Region-Specific Epidemiology

The rate of major vascular injuries occurring during the Afghanistan war ranged from 2% to 8% of all injured combatants (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 injuries to the corresponding veins. Arterial injuries were sometimes 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 condition (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 satisfactory 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 admission, 30% of patients had depressed consciousness; and 7% were unconscious, which made early and accurate diagnosis of vascular injuries difficult.

Region-Specific Systems of Care

Over the course of the armed conflict in Afghanistan, the following 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 preparation); (2) advanced trauma management at forward medical units, including augmented medical stations, medical companies, 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. 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 medical personnel (tactical evacuation) or which provided for aeromedical evacuation by special “Bisectrix” helicopters 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 injuries 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 primary amputation rate.

Photograph of a divisional separate medical battalion containing an operation room, a preoperative area, and an intensive care unit.

(From Afghanistan, Bagram, 1980.)

Among the medical supplies issued to individual servicemen before combat operations were first-aid kits containing sterile field dressings and rubber tourniquets designated for hemorrhage control. Combat medics were equipped with bags containing 15 to 20 field dressings, 4 to 5 tourniquets, 2 units of crystalloid, and a 3-day supply of drugs. Additional units of crystalloid were carried by combat lifesavers.

During the war, the number of patients with vascular injuries who did not receive prehospital care decreased from 14% to 3.2%. There were numerous improvements in prehospital care, such as in-uniform tourniquet systems, tourniquets with graduated compression, and special needles for percutaneous ligation of the femoral artery. The last tool developed by Nikolai Pirogov was a rarely used method of percutaneous ligation of the major artery in the middle of a thigh in case of a distal arterial injury ( Fig. 29-2 ). This technique consisted of ligation of femoral vessels by pulling a sterile special long curved needle through the muscles between the femur and vascular bundle making a knot over a stick until the arterial flow stopped ( Fig. 29-3 ). Possible venous bleeding from the wound can be controlled by tight bandage. This method of hemorrhage control prolongs warm ischemia time without any serious damage of arterial wall.

The special set for percutaneous ligation of femoral vessels containing different needles with a stick.

(From the Museum of Department of Operative Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russia.)

Technique of percutaneous ligation of femoral vessels in prehospital care. SFA, Superficial femoral artery; SFV, superficial femoral vein.

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 underwent 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 measures 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, general surgeons provided care to vascular patients during the early years of the war in Afghanistan. A new stage in the provision 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 outcomes for patients with vascular injuries.

Region-Specific Considerations for Diagnosis

The following clinical signs were considered key criteria in the diagnosis of vascular injuries to an extremity: injury location in the projection of a major vessel (88.2% of patients), intensive external bleeding (83.7%), weak or absent arterial pulses (73%), or large or growing hematoma in the wound region (43.5%).

Fundamental to diagnosis and care of acute limb ischemia is its classification according to Vadim Kornilov (1971) ( Fig. 29-4 ). This classification presented in the third edition of the Soviet Great Medical Encyclopedia (1974-1988) in the Guidelines 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 of artery thrombosis and embolism are the following:

• 1.
  

  Arterial injuries are accompanied by massive bleeding, which aggravates tissue ischemia.

  
  
• 2.
  

  There is no preceding chronic ischemia in extremities with a definite tissue adaptation to hypoxia.

  
  
• 3.
  

  Vascular injuries occur more commonly in young males having large muscle bulk, and a pronounced endotoxicosis can therefore accompany postischemic blood recirculation.

Dr. Vadim Alexeevich Kornilov, Colonel, 1937-1993.

Professor at War Surgery Department, Kirov Military Medical Academy, Saint-Petersburg. He has been recognized for his outstanding contribution in vascular trauma.

Among all admitted patients with injured arteries, signs of uncompensated ischemia were noted in 27.6% of cases. Compensated ischemia (owing to collateral vessels) was reported in 63.6% of cases. Some 8.7% of admitted patients had irreversible ischemic changes in the extremities. Additional angiography was used rather infrequently; only in the case of a reasonably suspected major vascular injury was operative exposure carried out. Indications for preoperative angiography occurred more commonly in patients with multiple injuries to major vessels and in those with blunt artery trauma. This diagnostic approach was applied in 16.7% of patients with extremity artery injuries. Under separate medical battalion conditions, arteriography would preferably be performed during surgery after exposure of the proximal segment of the artery. During definitive surgical care, 91% of patients with injured lower extremity arteries underwent femoral artery catheterization using a Seldinger technique to perform angiography following prolonged drug administration. (This approach allowed for a 2.5-fold decrease in the amputation rate. ) Owing to a lack of equipment, the informative method of duplex ultrasound examination was not used. Although by the end of the war a portable ultrasonic device to study major vessel patency had been developed (unpublished data), it did not find use in further conflicts in the North Caucasus.

Region-Specific Treatment Strategies

During combat in the Afghanistan war, the care of major vascular injuries evolved. Military treatment facilities consisted of physicians untrained in vascular surgery. In accordance 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 Treatment Facilities” (1981). The most important vascular operation at the advanced trauma-management stage appeared to be arterial ligation. Reconstructive vascular surgery was considered 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 incapacitating 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 augmentation 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.

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 associated injuries, resulted in death. Considering previous experience in World War II that demonstrated the high rate of amputations accompanied by ligation of major arteries, as well as a dramatic reduction in amputations (13.5%) while restoring arterial patency during the Vietnam War, Soviet surgeons in Afghanistan began to use primary restoration of major artery patency more frequently (40.9%).

Eger et al 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 operations on injured extremity arteries. This operation was recommended for the advanced trauma-management stage and was to be followed by definitive vascular reconstruction at the definitive surgery stage. 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%). 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 arteries. 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 accordance with “The Guidelines for War Surgery” (1988), an indication for TS at the advanced trauma-management stage is a large arterial defect accompanied by uncompensated ischemia. 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 contributing 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 injuries, 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%). Primary neural suture was applied in 13% of patients who had vascular injuries accompanied 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 hemostasis 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. Repaired vessels developed 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 servicemen, 33% returned to duty, while 43% of patients demonstrated 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 coordination 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 injuries. 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 principles. These shortcomings were manifested during mass casualty 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 (Tashkent) 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 vascular 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 Military Medical Academy and military medical institutes. In subsequent years, these officers were sent to combat settings to provide patient care.