acute Care Surg 75(2 Suppl 2):S105–S106, 2013.
8. Bailey JA, Morrison JJ, Rasmussen TE: Military trauma system in Afghani-
stan: lessons for civil systems? Curr Opin Crit Care 19(6):569–577, 2013.
INDEX
A Adenosine, administration of, 80
Abdomen, zones of, 259-260, 260f
Abdominal aorta, injury to, 336
blunt, 208-209
penetrating, 208-209
zones of, 219, 220f
Abdominal aortic trauma, 113-125
anatomy in, 114, 114f
aortic injuries in, 117-119
follow-up for, 119
investigations on, 118
treatment of, 118-119, 119f
in central retroperitoneal area (zone I), 114
clinical presentation of, 114-115
complications of, 123
endovascular treatment of, 123-125
embolization in, 123-124
solid organs and pelvic trauma, 124-125
iliac artery in, injuries to, 121-122, 122b
investigations in, 115
mechanism of injury in, 113-114
in pelvic retroperitoneum (zone III), 114
surgical management of, 122-123
surgical techniques for, 115-117
in upper lateral retroperitoneum (zone II),
114
visceral arteries in, injuries to, 119-121
celiac artery and branches, 119
endovascular treatment for, 121
inferior mesenteric artery, 120
mortality in, 121
renal artery, 120-121
superior mesenteric artery, 119-120
Abdominal injuries, vascular conduit for,
208-209
Abdominal vascular injuries, 36-37
in austere environment, surgery for, 259-260,
260f-261f
clearing trauma patients from, 40b
organ injury scale for, 127t
Abdominal vascular trauma, in Brazil, 336
ABI. see Ankle-brachial index (ABI)
Access to care, in Australia and New Zealand,
284
ACCP. see American College of Chest Physicians
(ACCP)
ACS COT. see American College of Surgeons
Committee on Trauma (ACS COT)
Acute ischemia
management of, 326
region-specific treatment strategies for, 335,
335f
Acute limb ischemia, 303
classification of, 303t
Acute vascular injury, endovascular management
of, 215-225
Note: Page numbers followed by “f ” refer to illustrations; page numbers followed by “t” refer to tables; page numbers followed by “b” refer to boxes.
Adenosine triphosphate (ATP)-dependent ionic
pump, failure of, 28
Adhesion molecule, 30-31
Advance dressing station (ADS), as second line
of care, 287
Advanced Skills in Vascular Surgery Course,
275
Advanced Surgical Skills for Exposures in
Trauma (ASSET), 276-277, 276t
Advanced Trauma Life Support (ATLS), 57, 59,
168-169, 284, 325
guidelines for patient assessment for vascular
injury, 39
injured extremity assessment guidelines, 244
Advanced Trauma Operative Management
(ATOM), 275-276
Aerodigestive injuries, in carotid/vertebral
injuries, 142
Afghanistan
military vascular surgery in, during Gulf War,
11
vascular injuries in, 301-305, 301.e1
considerations for diagnosis of, 303
epidemiology of, 301-302
strategies for sustaining and training of
trauma surgeons in, 305
systems of care in, 302-303, 302f
treatment strategies in, 304-305
Age, of patient, vascular trauma and, 17-18
Agency for Healthcare Research and Quality, 273
Air leaks, as lung injury complication, 96
Air-bag, inflation of, blunt thoracic injury and,
73
Allografts, 208
American Association for the Surgery of
Trauma, organ injury scale for abdominal
vascular injury, 126, 127t
American Board of Surgery (ABS), Primary
Certificate in Vascular Surgery, 271
American College of Chest Physicians (ACCP),
guidelines against use of IVC filters, 238
American College of Surgeons (ACS)
Committee on Advanced Trauma Life Support
program, guidelines for trauma
resuscitation, 57, 59
verification system for systems of care, 283
American College of Surgeons Committee on
Trauma (ACS COT)
Resources for the Optimal Care of the Injured
Patient, 24
Verification Review Committee, 24
Amputation, 253f, 322
in complex upper extremity vascular trauma,
152
forearm, 264-265, 267f
Amputation (Continued)
in lower extremity vascular injury, 180
versus salvage, 243
Analgesia, for lung injuries, 93
Anastomosis
of artery, first end-to-end, 6, 6f
end-to-end, 174, 313
pediatric, construction of, 230
Anatomy. see Surgical anatomy
ANGIO Mentor, 274
Angiography, 44-48, 45t, 310
catheter. see Catheter angiography
complications of, 48
in iliac artery injuries, 122
indications for, 44-45
multidetector computed tomography. see
Multidetector computed tomographic
angiography (MDCTA)
on-table, 47
operative strategy in, 46-47
operative technique in, 47-48, 47f-48f
pitfalls and danger points of, 46
portable, for vascular injury, 41
postoperative care in, 48
preparation for, 45
transcatheter, 44
“Angiology”, 299
Animal-derived conduits (xenografts), 208
Ankle-brachial index (ABI), 40, 169
for pediatric vascular injury, 228
Anterolateral thigh (ALT) flap, 249-250, 250f
Anterolateral thoracotomy, 67, 67f-68f, 73
bilateral, 74
and pericardiotomy, 79
left, 74, 75f
Anticoagulation
for pediatric vascular injuries, 232-233
in temporary vascular shunts, 203
Antiplatelet therapy
dual, for blunt carotid/vertebral injuries,
141
for pediatric vascular injury, 233-234
Antithrombotic therapy
for cervical arterial injuries, 140
postoperative, 146
Antyllus, 4
Aortic clamping, thoracic, 74, 75f-76f
Aortic injuries, 117-119
follow-up for, 119
investigations on, 118
treatment of, 118-119, 119f
Aortic occlusion, resuscitative, 67
Aortic occlusion balloons, for penetrating
trauma and blunt trauma, 223, 223f
Aortocaval fistulas, abdominal vascular injuries
and, 114-115
339
340 Index
Aortogram, of thoracic aortic stent-graft
placement, 285f
Aortography
in blunt thoracic aortic injury, 102-103
of traumatic false aneurysm, 101f
Aortorrhaphy, 88
Archigenes, 3-4
Argyle shunt, 201f-202f, 202t
Arnez classification, of degloving injury, 247b
Arrhythmias, blunt cardiac injury and, 78
Arterial conduits, 207
Arterial fistulas, abdominal vascular injuries and,
114-115
Arterial injury, 252, 253f
anatomic site of, 310t
blunt, 309
demographics of, 310t
endovascular repairs of, 320-321, 321f-322f
injured extremity index and, 169
mechanism of, 310t
modality distribution of, 310t
type of, 310t
Arterial occlusion
angiographic findings in, 45t
ultrasound findings in, 45t
Arterial reconstruction, method or type of,
311t
Arterial repair, 143
nonsuture method of, during World War II, 9,
9f
performed by Halowell, 5f
Arterial stenosis
angiographic findings in, 45t
ultrasound findings in, 45t
Arterial suture, techniques for, 7
Arterial trauma
classification of acute limb ischemia in, 303t
ligation for, 3
Arterial vascular injuries
iatrogenic, in Sweden, 298f
noniatrogenic, in Sweden, 298f
Arterial wall injury, 301
Arteriogram
intraoperative, for blunt thoracic aortic injury,
218f
in lower limb vascular injuries, 261f
in upper limb vascular injuries, 258f
Arteriography
in axillary artery injury, 150
for carotid arterial injury, 215
focal areas of narrowing on, in pediatric
vascular injury, 229f
injured extremity index and, 169
trauma, technical sophistication of, 46
Arteriorrhaphy, lateral, 174
Arteriovenous fistula, 311f
angiographic findings in, 45t
bilateral iliac artery to iliac vein, 322f
pediatric vascular injury and, 228
traumatic, manifestations of, 180
ultrasound findings in, 45t
Artery injuries, primary surgical operations for,
306t
Artificial blood vessels, 212
Ascending aortic arch, penetrating wound of,
88
ASSET. see Advanced Surgical Skills for
Exposures in Trauma (ASSET)
Association for Program Directors in Vascular
Surgery, 271
ATLS. see Advanced Trauma Life Support
(ATLS)
ATOM. see Advanced Trauma Operative
Management (ATOM)
Atriocaval shunt, 136, 136f
Auckland City Hospital Trauma Registry, 283
Austere environment
vascular surgery in, 252-268
working in, 265-268
Australia, vascular trauma in, 281-286
abstract, 283.e1
access to care in, 284
considerations for diagnosis of, 284-285
epidemiology in, 283
prehospital care in, 284
strategies for sustaining and training of
trauma surgeons in, 285-286
surgical training and certification in, 283-284
systems of care in, 283
treatment strategies in, 285, 285f
Autologous conduit, 207
in austere and military settings, 210-211, 211f
Autologous graft, definitive vascular repair with,
247
Autologous saphenous vein, as conduit, 313
Autologous vein, 174
conduit, 209t
use of, 211
Automobile accident, 325
Automobile crashes, in Brazil, 334
Axillary artery
anatomy of, 158, 161f
complete exposure of, 258f
Axillary artery injuries, 150
operative management of, 158-159
tourniquet in, 152
Axillosubclavian artery injury, endovascular
management of, 221-222, 222f
B presentation of, 85-86, 86f
Balkan Wars, surgical management history in,
309
Balloon occlusion, for hemorrhage control, 130,
135
Basilic vein, as conduit, 210
BATLS. see Battlefield Advanced Trauma Life
Support (BATLS)
Battlefield
clinical practice on, 28-29
trauma care, preventable death in, 185
Battlefield Advanced Trauma Life Support
(BATLS), 59
Bec de corbin, 4, 4f
Beck’s triad of hypotension, 77
Biologic conduits
allografts, 208
xenografts, 208
“Bird-beaking” phenomenon, 218, 219f
Bleeding, embolization in, 123-124
Blood components, effective and balanced use
of, 60
Blood-component replacement therapy, 57-58
Blood pressure, in thoracic aortic injuries,
103-104
Blunt abdominal aortic injury
classification of, 220f
endovascular management of, 219-220,
219f-221f
Blunt aortic injury (BAI), 208-209
Blunt arterial injury, 301
Blunt injury
in arterial injury, 309
thoracic aortic, 100-112
Blunt thoracic aortic dissection, 327
Blunt thoracic aortic injury (BTAI), 100-112
abstract, 100.e1
aortography in, 102-103
chest x-ray in, 102, 102f
clamp-and-sew technique in, 105, 106f
classification of, with treatment guidelines,
103f
Blunt thoracic aortic injury (BTAI) (Continued)
CT scan in, 102-103, 103f
definitive management of, 105, 105t
timing of, 104, 104f
diagnosis of, 102-103, 103t
endograft design for, advances in, 109-110
endovascular aortic repair for, 106-109, 107f
complications in, 107t, 108f-109f
versus open repair, 109t
endovascular management of, 217-218,
218f-220f
epidemiology of, 100, 101f
historical background of, 100
initial management of, 103-104
natural history of, 101-102
nonoperative management of, 110-111
open surgical repair of, 105-106, 106f
versus endovascular aortic repair, 109t
region-specific treatment strategies of, 285
screening of, 102-103, 102f
site of, 100, 101f
TEE in, 103
type of, 100, 101f
Blunt thoracic aortic rupture, computed
tomography of, 284f
Blunt trauma, 324
in abdominal vascular injuries, 113
aortic occlusion balloons for, 223
carotid traumatic dissection secondary to,
284f
to great vessels
diagnosis of, 86
etiology of, 83-84, 84f
incidence of, 83
to heart
diagnosis of, 78-79
incidence of, 77
presentation of, 77
in iliac artery injuries, 121
to lungs
etiology of, 92
incidence of, 92
Blunt vascular injuries (BVI), 226-227
Bogota (Borraez) bag, 331, 331f-332f
Boyden, Allen M., 8
Brachial artery, anatomy of, 159-160, 162f
Brachial artery injuries, 150-151
operative management of, 160-161, 162f
pediatric, management of, 231-232
Brachial plexus injury, 139, 142
Brachioradialis flap, 264, 264f
Brazil, vascular trauma in, 333-337, 334f
abstract, 333.e1
epidemiology of, 333
evaluation and diagnosis of, 334-335
incidence of, in rural setting, 333-334
mechanism of, 333
prehospital evaluation in, 334-335
rural setting, 333-334
strategies for sustaining and training of
trauma surgeons in, 336-337
treatment strategies for, 335, 335f
urban conflicts, 333
Brener shunt, 202t
British troops, noncompressible torso
hemorrhage in, 66
BTAI. see Blunt thoracic aortic injury (BTAI)
Bullet injuries, explosive and high velocity,
treatment of, 313
Burbank shunt, 202t
C
Cadaver-based training, for vascular trauma,
272, 277f

Cardiac, great vessel, and pulmonary injuries,
71-99
abstract, 73.e1
advanced trauma life support in, 73-74
evaluation and management of, in emergency
center, 73-74
mechanism of, 73
Cardiac box, 73
Cardiac compression, with sternal closure, 90
Cardiac failure, after repair of injury and, 82
Cardiac injuries, penetrating, 327
Cardiac rhythm, restoration of, for great vessel
injuries, 80
Cardiac tamponade, 77
Cardiovascular collapse, arrest following, 62
Carotid arterial injury, endovascular
management of, 215-217
Carotid artery, external, bleeding from, ligation
for, 254
Carotid artery injuries, 139
operative strategy and technique for, 142-144,
143f
penetrating right common, ePTFE
interposition graft in, 212f
repair of, 140
Carotid artery trauma, penetrating, 146
Carotid injuries
in austere environment, vascular surgery for,
253-254, 254f-255f
in Brazil, 335
Carotid-jugular fistulae, 254
Carotid traumatic dissection, secondary to blunt
trauma, 284f
Carrel, Alexis, 206, 297
CASEVAC. see Casualty evacuation (CASEVAC)
Casualty evacuation (CASEVAC), 194
CAT. see Combat Application Tourniquet (CAT)
Catheter angiography, 141-142
in fixed-imaging suite, for vascular injury, 42
in iliac artery injuries, 122
Catheter-based arch aortography, in blunt
thoracic aortic injury, 102-103
CathLab VR Simulator, 274
Cattell-Braasch maneuver, 260, 261f
Caval ligation, 131-132
Celiac artery, injuries to, 119
Celox, for hemorrhage, 188, 189t
Celsus, 3-4
Cerebral edema, management of, 146
Cerebral ischemia, 90
Cervical collar, for penetrating neck injuries, 254
Cervicomediastinal injuries, 326
Chest radiograph, anteroposterior, in
mediastinal vascular injury, 36
Chest vascular injuries, clearing trauma patients
from, 40b
Chest x-ray, 60-61
for lung injuries, 93
for penetrating injuries, 74
in screening of blunt thoracic aortic injury,
102, 102f
CIN. see Contrast-induced nephropathy (CIN)
Circulatory arrest, vein injuries and, 136-137
Civilian center, types of repair at, 289f
Civilian injuries, 287
Civilian populations, vascular trauma in, 16-17
Civilian setting, prophylactic four-compartment
fasciotomies in, 290-291
Civilians, noncompressible torso hemorrhage in,
66
Clamp-and-sew technique, 105, 106f
for pediatric thoracic aortic injuries, 232
Clamping, cross, 94
Clinical Practice Guideline (CPG)
Joint Theater Trauma System (JTTS), on
DCR, 193
Clinical Practice Guideline (CPG) (Continued)
uptake of, in systemizing vascular-injury care,
26
Coagulopathy of trauma, prevention and
treatment of, 191-192
Coil embolization, in control of bleeding, 123
College of Medicine of South Africa, 2-year
Higher Surgical Diploma, 325
College of Surgeons of Sri Lanka, 292
Colloids
in prehospital fluid resuscitation, 192
as resuscitation fluid, 60
Combat Application Tourniquet (CAT), 186-187,
186f
Combat casualty care, trauma systems in, 24
Combat Gauze, for hemorrhage, 188, 189f, 189t
Combat injuries, distribution of, 186f
Combat Ready Clamp (CRoC), 171-172, 190,
190f
Combat troops, vascular trauma in, 14-15
Combat-action tourniquet, 285, 285f
Committee on Tactical Combat Casualty Care,
188-189
Common carotid artery, blunt tear of, repair of,
89-90
Compartment pressure, normal, 165
Compartment syndrome
axillary or subclavian artery repair and, 146
fasciotomy and, 321-322, 322f
upper extremity vascular injury and, 165,
165b, 166f
vascular injury and, 42, 43f
Comprehensive vascular skills assessment
(CVSA), for surgical trainees, 274-275
Compression dressings, for hemorrhage control,
320f
Computed tomography angiography (CTA),
284-285
of carotid and vertebral injuries, 139
in iliac artery injuries, 122
of neck and thoracic outlet vascular trauma,
139
of pediatric vascular injury, 227-229, 229f
performance of, 141-142
three-dimensional, 55
two-dimensional, 54-55
Computed tomography arteriography, 86
Computed tomography (CT), 52-55, 59, 61
for blunt thoracic aortic injury, 102-103, 103f,
103t
for blunt thoracic aortic rupture, 284f
for caval injury, 127
complications of, 55
for endovascular repair of blunt thoracic
aortic injury, 218f
historical background of, 44
indications for, 52, 53f
for lower extremity vascular trauma, 171
postexamination care in, 55
strategy for, 54
technique for, 54-55
for vascular injury, 310
Conformable GORE TAG Thoracic
Endoprosthesis, for blunt thoracic aortic
injury, 217
Continuous wave Doppler, 40
machine, in Columbia and Latin America, 330
Contrast angiography, in thoracic vascular
trauma, 336
Contrast arteriography, in lower limb vascular
injuries, 261, 261f
Contrast-induced nephropathy (CIN), 45
Covered stents, for pseudoaneurysms, 216
CPG. see Clinical Practice Guideline (CPG)
Cranial nerves, 142
CRASH-2 trial, 191
Index 341
Crew resource management (CRM), skills,
272-273
Croatia, vascular trauma in, 293-296
abstract, 293.e1
considerations for diagnosis of, 295
epidemiology of, 293
strategies for sustaining and training of
trauma surgeons in, 296
system of care in, 293-295
treatment strategies in, 295-296
war vascular injuries in, 293, 294f-295f
Croatian National Institute of Public Health,
293
Cross-clamping, of hilum of lung, 94
Crossover left innominate vein, 90
Crush injuries, in abdominal vascular injuries,
113
Cryoprecipitate, 62
Cryopreserved allograft conduit, 209t
Cryopreserved arterial allografts, 208
Cryopreserved artery, 208
Cryopreserved saphenous vein allografts, 208
Crystalloid
in prehospital fluid resuscitation, 192
as resuscitation fluid, 60
CT. see Computed tomography (CT)
CTA. see Computed tomography angiography
(CTA)
CVSA. see Comprehensive vascular skills
assessment (CVSA)
D
Damage control
considerations for vascular conduit in repair
of vascular injury, 206-214
prehospital care of patient with vascular
injury, 183-197
Damage control resuscitation (DCR), 29-31,
30f-31f, 193-194
for noncompressible torso hemorrhage, 66
for thoracic trauma, 74
for vascular trauma, 56-63
abstract, 56.e1
definitions, 56-57
fluids and medications, 60
imaging in, 60-61
preparation for, 58-59, 58b
survey, 57
techniques and procedures in, 59-60
Damage control surgery (DCS), 57
for noncompressible torso hemorrhage, 66
Data collection, in systemizing vascular-injury
care, 26, 26b
DCBI. see Dismounted complex blast injury
(DCBI)
DCR. see Damage control resuscitation (DCR)
DCS. see Damage control surgery (DCS)
DDR. see Direct digital radiography (DDR)
Death
potentially preventable, 56
preventable, 185
DeBakey, vascular injury burden in WWII, 14
Debridement, in complex upper extremity
vascular trauma, 152
Deceleration
injury, 73
severe, in abdominal vascular injuries, 113
Decision making, in choice of vascular conduit,
208-210
Deep venous thrombosis (DVT)
duplex scanning for, 49-50
duplicated IVC in, 239f
IVC filters and, 236, 239-240
Definitive arterial reconstruction, for pediatric
vascular injury, 226
342 Index
Definitive Surgical Trauma Care (DSTC), 275,
325
Definitive Surgical Trauma Skills (DSTS), 275
Degloving component, in injured extremity, 244
Degloving injury, 246-247
Arnez classification of, 247b
Diagnosis of vascular injury, 33-43
abstract, 35.e1
clearing trauma patients from presence of,
40-41, 40b
compartment syndrome and, 42, 43f
definitive diagnosis of, 41-42
catheter angiography in fixed-imaging suite,
42
multidetector CT angiography in, 41-42
portable angiography in, 41
surgical exploration in, 41, 41f
hard signs of, 39b
mechanism, setting, and patterns of, 35
pattern of recognition in, 35-39, 36b
abdominal, 36-37
head and neck, 35-36, 37f-38f
high-risk, 39
lower extremity, 38-39
thoracic, 36, 38f
upper extremity, 37-38, 39f
penetrating, 35
physical examination of, 39-40, 39b
soft signs of, 39b
Digital subtraction angiography (DSA), 47, 295
Direct digital radiography (DDR), 60-61
Direct pressure, for hemorrhage control, 190
Dislocation, elbow, brachial artery injury and,
150
Dismounted complex blast injury (DCBI),
189-190, 189f
Distal ischemia
dislocated knee associated with, 284f
occlusive injuries with, 39
Distal small vessel, versus proximal large vessel,
202-203
Doppler ultrasound, adjunctive measures, 40
DSA. see Digital subtraction angiography (DSA)
DSTC. see Definitive Surgical Trauma Care
(DSTC)
DSTS. see Definitive Surgical Trauma Skills
(DSTS)
Duplex color flow imaging, 40
Duplex ultrasonography, for venous injuries, 180
Duplicated inferior vena cava, 239f
DVT. see Deep venous thrombosis (DVT)
E Exploratory laparotomy, for lower penetrating
Eastern Association of the Surgery in Trauma,
236-238
Ebers’ papyrus, 3
EBVS. see European Board of Vascular Surgery
(EBVS)
Eck, Nikolai, 301
EFAST. see Extended FAST examination
(EFAST)
Egyptians, ancient methods of hemostasis by, 3
Elbow dislocation, brachial artery injury and,
150
Elective peripheral vascular bypass, studies of,
206
Electrolyte disturbances, transfusions and, 60
Ellis, 5
Embolization, control of bleeding by, 123-124
complications in, 125
Emergency center thoracotomy, 74
Emergency Medical Tourniquet (EMT), 186-187,
186f
Emergency room, triage in, 320
Empyema, 96
EMT. see Emergency Medical Tourniquet (EMT)
Endograft design, advances in, 109-110,
110f-111f
Endothelial cell migration, for vascular repair, 30
Endothelial injury, 28
Endothelialization, 30
Endovascular aortic repair (EVAR), for thoracic
aortic injuries, 106-109, 107f
complications in, 107t, 108f-109f
versus open repair, 109t
Endovascular embolization, 217
Endovascular grafts, 135
for hemorrhage control, 130
Endovascular management, of acute vascular
injury, 215-225
abstract, 215.e1
aortic occlusion balloons for penetrating
trauma and blunt trauma, 223
of axillosubclavian artery injury, 221-222,
222f
of blunt abdominal aortic injury, 219-220,
219f, 221f
of blunt thoracic aortic injury, 217-218
of carotid arterial injury, 215-217
of extremity vascular injury, 222-223, 222f
long-term follow up in, 223
repair versus observation, 218-219
of vertebral artery injury, 217
Endovascular repair
of arterial injuries, 320-321, 321f-322f
of vascular trauma, in Serbia, 314
Endovascular simulators, 274
barriers to, 275
Endovascular stent-graft placement, 220
Endovascular surgery, in Northern Europe, 299
Endovascular techniques, 215
in vascular surgery, 135
Endovascular therapy, 145-146
Epidemiology, definition of, 13
EPTFE. see Expanded polytetrafluoroethylene
(ePTFE)
Equipment requirements, in resuscitations, 59
Esmarch-Langenbeck tourniquet, 303
Ethics, in resuscitation, 62
European Board Fellowship Examination, 298
European Board of Vascular Surgery (EBVS), 274
European Vascular Examination, 300
European Vascular Masterclass (EVM), 277-278
Evacuation methods, of vascular injuries, 317
EVM. see European Vascular Masterclass (EVM)
Exacerbation, of coagulopathy of trauma, 191
Expanded polytetrafluoroethylene (ePTFE)
grafts, 174, 207-208, 211, 212f, 331
abdominal trauma, 170
Exsanguination, 14
“Exsanguination shock”, 193-194
Extended FAST examination (EFAST), 92-93
External carotid artery, 207
External carotid-internal carotid transposition,
143f
External nonextremity hemorrhage, control of,
187-189
Extracorporeal life support (ECLS) cannulation,
for pediatric vascular injury, 233
Extremity compartment syndrome, 204, 331
Extremity hemorrhage, control of, 185-187
Extremity injuries, 28-29, 242
assessment of, 244-246, 245t
incidence of, 15
pediatric, management of, 229-231, 230f-231f
Extremity vascular injuries, 319-320
among local national populations, 15
case of, 293
endovascular management of, 222-223, 222f
hard signs of, 169
Extremity vascular injuries (Continued)
lower. see Lower extremity vascular injuries
upper. see Upper extremity vascular injury
Extremity vascular trauma, in Brazil, 335f, 336
Extremity vessels, vascular conduit for, 209
F
False aneurysm. see Traumatic false aneurysm
Fasciocutaneous flaps, 264, 264b, 266f-267f
for lower limb wounds, 249-250
muscle flaps versus, 249, 250f
Fasciotomy, 331
absolute indications for, 263
compartment syndrome and, 321-322, 322f
indications for, in combat setting, 165, 165b
lower extremity, 173
two-incision approach in, 181, 181f
for pediatric extremity injuries, 232
performance of, for extremity injuries, 248
prophylactic
four-compartment, 290-291, 291f
ligation of vena cava and, 132
temporary vascular shunt and, 204
of upper extremity, 165, 166f
Fellow of the European Board of Vascular
Surgery (FEBVS), 300
Femoral artery
common, reconstructed, with synthetic graft,
295f
exposure of, 177-178
traumatic lesions in, 222
Femoral injuries, 170, 170f-171f
complications of, 180
considerations for, 177-179, 177f-178f
preoperative preparation for, 172, 172f
Femoral vein
common, reconstructed, with synthetic graft,
295f
exposure of, 177-178
Femoral vessels
percutaneous ligation of, 302, 302f
surgical anatomy of, 177f
Fibular artery, end-to-side insertion of, 295f
First line of care, in Sri Lanka, 287
Fix and flap reconstruction, 248
Fixed imaging units, 47, 48f
Flap reconstruction, 249
Fleming, 4-5
Fluid resuscitation, for noncompressible torso
hemorrhage, 190
Fluoroscopy, mobile cine loop, 47, 48f
Focused abdominal sonography in trauma
(FAST), 61
Fogarty catheters, 261-262
Fogarty thromboembolectomy catheter, 313
Forearm
amputation, 264-265, 267f
compartment syndrome in, 42
compartments of, 256
machete wound to, 259f
Forearm artery injury, 151
Four-quadrant ultrasound, 61
Fracture-associated extremity vascular trauma,
242
Fractures
blunt thoracic aortic injury and, 36
of humerus, axillary artery injury and, 150
open, 242, 243t
stabilization of site, 247
supracondylar, brachial artery injury and, 150
Free flaps, 249
Fresh frozen plasma
biological model and mechanism of action of,
30, 30f
refrigeration of, for vascular repair, 30
 Index 343

Fullen’s classification, of superior mesenteric Heart, injured, 75-82 Homeland War

artery injury, 120t diagnosis of, 77-79 improvised ICU and operating areas in Osijek
Functional motor assessment, of extremities, history of, 75 University hospital during, 295f
245t incidence of, 75-77 surgical building of Osijek University hospital
Functional sensory assessment, of extremities, major complications in, 82 after, 294f
245t nonoperative management of, 79 vascular injuries after, 293
operative management of, in emergency Homemade device, 287
department and operating room, 79-82 Homicide, in Brazil, 333, 334t
G cardiopulmonary bypass, acute need for, 81, Horizontal resuscitation, versus vertical, 57
Galen, 4 81f, 81t Hounsfield units (HU), 54
Gastric artery, left, injuries to, 119 cardiorrhaphy, treatment in operating Human umbilical vein (HUV), as conduit, 208
Gastrocnemius muscle flaps, 264 room after, 81-82 Humeral head, anterior dislocation of, axillary
Gastroepiploic artery, 207 hemorrhage from the heart, control of, artery injury and, 150
Gelfoam, in control of bleeding, 123 79-80, 79t Humerus, fracture of, axillary artery injury and,
General surgical training, 327 incisions in, 79 150
Geriatric patients, vascular injury in, 18 pericardiotomy, 79 Hunter, John, 4
Glasgow Coma Scale (GCS), 254 suturing techniques, 80-81 Hunter, William, 4
in resuscitation, 62 presentation of, 77 Hypertonic saline dextran, 60
Glycocalyx, 30-31 blunt trauma, 77 Hypocapnia, induced, 62
Gore Thoracic Aortic Graft, for thoracic aortic penetrating trauma, 77 Hypotension
aneurysms, 217 survival, 82, 83t avoidance of, 142
“Gothic” arches, 217 Heliodorus, 3 injured extremity index in, 169
Goyanes, 7-8 Hematoma Hypotensive resuscitation, 61
Graft collapse, in blunt thoracic aortic injury pelvic, 68-69 Hypothenar eminence hammer syndrome, 151
repair, 218, 219f retroperitoneal, in major vein injury, 127 Hypothermia, injured extremity index in, 169
Grafts HemCon dressing, for hemorrhage, 187-188, Hypothermia-induced coagulopathy, 191
autologous, definitive vascular repair with, 189t Hypovolemia, 56
247 Hemodynamic collapse, axillary artery injury Hypoxia, avoidance of, 142
endovascular, 130, 135 and, 150
ePTFE, 174, 207-208, 211, 212f, 331 Hemopneumothorax, subclavian artery injury
interposition. see Interposition graft and, 149-150 I
panel, 209-210 Hemorrhage, 56 Iatrogenic injuries, 297, 309
prosthetic, 313 active, angiographic findings in, 45t pediatric, management of, 229-230
spiral vein, for inferior vena cava repair, 132, acute vascular Iatrogenic trauma, pediatric, 226
132f management of, 325-326, 326f Iatrogenic vascular trauma, 18
stent, 135 region-specific treatment strategies for, 335, IATSIC. see International Association for the
Great vessels, injuries to, 82-91 335f Surgery of Trauma and Surgical Intensive
definition/classification of, 82, 83t control of, 319-320, 320f Care (IATSIC)
diagnosis of, 86 direct pressure for, 190 IEDs. see Improvised explosive devices (IEDs)
etiology of, 83-84 in inferior vena cava injuries, 129-131, 131f IEI. see Injured extremity index (IEI)
extravascular management of, 86, 87f from lung, 95-96, 95f Iliac artery
history of, 82-83 in portal vein injuries, 133 injury to, 121-122, 122b
incidence of, 83 in superior mesenteric vein injuries, 135 absence of femoral pulse and, 169-170
major complications of, 90-91 external, finger control of, 86 in military setting, 168
operative management of, in emergency initial control of, 3-5 ligation of, 176-177
department and operating room, 86-90 in junctional injuries, control of, 171-172 Iliac vein, injury to, in military setting, 168
presentation of, 84-86 life-threatening, 39 Iliac vessel
survival in, 91, 91t Hemorrhagic shock, 28, 30f exposure of, 175-176
Greater saphenous vein (GSV) class III, 29 surgical retroperitoneal, 176, 176f
as conduit, 210 Hemostasis, Egyptians and, 3 injury to, 113-125, 169-170
interposition repair using, for pediatric Hemostatic agents symptoms of, 169-170
extremity injury, 230 comparison of, 189t Iliofemoral vessels, 218
Groin flap, 266f for external nonextremity hemorrhage, Imaging, for vascular trauma, 44-55
Gulf War, military vascular surgery during, 11 187-189 abstract, 44.e1
Gunshot wound survival time analysis of, 188f historical background of, 44
in abdominal vascular injuries, 113 Hemostatic resuscitation, 60 modalities in, 44-55
Cattell-Braasch maneuver for, 261f Hemothorax, 92 Implantable prosthetic conduit, 198
to thigh, 311f retained, thoracoscopy evacuation of, 93, 96 Improvised explosive devices (IEDs), 206-207
Gunshot-induced fractures, 305 Heparin, 206 junctional bleeding cause by, 189-190
Gustilo-Anderson classification, of open tibial infusion, 233 massive soft-tissue destruction from, 207f
fractures, 243t role of, in pediatric vascular injury, 233 Incisions
use of, in vascular trauma, 173-174 for great vessel injuries, 86-88, 87f-88f
Heparinized saline, 233 for lung injuries, 94
H Hepatic artery, injury to, 119 Inferior mesenteric artery, injuries to, 120
Haire, 4 Hepatic hemorrhage, control of, abdominal Inferior vena cava (IVC), injuries to, 126-138
Hallowell, in early vascular surgery, 5, 5f exposure and, 68 abstract, 126.e1
Halsted, 5 Hextend, 192 complication of, 127
Hard signs High-energy extremity wounds, 242 considerations for repair of, 131
of extremity vascular injury, 169 High-energy penetrating blast wounds, 230 exposure and mobilization of, 128-129, 130f
of vascular injury, 39b, 252-253, 310, High-velocity projectile, in abdominal vascular hemorrhage control in, 129-131, 131f
311f injuries, 113 historical background in, 126-127
Harken, Dwight E., 80 Hilar snare, 95 ligation in, 131-132
Head vascular injuries, 35-36, 37f Hilar twist, 95 management options for, 135-137
clearing trauma patients from, 40b in lungs, 67-68 operative management of, 128-135
“Health Care in Danger,” symposium entitled, Hollow tubular devices, as temporary vascular postoperative care, and complications in, 137,
265-266 shunts, 199-200 137b
344 Index
Inferior vena cava (IVC), injuries to (Continued)
preoperative preparation for, 127-128
reconstructive techniques for, 132, 132f
surgical anatomy in, 128, 129f
vascular repair of, 90
Inferior vena cava (IVC) filters, 236-241, 237f,
237t
abstract, 236.e1
complications of, 239-240, 240b
long-term, 239-240
short-term, 239
contraindications of, 238
indications of, 236-238
expanded, 236
recommended, 236
trauma and, 236-238
techniques of, 238
insertion, 238, 238b, 238f-239f
retrieval, 238, 239f-240f
terminology of, 236
use of, 237b
Inflow occlusion, for control of hemorrhage, 80
Infraclavicular axillary artery, exposure of, for
proximal control, 257f
Infrarenal inferior vena cava, 128, 129f
filter, 239f
Injured extremity index (IEI), 169
for pediatric vascular injury, 228
In-line shunts, 200, 203f
Innominate artery
blunt tear of, repair of, 89, 89f
penetrating wound of, repair of, 88-89
Insertion, of IVC filters, 238, 238b, 238f-239f
Intercollegiate Surgical Curriculum Program
(ISCP), 271
Internal carotid repairs, 142
Internal iliac artery, 207
Internal mammary (internal thoracic) artery,
207
International Association for the Surgery of
Trauma and Surgical Intensive Care
(IATSIC), 275
Interosseous (IO) access, 59
Interpersonal violence, 283
Interposition graft
ePTFE, 212f
saphenous, in brachial artery, 211f
Interposition or bypass conduit, 313
Interposition or bypass grafting, technical
factors of, 206
Intracardiac lesions, delayed diagnosis of, 82,
82t
Intravascular shunts
historical use of, 198
modern use of, 198-199, 199t, 200f
Intravascular ultrasound (IVUS), 51-52
of blunt thoracic aortic injury, 219, 220f
Intravenous hemostatic agents, for coagulopathy
of trauma, 191-192
Intravenous tubes, sterile, 291f
Iodoxinol, 46
Ionizing radiation, attendant risk in, 46
Iraq, military vascular surgery in, during Gulf
War, 11
Ischemia
acute, management of, 326
in brachial artery injury, 150-151
left arm, 218
limb-threatening, 170-171
pathogenesis of, 28
Ischemia reperfusion injury, risk of, 291
Ischemic endothelial cells, 28
Ischemic reperfusion injury, 28
Ischemic threshold, 29
ISCP. see Intercollegiate Surgical Curriculum
Program (ISCP)
Israel, vascular trauma in, 316-323 Latin America, vascular trauma in (Continued)
abstract, 316.e1 systems of care, 329
epidemiologic considerations for, 316, variables of, 330t
317f-318f Latissimus dorsi (LD) flap, 250
incidence of, 316-317 Leadership, in horizontal resuscitation, 57
late complications of, 322-323 LEAP. see Lower Extremity Assessment Project
mortality from, 323 (LEAP)
prospects for future, 323 Lebanon War experience, tourniquets in,
system of care in, 317-318, 317f-319f 319-320
treatment strategies for, 319-323, 320f-322f Left arm ischemia, 218
IVC. see Inferior vena cava (IVC) Leg, anterior compartment of, 173
IVUS. see Intravascular ultrasound (IVUS) Liberation Tigers of Tamil Eelam (LTTE), 287
Ligation
of artery, 331
J for carotid artery injury, 254
Janelidze, Yustin, 301 for inferior vena cava injuries, 131-132
Jassinowsky, Alexander, 301 for initial control of hemorrhage, 3
Javid shunt, 200f, 202t portal vein, 134
Jerome of Brunswick, 4 of superior mesenteric vein, 135
JETT. see Junctional Emergency Treatment Tool for vascular trauma, 206
(JETT) Limb
Joint Theater Trauma System (JTTS) amputation, 244, 244b
civilian versus military, 24t-25t loss of
Clinical Practice Guideline (CPG), on DCR, associated with upper extremity arterial
193 injury, 149
organization of, 24-25 statistical analysis of factors associated with,
Joint Trauma System (JTS), 24 312t
JTS. see Joint Trauma System (JTS) prescrubbing of, 246
JTTR. see U.S. Joint Theater Trauma Registry Limb hypoperfusion, 228
(JTTR) Limb ischemia
JTTS. see Joint Theater Trauma System (JTTS) acute, 28
Judd-Allis clamps, in vein injuries, 129-130, severity of, 306
131f Limb salvage, 243
Junctional bleeding, 189-190, 189f-190f in austere environment, 263
Junctional distal iliac injuries, 169-170, 169f outcomes of, 250-251
complications of, 180 role of temporary vascular shunt in, 204
considerations for, 175-177, 176f-177f Limb Salvage Index (LSI), 154-155
preoperative preparation for, 171-172, 172f Limb trauma, component of, 242
Junctional Emergency Treatment Tool (JETT), Lobectomy, 95-96
171-172 Lodox Statscan unit, 326, 326f-327f
Junctional hemorrhage, 187 Looped shunts, 200, 202f
Junctional vascular injury, 168 Lower extremity
mortality in, 173 crush injuries of, 38-39
soft sign of, 170 mangled, 170, 211
Junctional vascular trauma, 64 Lower Extremity Assessment Project (LEAP),
Junctional zone, of upper extremity 243
anatomy of, 157 Lower extremity vascular injuries, 38-39
injury to, operative management of, 157-158, abstract, 168.e1
159f-160f avoidance of pitfalls in, 173
clearing trauma patients from, 40b
complications of, 180-181, 180f
K considerations for, 174-179
Ketamine, 60 diagnosis of, 168-171
Knee, dislocation of, 242 history and background of, 168
associated with distal ischemia, 284f incidence of, 168, 169t
posterior, 38, 172f junctional distal iliac and proximal femoral
Korean Conflict, vascular surgery during, 9-11 injuries, 169-170, 169f
Kornilov, Vadim Alexeevich, 303f operative strategy and technique for, 173-174,
Korotkov, Nikolai, 301 174f
Kunlin, Jean, 206 postoperative care for, 179-180
Kussmaul’s sign, 77 preoperative preparation for, 171-173, 171f
presentation of, 168-171
Lower limb
L compartment syndrome, after vascular
Laceration, direct, in abdominal vascular trauma, 123
injuries, 113 vascular injuries, in austere environment,
Laparotomy, 331, 331f surgery for, 261-263, 261f-262f
Lateral malleolar flap, 266f wounds, commonly used flaps for, 249-250
Lateral suture repair, 313 LSI. see Limb Salvage Index (LSI)
Latin America, vascular trauma in, 329-332 LTTE. see Liberation Tigers of Tamil Eelam
abstract, 329.e1 (LTTE)
epidemiology of, 329, 330f Lungs, injuries to, 91-97
regional diagnosis and management of, classification of, 91, 91t
329-332, 331f complications to, 96
strategies for training of trauma surgeons in, diagnosis of, 92-93
332 etiology of, 92

Lungs, injuries to (Continued)
history of, 91-92
incidence of, 92
nonoperative management of, 93
operative management of, in emergency
department and operative room, 93-96
indications for, 93, 94b, 94f
proximal vascular control in, 94-95, 94b
presentation of, 92
survival of, 97, 97t
thoracic damage control in, 97, 97b
Lytic therapy, for pediatric vascular injury, 233
M Murphy, J.B., 6
Machete wound, to forearm, 259f
Magnetic resonance angiography (MRA), 326
Magnetic resonance imaging (MRI), for vascular
injury, 310
Main dressing station (MDS), as second line of
care, 287-288
Major trauma centers (MTCs), 21
Mangled extremity
definition of, 154-155
lower, 170, 211
management of, 263
Mangled Extremity Severity Score (MESS),
154-155, 154t
Mangled Extremity Syndrome Index (MESI),
154-155, 154t
Mass shooting, 283
Massive transfusion, 60
MATTERS study, 191, 192f
Mattox maneuver, 260, 260f
MBH. see Military base hospital (MBH)
McClean, Jay, 206
MDCTA. see Multidetector computed
tomographic angiography (MDCTA)
Mechanism of injury, 35
in abdominal aortic trauma, 113-114
arterial, 310t
of cardiac, great vessel, and pulmonary
injuries, 73
upper extremity vascular injury, 149
MEDEVAC. see Medical evacuation (MEDEVAC)
Medial visceral rotation, 115
exposing inferior vena cava, 130f
left-sided, 116f-117f
right-sided, 118f
Median sternotomy, 73, 79, 87, 87f
for right innominate artery injuries, 232
for zone I neck injuries, 255
Medical battalion, 302f
Medical care, in Croatia, 293-294
Medical emergency response team (MERT), 194
Medical evacuation (MEDEVAC), 194
Medical trauma system, region-specific systems
of care, 302
Mentice VIST simulator, 274
Mesenteric arterial injuries, 204
Mesenteric venous systems, 126-138
Mesenteric vessels, intraluminal shunting of,
204
MESI. see Mangled Extremity Syndrome Index
(MESI)
MESS. see Mangled Extremity Severity Score
(MESS)
Midsubclavian injury, with insertion of
intraluminal shunt, 198-199, 200f
Military base hospital (MBH)
Anuradhapura, 288, 289f
considerations for diagnosis, 290
Military campaign, 287
Military conflict, vascular trauma and, 14-16
Military Operational Surgical Training (MOST),
277, 277f
Military setting, prophylactic four-compartment
fasciotomies in, 290-291
Minimal aortic injury (MAI), 110-111
Morphine, 60
MOST. see Military Operational Surgical
Training (MOST)
MTCs. see Major trauma centers (MTCs)
Multidetector computed tomographic
angiography (MDCTA)
of lower extremity vascular trauma, 171
for vascular injury, 41-42
Multidetector computed tomography (MDCT),
52, 295
Multiplanar degloving, 246-247, 246f
Muscle flaps, 264b
versus fasciocutaneous flaps, 249, 250f
for lower limb wounds, 250
vascularized composite, for coverage of
vascular reconstruction, 264
Muscle ischemia, 290
Myocardial ischemia, 77
N considerations for diagnosis of, 306
National Trauma Data Bank (NTDB), 16, 215,
234
NCTH. see Noncompressible torso hemorrhage
(NCTH)
Neck
direct trauma to, 36
penetrating trauma of, 326
zones of, 142, 253-254, 254f
Neck injuries
in austere environment, vascular surgery for,
253-256
associated, 254-255
zone I, 255-256, 257f
zone III, 255, 256f
management of, 215
penetrating, 285
Neck outlet, vascular trauma to, 139-148
abstract, 139.e1
complications of, 145-146
indications of, 139-140, 140f-141f
operative strategy and technique for, 142-145
outcomes of, 145-146
pitfalls and danger points in, 141-142
postoperative care for, 145-146
preoperative preparation for, 140-141
Neck vascular injuries, 35-36, 38f
clearing trauma patients from, 40b
Negative pressure therapy, for upper extremity
vascular injury, 164
Negative pressure wound therapy (NPWT)
dressings, 247-248
Nelson, Horatio, 4
Nephropathy, contrast-induced, 45
Neurologic deficit
in carotid/vertebral injuries, 142
postoperative lateralizing, after carotid
reconstruction, 146
Neurological deficit, great vessel injuries and, 91
Neutrophils, 28
New Zealand, vascular trauma in, 281-286
abstract, 283.e1
access to care in, 284
considerations for diagnosis of, 284-285
epidemiology in, 283
prehospital care in, 284
strategies for sustaining and training of
trauma surgeons in, 285-286
surgical training and certification in, 283-284
systems of care in, 283
treatment strategies in, 285, 285f
“No reflow” phenomenon, 28
Index 345
Noncompressible hemorrhage, 190
Noncompressible torso hemorrhage (NCTH),
vascular trauma and, 64-70, 65f, 65t
abstract, 64.e1
clinical management strategies in, 66
damage control resuscitation in, 66
damage control surgery in, 66
defining, 65
epidemiology of, 66
in British troops, 66
in civilians, 66
military and civilian epidemiology of, 64-65
mortality of, 64
operative exposures and control of, 67-69
hepatic hemorrhage, 68
pelvic hemorrhage, control of, pelvic access
and, 68-69, 69f
pulmonary parenchymal hemorrhage,
67-68
renal hemorrhage, 68
splenic hemorrhage, 68
resuscitative surgical maneuvers in, 66-67
North Caucasus, vascular injuries in, 305-307
abstract, 301.e1
epidemiology of, 305
strategies for sustaining and training of
trauma surgeons in, 307
systems of care in, 305-306
treatment strategies in, 306-307, 306t, 307f
Northern Europe, vascular injuries in, 297-300
abstract, 297.e1
considerations for diagnosis of, 299
epidemiology of, 297, 298f
strategies for sustaining and training of
trauma surgeons in, 299-300
systems of care in, 297-299, 299t
treatment strategies in, 299
Novel hybrid resuscitation, 61
NTDB. see National Trauma Data Bank (NTDB)
O
Obesity, vascular trauma and, 18
Occlusion balloons
aortic, for penetrating trauma and blunt
trauma, 223f
for extremity vascular injury, 222f
for hemorrhage control, 130, 135
OIF. see Operation Iraqi Freedom (OIF)
Open fractures, 242, 243t
Open operative repair, of blunt thoracic aortic
injury, 105
Open repair, of injured iliac arteries, 229
Open surgical repair, of blunt thoracic aortic
injury, 105-106
versus endovascular aortic, 109t
Open surgical subxyphoid pericardial window,
77
Open tibial fractures, 243t
Open tibial shaft fractures, limb salvage patients
with, 243
Operating room, priority in, 320
Operation Enduring Freedom (OEF), 186
Operation Iraqi Freedom (OIF), 198-199
Optimal vascular conduit, problem
identification of, 206, 207f
Order of St John, 284
Organ injury scale, for abdominal vascular
injury, 127t
Orthopedic fractures, grading of, 242-243, 243t
Orthopedic injury, 242
Osijek University hospital
improvised ICU and operating areas in, 295f
surgical building of, after Homeland War,
294f
346 Index

Ownership, in systemizing vascular-injury care, Phrenic nerves, 142 Primary Certificate in Vascular Surgery, ABS,
25-26 PHTLS manual. see PreHospital Trauma Life 271
Support (PHTLS), manual Primary limb amputations, vascular injury, 306
Physical examination, in penetrating injuries, Primary repair, of pediatric extremity injuries,
P 139 230-231
Packed red blood cells (PRBCs), 62 Plasma, 62 Prophylactic fasciotomy
for noncompressible torso hemorrhage, 66 for coagulopathy of trauma, 191 in austere environment, 263
“Panel graft”, 209-210 in prehospital fluid resuscitation, 192-193 ligation of vena cava and, 132
Paraplegia, 105-106, 218 refrigeration of, 30 Prophylactic filters, 236
Paré, Ambroise, 3 thawed, 30 Prosthetic conduits, 207-208, 209t
Patch angioplasty Plate fixation, of open fractures, 247 in austere and military settings, 211, 212f-213f
of pediatric extremity injuries, 230-231 Platelets triplex, 210
technique of, 206 in damage control resuscitation, 29-30 Prosthetic grafts, 313
Pavlov, Ivan, 301 replacement, 60 Proximal carotid artery injuries, management of,
Pediatric arterial anastomoses, 230 Pneumatic compression devices, for lower 232
Pediatric truncal vascular trauma, 227 extremity vascular injury, 179-180 Proximal extremities, injured deep veins of,
Pediatric vascular injury, 17-18, 226-235 Pneumonectomy, 96 pediatric, 231
abstract, 226.e1 Pneumothorax, 92 Proximal femoral injuries, 169-170
anatomic and physiologic considerations in, open, 92 complications of, 180
228 tension, 92 considerations for, 175-177, 176f-177f
demographics and etiology of, 226-227, 227f Poly traumatized extremity, surgical preoperative preparation for, 171-172, 172f
diagnostic evaluation of, 228-229 management of, 246-248 Proximal large vessels, versus distal small vessel,
endovascular applications of, 232 Polytetrafluoroethylene (PTFE), reconstructed 202-203
future directions of, 234 popliteal artery with, 293, 295f Proximal vascular control, minimization of
management of, 229-233 Pontresina course, 277-278 blood loss and, 142
adjuncts to, 233 Popliteal artery, reconstruction of using Pruitt-Inahara shunt, 200, 202t, 203f
nonoperative management of, 232-233 polytetrafluoroethylene (PTFE) graft, 293, Pseudoaneurysm, 44
outcomes following, 234 295f abdominal vascular injuries and, 114-115
postoperative management of, 233-234 Popliteal injuries, 170, 170f-171f angiographic findings in, 45t
unique features of, 227t complications of, 180 ultrasound findings in, 45t
Pelvic access, and pelvic hemorrhage control, considerations for, 177-179, 177f-178f PSI. see Predictive Salvage Index (PSI)
68-69, 69f preoperative preparation for, 172, 172f Pulmonary artery, intrapericardial clamping of,
Pelvic hematoma, 68-69 Popliteal space, exposure of, 178 94
venous injury and, 171 Popliteal vessel Pulmonary contusion, supportive care after, 93
Pelvic hemorrhage, control of, pelvic access and, surgical anatomy of, 178, 178f Pulmonary parenchymal hemorrhage, thoracic
68-69, 69f surgical exposure of, 178, 178f exposure and control of, 67-68
Pelvic packing, 115 Portal vein, injury to, 132-134, 133f Pulmonary pseudocyst, 96
preperitoneal, sequence of, 69f exposure and mobilization of, 133 Pulmonotomy, 95, 95f
Pelvic trauma, endovascular treatment of, hemorrhage control in, 133 Pulse
124-125, 124f-125f ligation in, 134 examination of, at wrist and foot, 39-40
Pelvic x-ray, 61 repair of, 133 palpation of, in lower extremity vascular
Pelvis Post Graduate Institute of Medicine of Sri injury, 169
arterial bleeding from, 69 Lanka, 292
immobilization of, 59 Postoperative surveillance, for pediatric vascular
Penetrating injury injury, 234 Q
to inferior vena cava, 128 Poverty, vascular trauma and, 18-19 QI. see Quality improvement (QI)
neck injuries, 285 PRBCs. see Packed red blood cells (PRBCs) Quality improvement (QI), trauma, 22
pediatric extremity injuries, management of, Predictive Salvage Index (PSI), 154-155 QuikClot, for hemorrhage, 187-188
230f Prehospital care, for vascular injury, 183-197
Penetrating trauma, 324, 325f abstract, 185.e1
in abdominal vascular injuries, 113 in Australia and New Zealand, 284 R
aortic occlusion balloons for, 223 control of external nonextremity hemorrhage Race, vascular trauma and, 18-19
in axillary artery injury, 150 in, 187-189 Radial artery, anatomy of, 161, 162f
to great vessels control of extremity hemorrhage in, 185-187 Radial artery injuries, 151
diagnosis of, 86 general aspects of, 185 operative management of, 161-163, 163f
etiology of, 83 hemorrhage control in, 190 Radial forearm flap, 264, 267f
incidence of, 83 junctional bleeding in, 189-190 Radiation, exposure to, from diagnostic CT
presentation of, 84, 84f-85f noncompressible hemorrhage in, 190 scans, 54
to heart prehospital fluid resuscitation in Rangers, TCCC and, 186
diagnosis of, 77-78 crystalloids and colloids, 192 RAP. see Risk Assessment Profile (RAP)
incidence of, 75-77 plasma, 192-193 RBCs. see Red blood cells (RBCs)
presentation of, 77 preventable death in, 185 RDCR. see Remote damage control resuscitation
in iliac artery injuries, 121 prevention and treatment of coagulopathy of (RDCR)
to lungs trauma in, 191-192 REBOA. see Resuscitative endovascular balloon
etiology of, 92 during transport, 193-195 occlusion of the aorta (REBOA)
incidence of, 92 comprehensive tactical evacuation care Recombinant factor VIIa (rVIIA), for
of neck, 326 considerations of, 194-195 coagulopathy of trauma, 191
region-specific epidemiology of, 283 future directions of, 195 Reconstruction
Percutaneous ligation, of femoral vessels, 302, Prehospital fluid resuscitation arterial
302f crystalloids and colloids, 192 for pediatric vascular injury, 226
Performance indicators, 22 plasma, 192-193 arterial, method or type of, 311t
Pericardiocentesis, 77 PreHospital Trauma Life Support (PHTLS), 185 fix and flap, 248
Permanent filters, 237t manual, 172 flap, 249
Peroneal vessels, approach to, 179 Preperitoneal pelvic packing, sequence of, 69f in soft tissue and skeletal wound
Personal protective equipment, for trauma, 58 “Pretrained novice,” concept of, 273 management, 248-250
Pfannenstiel incision, 68 Preventable death, 185 choice and type of, 249

Reconstruction (Continued) Scandinavia, vascular injuries in, 297-300
vascular, Croatia licenses general surgeons to abstract, 297.e1
perform, 294-295 considerations for diagnosis of, 299
Rectus abdominus flap, 264, 265f epidemiology of, 297, 298f
Red blood cells (RBCs) strategies for sustaining and training of
in damage control resuscitation, 29-30 trauma surgeons in, 299-300
packed, 62 systems of care in, 297-299, 299t
for noncompressible torso hemorrhage, treatment strategies in, 299
66 Scapulothoracic dissociation, 151
Referral trauma centers, in Rio de Janeiro, 335 “Scoop and run” method, 288
Regional heparinization, 200-201 SCORE. see Surgical Council on Resident
Regional trauma system, 21, 22f Education (SCORE)
Remote damage control resuscitation (RDCR), Second line of care, in Sri Lanka, 287-288
193-194 Seldinger technique, 297
Remote endoluminal occlusion, 222, 222f Serbia, vascular trauma in, 309.e1
Renal artery, injuries to, 120-121 abstract, 309.e1
Renal hemorrhage, control of, abdominal considerations for diagnosis of, 310, 311f
exposure and, 68 epidemiology of, 310t
Reperfusion, pathogenesis of, 28 systems of care in, 309-310
Reperfusion injury, 28, 312. see also Ischemia treatment strategies for, 311-313, 311t-312t,
reperfusion injury 312f, 314f
upper extremity, axillary or subclavian artery Severely injured limb
repair and, 146 strategies in managing of, 243-244
Resources for the Optimal Care of the Injured major limb amputation for trauma, 244,
Patient, 24 244b
Responsibilities, in systemizing vascular-injury sequencing of interventions, 243-244
care, 25-26 Shock, subclavian artery injury and, 149-150
Resuscitation Shotgun wound. see Gunshot wound
crystalloid, 31 Shunts
damage control, 29-31, 30f-31f Argyle, 201f-202f, 202t
immediate, for vascular trauma, 56-63 atriocaval, 136, 136f
definitions, 56-57 Brener, 202t
end points of, 61-62 Burbank, 202t
ethics in, 62 Javid, 200f, 202t
fluids and medications in, 60 Pruitt-Inahara, 200, 202t, 203f
hemostatic, 60, 56.e1 straight, 202t
horizontal versus vertical, 57 Sundt, 202f-203f, 202t
hypotensive, 61 temporary vascular. see Temporary vascular
imaging in, 60-61 shunts
novel hybrid, 61 temporary venous, 136
paradigms for, 57 venous, 136-137
preparation for, 58-59, 58b SIC. see Societé International de Chirugie (SIC)
techniques and procedures in, 59-60 Simantha Simsuite Endovascular Simulator, 274
three-dimensional versus two-dimensional, Simulation-based vascular training, 273-275
57-58 Skin staplers, disposable, 80
Resuscitative endovascular balloon occlusion of Slings, for upper extremity injuries, 258, 258f
the aorta (REBOA), 67 Societé International de Chirugie (SIC), 275
Resuscitative surgical maneuvers, in Soft signs, of vascular injury, 39b, 252-253, 310,
noncompressible torso hemorrhage, 66-67 311f
Resuscitative thoracotomy (RT), 66-67 Soft tissue, coverage of repair with, 247-248, 248f
for vein injury, 127-128 SOFTT. see Special Operations Forces Tactical
Retrievable filters, 237f, 237t, 238, 239f-240f Tourniquet (SOFTT)
Retrohepatic cava, injury to, 128 Soft-tissue and skeletal wound management
Retrohepatic inferior vena cava, 128, 129f abstract, 242.e1
Retroperitoneal hematoma, in major vein injury, assessment of injured extremity, 244-246, 245t
127 epidemiological factors of, 242
Revascularization, for severely injured limb, grading of orthopedic fractures, 242-243, 243t
243-244 initial surgical management in, 246-248
Right innominate artery injuries, median reconstruction in, 248-250
sternotomy for, 232 salvage versus amputation, 243
Ringer’s lactate, for thoracic trauma, 74 in setting of vascular injury, 242-251
Risk Assessment Profile (RAP), 236-238, 237b strategies in managing severely injured limb,
Royal Australasian College of Surgeons (RACS), 243-244
283-284 Soft-tissue injury, in austere environment,
Royal College of Surgeons of England, 275 vascular surgery for, 263, 264b
Rufus of Ephesus, 4 Soleus muscle flaps, 264, 265f
Rural populations, vascular trauma in, 17 Solid organs, trauma in, endovascular treatment
Russia, 301-308 of, 124-125
South Africa, vascular trauma in, 324-328
abstract, 324.e1
S considerations for diagnosis of, 326, 326f-327f
Saphenous fasciocutaneous flap, 266f epidemiology of, 324-325, 325f
Saphenous vein strategies for sustaining and training of
bypass, 206 trauma surgeons in, 327-328
reversed, 174 systems of care in, 325-326
in vascular repair, 262-263 treatment strategies for, 326-327
Index 347
Special Operations Forces Tactical Tourniquet
(SOFTT), 186-187, 186f
Special-Purpose Medical Team, 306, 306f
Specialty Skills in Vascular Surgery Course, 275
Spiral vein graft, for inferior vena cava repair,
132, 132f
Splenic artery, injuries to, 119
Splenic hemorrhage, control of, abdominal
exposure and, 68
Sri Lanka, vascular injuries in, 287-292, 287.e1
considerations for diagnosis of, 290, 291f
epidemiology of, 287, 288f-289f
sustaining and training the next generation in,
292
systems of care and transport in, 287-290
Sri Lankan Army medical corps, 287
Stab wounds, in abdominal vascular injuries,
113
Stapled wedge resection, 95
State Institute of Cardiology Aloísio de Castro
(IECAC), 334f
Stenosis, arterial
angiographic findings in, 45t
ultrasound findings in, 45t
Stent grafts, 135
thrombosed, 109f
Stents
covered, 216
uncovered, 216
Sternotomy, limited, for zone I neck injuries, 256
Straight shunt, 202t
Stryker Pressure Monitor™, 42, 43f
Styptics, in initial control of hemorrhage, 3
Subclavian artery
anatomy of, 157, 158f
blunt thoracic aortic injury in, 101f, 110, 110f
blunt trauma to, 84-86
injuries to, 149-150
endovascular management of, 221, 222f
endovascular repair of, 145
operative management of, 157-158,
159f-160f
operative strategy and technique for,
144-145, 145f
repair of, 146
surgical treatment of, 145
segments of, surgical approach to, 335-336
Subclavian injuries, in Brazil, 335-336
Subclavian vessels, right and left, 90
Sundt shunt, 202f-203f, 202t
Superior mesenteric artery (SMA), injury to,
119-120, 119f
Fullen’s classification of, 120t
Superior mesenteric vein, injuries to, 134-135
exposure and mobilization of, 134-135, 134f
hemorrhage control in, 135
ligation in, 135
repair of, 135
Superior vena cava, injuries to, vascular repair
of, 90
Supraclavicular incisions, for pediatric truncal
vascular injuries, 232
Supracondylar fracture, brachial artery injury
and, 150
Supracondylar humerus fractures, pediatric,
management of, 231-232
Suprahepatic inferior vena cava, 128, 129f
Suprarenal filter, 238f
placements, indications for, 238b
Suprarenal inferior vena cava, 128, 129f
Sural artery flap, 267f
Surgical anatomy
of femoral vessels, 177f
in inferior vena cava injuries, 128, 129f
of junctional zone, 176f
of popliteal vessel, 178, 178f
348 Index
Surgical Council on Resident Education
(SCORE), 271
Surgical damage control, 198-205, 198.e1
Surgical debridement, of injured tissues, 246-247
Surgical techniques, for abdominal aortic
trauma, 115-117
Suture pneumonorrhaphy, 95
Suture repair, 80
factors for, 74
Synthetic conduits, 331
Syringe suction bottle, 255f
Systemic heparinization, 229-230
Systems of care
in Afghanistan, 302-303
in Australia and New Zealand, 283
in Croatia, 293-295
in Israel, 317-318, 317f-319f
in Latin America, 329
in North Caucasus, 305-306
in Scandinavia and Northern Europe,
297-299, 299t
in Serbia, 309-310
in South Africa, 325-326
and transport, in Sri Lanka, 287-290
in vascular injury management, 21-27
abstract, 21.e1
clinical practice guidelines in, 26
data collection and comparison in, 26, 26b
introduction and tracking of new
technology in, 26-27
key components of, 21-23
ownership and responsibilities in, 25-26
trauma center function in, 23-24
T Thoracic spine, fracture of, 36
TACEVAC. see Tactical Evacuation Care
(TACEVAC)
Tactical Combat Casualty Care (TCCC), 185
PreHospital Trauma Life Support manual, 172
Tactical Evacuation Care (TACEVAC), 194
comprehensive, considerations in, 194-195
TAI. see Traumatic aortic injury (TAI)
Talent Thoracic Stent Graft, for thoracic aortic
aneurysms, 217
TCCC. see Tactical Combat Casualty Care
(TCCC)
Team-based training, for vascular trauma,
272-273
TeamSTEPPS program, 273
Technology, new, in systemizing vascular-injury
care, 26-27
TEE. see Transesophageal echocardiography
(TEE)
Teflon pledgets, 81
Temperature, of patient, in resuscitation, 62
Temporary balloon occlusion, 232
Temporary intravascular shunts (TISs), 290,
291f
Temporary shunting
in Afghanistan, 304
in North Caucasus, 306-307, 307f
vascular, for severely injured limb, 244
Temporary vascular shunts, 176-177, 177f,
198-206, 258, 313
abstract, 198.e1
anatomic location in, 202-203
combat versus civilian use of, 201t
dwell time of, 201-202
external, 322
for extremity vein injury, 175
indications of, 199, 201t
insertion technique of, 200-201
materials for, 199-200, 201f-202f
for multiply-injured patient, 198
for pediatric vascular injury, 233
Temporary vascular shunts (Continued)
for reestablishment of circulation, 246
special considerations in, 202-205
types of, 202t, 203f
in upper extremity vascular injury, 153-154,
153f
vascular branch points in, 204
Temporary venous shunts, 136
Tertiary military base hospitals, as third line of
care, 288
TEVAR. see Thoracic endovascular aortic repair
(TEVAR)
ΤGF−β. see Transforming growth factor-β
(ΤGF−β)
Therapeutic filters, 236
Thermal blankets, 59-60
Thoracic aorta
blunt trauma in, 18
penetrating injury to, 208-209
Thoracic aortic injury, blunt, 100-112, 100.e1
Thoracic aortic stent-grafts
aortogram of, 285f
for pediatric vascular injuries, 232
Thoracic endovascular aortic repair (TEVAR),
46, 217
Thoracic injuries, vascular conduit for, 208-209
Thoracic outlet, vascular trauma to, 139-148
abstract, 139.e1
complications of, 145-146
indications of, 139-140, 140f-141f
operative strategy and technique for, 142-145
outcomes of, 145-146
pitfalls and danger points in, 141-142
postoperative care for, 145-146
preoperative preparation for, 140-141
Thoracic vascular injuries, 36, 38f
Thoracic vascular trauma, in Brazil, 336
Thoracotomy, resuscitative, for vein injury,
127-128
Three-dimensional resuscitation, versus
two-dimensional, 57-58
Threshold, ischemic, 29
Thromboelastography (TEG), 60
Thrombolytic therapy, in arterial trauma, 233
Thrombophilia, 49-50
Thromboprophylaxis, mechanical, for lower
extremity vascular injury, 179-180
Thrombosed stent graft, 109f
Thrombosis
after vascular trauma, 123
in lower extremity vascular injury, 180-181
Tibial artery injuries, 168
Tibial fractures, open, 243t
Tibial level injuries, 170-171
complications of, 180-181
considerations for, 179
preoperative preparation for, 172-173, 173f
Tibial plateau fracture, 38-39
Tibial vascular injury, 172-173
Tibial vessels
approach to, 179
imaging of, 170-171
injured by blunt mechanisms, 170-171
TISs. see Temporary intravascular shunts (TISs)
Topical hemostatic agents, 59
Torso hemorrhage, noncompressible, 190
Torso trauma, 168
Torso vascular injuries, 204
Total hepatic vascular exclusion, for hemorrhage
control, 130-131
Tourniquet, 28-29, 287, 319-320, 320f
blood pressure cuff as, 168-169
combat-action, 285, 285f
development of, 4
Esmarch-Langenbeck, 303
Tourniquet (Continued)
for extremity hemorrhage, 185-187, 186f
for hemorrhage control, 172
tips for, 188b
for traumatic limb amputations, 59
in upper extremity vascular injury, approach
to, 152-153
Tranexamic acid (TXA), 74
for coagulopathy of trauma, 191
Transabdominal torso injuries, 326-327
Transbrachial retrograde arteriography, 86
Transcatheter angiography, 44
Transesophageal echocardiography (TEE), 51
for blunt thoracic aortic injury, 103, 103t
Transfemoral intraaortic occlusion balloon
(IAOB), 223
Transforming growth factor-β (ΤGF−β), 30
Transfusion, massive, 60
Transluminal arteriography, 173
Transmediastinal torso injuries, 326-327
Transplantation, vein injuries and, 136-137
Transthoracic echocardiography, cardiac
tamponade and, 78, 78f, 78t
Trap gun, 288f
Trauma
in Brazil, 333-334, 334t
limb amputation for, 244, 244b
Trauma center, function of, 23-24
Trauma quality improvement, 22
Trauma receiving units (TRUs), 23
Trauma Secretariat of the Ministry of Health, 292
Trauma service, 23
Trauma systems
in combat casualty care, 24
key components of, 21-23
organization of Joint Theater Trauma System,
24-25, 24t-25t
overview of, 21, 22f
Trauma units (TUs), 21-22
Traumatic aortic injury (TAI), thoracic CTA for,
52, 53f
Traumatic false aneurysm, 100, 101f
abdominal vascular injuries and, 114-115
Triage, in emergency room, 320
“Trial of debridement”, 246
Triplex prosthetic conduit, 210
“Trishaw”, 288, 290f
Troponin, cardiac, 78-79
TRU. see Trauma receiving units (TRUs)
Truncal vascular injuries
pediatric, management of, 232
temporary vascular shunts for, 204-205
TU. see Trauma units (TUs)
Tube thoracostomy, for lung injuries, 93
“Tuk-tuk”, 288, 290f
Two-dimensional resuscitation, versus three-
dimensional, 57-58
U
UK Defence Medical Services, guidelines
concerning trauma amputation, 244, 244b
UK military model, 58
UK Trauma Registry, 66
Ulnar artery
anatomy of, 161, 162f
injuries to, 151
operative management of, 161-163, 163f
Ultrasound, 48-52
complications of, 52
as diagnostic tool, 50
as guide to invasive procedures, 50-51, 51f
indications for, 49-50, 50f
intravascular, 51-52
of blunt thoracic aortic injury, 219, 220f
pitfalls and danger points of, 50, 52-54

Ultrasound (Continued) Vascular conduit (Continued)
postexamination care in, 52 future considerations of, 212
preparation for, 50, 52 artificial blood vessels, 212
as screening tool, 50 improvements in storage, 212
strategy for, 50-51, 51f problem identification of, 206, 207f
technique for, 51-52 types of, 206-208
transthoracic, 78, 78f allografts, 208
Umbilical vein catheters, 258-259 autologous, 207
Uncovered stents, 216 prosthetic, 207-208
Uniformed Services University of the Health xenografts, 208
Sciences, 275 “Vascular damage control surgery”, 304
Unilateral external fixation frame (KST-1), 307f Vascular injuries
Upper extremity vascular injury, 37-38, 39f in Afghanistan
abstract, 149.e1 considerations for diagnosis of, 303
axillary artery injuries, 150 epidemiology of, 301-302
brachial artery injuries, 150-151 strategies for sustaining and training of
clearing trauma patients from, 40b trauma surgeons in, 305
compartment syndrome and, 165, 165b, 166f systems of care in, 302-303, 302f
complex, general considerations in addressing, treatment strategies in, 304-305
152, 152f in Brazil, specific patterns of, 335-336, 336f
complications after, 165 abdominal vascular trauma, 336
diagnosis of, 149-151 carotid injuries, 335
endovascular management of, 155-157, extremity vascular trauma, 335f, 336
156f-157f subclavian injuries, 335-336
epidemiology of, 149, 150t thoracic vascular trauma, 336
indications of, 149-151 epidemiology of, 13-20, 14b, 14t
mangled extremity scores in, application of, abstract, 13.e1
154-155, 154t categorization of trauma in, 13-14
monitoring for, 163-164 in civilian populations, 16-17
nonoperative management of, 163 context of trauma in, 13-14
operative strategy for, 153-154 iatrogenic vascular trauma in, 18
operative technique for, 157-163 lifestyle and trauma in, 18-19
outcomes after, 150t, 164-165 patient age in, 17-18
postoperative care for, 163-164 socioeconomic factors of trauma in, 18-19
preoperative preparation for, 151-153 trauma and military conflict in, 14-16
presentations of, 149-151 hard signs of, 252-253
radial artery injuries, 151 legacy, 1-12
rehabilitation in, 164 abstract, 3.e1
scapulothoracic dissociation, 151 in civilian experience, 11
subclavian artery injuries, 149-150 early vascular surgery in, 5-8
tourniquets in, approach to, 152-153 during Gulf War, 11
ulnar artery injuries, 151 initial control of hemorrhage in, 3-5
wound care in, 164, 164f during Korean Conflict, 9-11
Upper extremity venous injury, optimal in Vietnam, 10-11, 10t
management of, 155 during World War I, 8
Upper limb injury complexes, 242 during World War II, 8-9
Upper limb vascular injuries, in austere mode of, 289f
environment, surgery for, 256-259, in North Caucasus
257f-259f considerations for diagnosis of, 306
brachial and forearm vessels, 256-259 epidemiology of, 305
Upper limb wounds, commonly used flaps for, strategies for sustaining and training of
250 trauma surgeons in, 307
Urban populations, vascular trauma in, 16-17 systems of care in, 305-306
U.S. Army Institute of Surgical Research treatment strategies in, 306-307, 306t,
(USAISR), 186-187 307f
U.S. Department of Defense (DoD), pediatric. see Pediatric vascular injury
TeamSTEPPS program, 273 prehospital care of patient with, 183-197
U.S. Joint Theater Trauma Registry (JTTR), in Scandinavia and Northern Europe
noncompressible torso hemorrhage and, considerations for diagnosis, 299
64-66 epidemiology of, 298f
US troops, thoracic injury in, 64-65 strategies for sustaining and training of
USAISR. see U.S. Army Institute of Surgical trauma surgeons in, 299-300
Research (USAISR) systems of care in, 297-299, 299t
treatment strategies, 299
soft signs of, 252-253
V soft-tissue and skeletal wound management in
Vascular anastomosis, pediatric, construction of, setting of, 242-251
230 systems of care in, 21-27
Vascular conduit abstract, 21.e1
abstract, 206.e1 clinical practice guidelines in, 26
in austere and military settings, 210-211 combat casualty care in, 24
considerations for, in repair of vascular injury, data collection and comparison in, 26, 26b
206-214 introduction and tracking of new
decision making in choice of, 208-210 technology in, 26-27
ideal, for vascular trauma, 209-210, 209t ownership and responsibilities in, 25-26
location and nature of injury, 208-209, 209t temporary shunts for, 199
Index 349
Vascular injuries (Continued)
upper extremity
abstract, 149.e1
axillary artery injuries, 150
brachial artery injuries, 150-151
compartment syndrome and, 165, 165b,
166f
complex, general considerations in
addressing, 152, 152f
complications after, 165
diagnosis of, 149-151
endovascular management of, 155-157,
156f-157f
epidemiology of, 149, 150t
indications of, 149-151
mangled extremity scores in, application of,
154-155, 154t
monitoring for, 163-164
nonoperative management of, 163
operative strategy for, 153-154
operative technique for, 157-163
outcomes after, 150t, 164-165
postoperative care for, 163-164
preoperative preparation for, 151-153
presentations of, 149-151
radial artery injuries, 151
rehabilitation in, 164
scapulothoracic dissociation, 151
subclavian artery injuries, 149-150
tourniquets in, approach to, 152-153
ulnar artery injuries, 151
wound care in, 164, 164f
Vascular repair
for great vessel injuries, 88-90
methods of, 320, 320f-321f
Vascular surgery
in austere environment, 252-268
for abdominal vascular injuries, 259-260,
260f-261f
abstract, 252.e1
equipment for, 252, 253f
forearm amputation, 264-265, 267f
fundamentals of, 252-253, 253f
futility of, 263, 263f
for lower limb injuries, 261-263, 261f-262f
for neck injuries, 253-256
for soft-tissue injury, 263, 264b
for upper limb injuries, 256-259, 257f-259f
vascularized composite muscle flaps for
coverage of vascular reconstruction,
264
early, 5-8, 5t
education in, in Belgrade, 314
in Northern Europe, 297
Vascular surgical training, 269-280
abstract, 269.e1
Advanced Surgical Skills for Exposures in
Trauma (ASSET), 276-277, 276t
Advanced Trauma Operative Management
(ATOM), 275-276
animal use for, 272
cadaver-based, 272
cases over the duration of, 270t
and certification, 283-284
components of, 271
considerations in, 270-271
current curricula in, 275
Definitive Surgical Trauma Care (DSTC), 275
Definitive Surgical Trauma Skills (DSTS), 275
European Vascular Masterclass (EVM),
277-278
evolution of, 270
levels of, 271
Military Operational Surgical Training
(MOST), 277, 277f
simulation-based, 273-275
350 Index

Vascular surgical training (Continued) Vascular trauma (Continued) Vertebral artery (Continued)
team-based, 272-273 in Latin America, 329-332 natural history of, 140
tools in, 272 abstract, 329.e1 operative strategy and technique for, 141f,
trend in, 271 epidemiology of, 329, 330f 144
Vascular trauma regional diagnosis and management of, Vertical resuscitation, versus horizontal, 57
among local national populations, 15-16 329-332, 331f Vessel injury, single, in forearm, 259
arrest following, 62 strategies for training of trauma surgeons Vessel ligation, 173
in Brazil, 333-337, 334f in, 332 Vessel-loop shoelace technique, 331, 331f
abstract, 333.e1 systems of care, 329 Vicryl mesh, 68
epidemiology of, 333 variables of, 330t Vietnam
evaluation and diagnosis of, 334-335 lifestyle and socioeconomic factors and, 18-19 experience in, vascular surgery in, 10-11, 10t
incidence of, in rural setting, 333-334 management of, 11 via Gulf War 1991 to Afghanistan and Iraq,
mechanism of, 333 and military conflict, 14-16 military vascular surgery in, 11
prehospital evaluation in, 334-335 pathophysiology of, 28-32 Vietnam Vascular Registry, 10, 10t
rural setting, 333-334 abstract, 28.e1 Violent injury, in urban populations, 16
strategies for sustaining and training of clinical practice on battlefield and, 28-29 Visceral arteries, injuries to, 119-121
trauma surgeons in, 336-337 damage control resuscitation in, 29-31, celiac artery and branches, 119
treatment strategies for, 335, 335f 30f-31f endovascular treatment for, 121
urban conflicts, 333, 334f ischemic threshold in, 29 inferior mesenteric artery, 120
categorization of, 13-14 pathogenesis of ischemia and reperfusion mortality in, 121
and civilian populations, 16-17 in, 28 renal artery, 120-121
in combat troops, 14-15 and patient age, 17-18 superior mesenteric artery, 119-120
context of, 13-14 region-specific considerations for diagnosis of, Visceral rotation, medial, 115, 116f-117f
in Croatia, 293 284-285 Visceral vessel injuries, 113-125
considerations for diagnosis of, 295 in Serbia, 309-315 Vitallium tube techniques, 198
epidemiology of, 293 abstract, 309.e1 experimental and clinical application of,
strategies for sustaining and training of considerations for diagnosis of, 310, 311f 199f
trauma surgeons in, 296 endovascular repair of, 314 von Esmarch, Freidrich, 4
system of care of, 293-295 epidemiology of, 309, 310t
treatment strategies for, 295-296 systems of care, 309-310
war, 293 treatment strategies for, 311-313, 311t-312t, W
future surgeon training in, 269-280 312f, 314f Wallstents, for pseudoaneurysms, 216
abstract, 269.e1 in South Africa, 324-328 Walter Reed Army Medical Center, arteriography
Advanced Surgical Skills for Exposures in abstract, 324.e1 and, 44-45
Trauma (ASSET), 276-277, 276t considerations for diagnosis of, 326, War
Advanced Trauma Operative Management 326f-327f noncompressible torso hemorrhage and,
(ATOM), 275-276 epidemiology of, 324-325, 325f perspective on, 65
animals in, 272 strategies for sustaining and training of resuscitation and, 57
cadaver-based, 272 trauma surgeons in, 327-328 three-dimensional resuscitation and, 57-58
cases over the duration of, 270t systems of care in, 325-326 War vascular injuries, in Croatia, 293, 294f-295f
components of, 271 treatment strategies for, 326-327 Warfare, modern, pediatric vascular injury and,
considerations in, 270-271 Vein graft, for arterial defect, 7f 227
current curricula in, 275 Vein repair, for pediatric extremity injuries, 231 Wartime injuries, 251
Definitive Surgical Trauma Care (DSTC), Venorrhaphy. see Arteriorrhaphy World Health Organization (WHO), on
275 Venous injury, 322 automobile accidents in Brazil, 334
Definitive Surgical Trauma Skills (DSTS), extremity World War I experience, vascular surgery and, 8
275 considerations for, 174-179 World War II
European Vascular Masterclass (EVM), later manifestation of, 180 arterial repair, nonsuture method of, during,
277-278 ligation of, 175 9, 9f
evolution of, 270 neck/thoracic outlet arterial injuries experience, vascular surgery and, 8-9
levels of, 271 associated with, 142 interposition grafts and, 206
Military Operational Surgical Training Venous pressure, reduced, 203 WoundStat, for hemorrhage, 188, 189t
(MOST), 277, 277f Venous repair, considerations for, 131
simulation-based, 273-275 Venous shunting, 203
team-based, 272-273 Venous shunts, 136-137 X
tools in, 272 Venous thromboembolism (VTE), IVC filters Xenografts, 208
trend in, 271 and, 236
iatrogenic, 18 Venous thrombosis
ideal conduit for, 209-210, 209t duplex scanning for, 49-50 Z
in Israel, 316-323 ultrasound findings in, 45t Zenith TX-2, for thoracic aortic aneurysms,
abstract, 316.e1 Venovenous bypass, 136-137 217
epidemiologic considerations for, 316, Ventilator-associated pneumonia, 96 Zone I injuries
317f-318f Verification Review Committee (VRC), ACS of carotid arterial injury, 215, 216f
incidence of, 316-317 COT, 24 of neck, operative management of, 255-256,
late complications of, 322-323 Vertebral artery, 144 257f
mortality from, 323 anatomic segments of, 141f Zone II injuries, of carotid arterial injury, 215
prospects for future, 323 injuries to, 139 Zone III injuries
system of care in, 317-318, 317f-319f endovascular management of, 217, 217f of carotid arterial injury, 215
treatment strategies for, 319-323, 320f-322f management of, 144 of neck, operative management of, 255, 256f