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.” 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. 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. Later, Dr. Norman M. Rich stated that Soubbotitch’s technique and results were not surpassed until 40 years later, during the Korean Conflict. At the end of the 20th century, the former Yugoslavia experienced civil war, and this unpleasant 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.

Over the past 20 years in the former Yugoslavia, the number of treated civilian and war arterial injuries markedly increased to reach epidemic proportions. However, the actual incidence 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 incidence, epidemiology, diagnostics, and vascular injury treatment can be found in the database of the Clinic for Vascular and Endovascular Surgery of the Serbian Clinical Centre. This is the oldest and largest vascular institution in the whole territory of the former Yugoslavia, which deals with urgent vascular 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. Also, 142 iatrogenic vascular injuries were documented in the period between 1992 and 2007. Demographics, injury modality distribution, mechanism, 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 significant 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 procedures. 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 popliteal 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 Thessaloniki 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 of the wagon and the neighing of horses and still smell the stench of gangrenous limbs.”

During the 20th century, the transport of the injured has significantly improved in terms of speed and efficiency, from around 12 hours during the World War II, to only 1 or 2 hours in Vietnam. In the most developed countries with good emergency services practicing “scoop and run” tactics, the transportation of the injured is now only 30 to 45 minutes. However, during the Yugoslavian Civil War, the transport time was again prolonged and as much as 12 hours. The prolonged evacuation time in this conflict existed in part because of the uncertainty of who and where the enemy was located. Due to unfavorable traffic conditions and the limited number of ambulance services in the Western Balkan countries, the transportation of persons with vascular trauma is not efficient even in peacetime. According to the results of one of our studies, the amputation rate in patients treated more than 12 hours after injury is significantly higher than in those operated within the first 6 hours.

The other challenge with the treatment of vascular trauma in Serbia and the majority of the Western Balkan countries is the lack of qualified vascular surgeons. It was the case during the Yugoslavian Civil War and unfortunately remains the case during peacetime that vascular injuries are most often treated by less-experienced general surgeons. This phenomenon was the main reason for a number of secondary procedures after unsuccessful operations performed by less-experienced surgeons on patients with war-related vascular injury. Having less-experienced surgeons with limited vascular experience manage complex war-related trauma was felt to contribute to the higher amputation rate (19%) in some studies from this region. In the fourth part of this chapter, some of the shortfalls associated with inadequate primary procedures during the management of vascular trauma will be presented.