Key Words:
vascular injury , diagnostics , reconstruction , education
Region-Specific Epidemiology
In peacetime, vascular trauma in Croatia (approximately 4,500,000 inhabitants) is rare and due mostly to blunt mechanisms 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 extremity injuries. The Republic of Croatia experienced a Homeland War from 1991-1995 while detaching from the former Yugoslavia ( Fig. 27-1 ). In the beginning of the aggression on Croatia, there were no war surgery–skilled surgeons. 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 vascular trauma before the war.
War Vascular Injuries
Data from the Homeland War revealed a much higher incidence of vascular injuries, especially those to the extremities. In general, autologous vein was recommended as the best option for a substitute arterial conduit for extremity vascular reconstruction. 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 beginning of the war (1991), some of the hospitals had to be transformed into combat hospitals due to their proximity to the battlefield ( Fig. 27-2 ). One example is Osijek University Hospital ( 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 by end-to-end anastomosis. Synthetic material (30% of cases) and saphenous vein (30% of cases) were also used as bypass or interposition grafts. 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 extraanatomic, 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 ).
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