The effectiveness of early tourniquet application observed in Iraq and Afghanistan has led to doctrinal changes that have produced a surge of patients presenting with vascular injuries that in past conflicts would never have reached a field hospital alive. Theater policy in Afghanistan dictated all deployed soldiers had at least one Combat Application Tourniquet to render self- or buddy aid. Therefore, during your deployment you will find yourself fixing more vascular injuries than you may ever have imagined. Optimal management requires proper planning and recognition of the essential priorities necessary to prevent immediate hemorrhagic death. Explosion-associated injury, the most common vascular wounding pattern, involves fractures, thermal injury, and embedded fragments over a majority of the body surface.

While in a civilian trauma setting definitive airway control is often the first management priority, in a deployed environment priority shifts to immediate hemorrhage control and vascular access for resuscitation. It should be emphasized that both of these activities may be carried out simultaneously between the nurses, surgeons, and anesthesia providers involved in the patient’s care. Clear delineation of team member responsibility is critical to success, and the surgeon should act as the team leader, setting and assessing the accomplishment of care priorities. A volume-depleted patient may not always manifest active arterial bleeding at the time of admission. Prehospital tourniquets should nonetheless be inspected and readjusted, augmented, or replaced once the resuscitation restores adequate peripheral perfusion.

Recognizing the need for vascular reconstruction at the time of the trauma admission is crucial for success as indecision and progressive ischemic burden can result in ultimate graft failure and subsequent limb loss. Most of the extremity injuries involve fractures and large soft tissue wounds that can make the diagnosis by physical exam alone inaccurate. Radiographs can provide early clues that extremity vascular injuries exist, and you should take a close look at the plain films as you enter the admitting area. For example, supracondylar femur and tibial plateau fractures are frequently associated with injuries to the distal femoral and popliteal artery. These are among the most common lower extremity vascular injury patterns that you will encounter. Deformed extremities are straightened, and the onset of additional hemorrhage is controlled with direct pressure, gauze packing, hemostatic dressings, or additional tourniquets. Alternatively, in stable patients without active bleeding, prehospital tourniquets should be carefully loosened to determine the degree (if any) of vascular injury. A Doppler assessment is advised to confirm the absence of pedal pulses and to perform an ankle-brachial index when possible. A patient assessment done in concert with an orthopedic surgeon will facilitate the necessary discussion regarding the sequence of the operation and preferred techniques for external fixation that best aid in the anticipated vascular exposure. The usual proper sequence should be (1) stabilize the patient, (2) stabilize the fracture, and (3) repair the vascular injury. Important information to relay to the entire operative team should include ideal patient positioning, the plan for vein harvesting in a contralateral extremity, and the desire for a C-arm or arteriography. Special instruments located in “peel packs” can ease the apprehension of not having the favored instruments when needed quickly. The earlier you relay this information to the OR, the easier and faster your case will be.

A dedicated two-team approach is recommended for the surgical management of military vascular injuries. For extremity injury this practice reduces ischemic time as the primary team may be preoccupied with thoracotomy or laparotomy to control hemorrhage or other damage control maneuvers. Ultimately, however, if resources are limited – as they usually are at far forward facilities – always follow the axiom of “life over limb.” A perfectly revascularized limb is of absolutely no use to a dead patient. When available, do not hesitate to involve a second team as they can be used to apply external fixation, perform fasciotomies, begin a peripheral vascular exposure, or harvest vein from a noninjured or amputated extremity (Fig. 22.1). It is important to take some extra “careful” time when doing the vein harvest. The quality of the venous conduit is the best predictor of graft patency. Unnecessary haste and carelessness in harvest may lead to conduit injuries, the repair of which will degrade the conduit quality. You should always caution your assistant on the potential for injury to the saphenous vein when performing a fasciotomy as the vein is located right where the medial fasciotomy incision is usually performed. Position the patient to enable unimpeded access to another body cavity or limb in the event of unexpected deterioration or need for additional vein harvesting.

Initial control of hemorrhage is often accomplished by digital occlusion using an assistant’s hand prepped directly into the bleeding wound bed with betadine spray. This is followed by a careful dissection proximal and distal to the site of injury. It is always safer and more prudent to proceed from known, undisturbed anatomy to the zone of injury than to dive into a hematoma. Balloon catheters may also tamponade hemorrhage when a tourniquet or manual pressure is not effective, but blind insertion of surgical instruments can be unproductive or harmful and is discouraged. Tourniquets are left in place until the anesthetist has sufficient time to resuscitate the patient. You may find that the transected vessel ends can be difficult to identify in the destroyed tissue. Although often thrombosed at the time, these vessels must be found and ligated because they will rebleed later after the patient is resuscitated. Retrograde advancement of a Fogarty catheter from an uninjured distal site can also be used to locate the transected artery in a horrific wound that is no longer bleeding. When making a decision to amputate or salvage an extremity, you should consider the patient’s condition, extent of injury, and your willingness to commit the patient to the necessary definitive orthopedic care and physical rehabilitation. No one situation or scoring system can replace the surgical judgment developed by an experienced team.

While often not feasible in war wounds because of the extent of injury, a primary end-to-end repair is preferred when lateral sutures cannot repair the injured vessel. Advantages of this repair include a single anastomosis and use of autologous tissue. Dividing nearby branches may gain some length in noncalcified vessels, but this repair should be both expedient and tensionless. If the vessel has not been transected, realize that the ends will retract significantly once you complete the division, so it can be helpful to place several stay sutures that traverse the injured area to hold it in place and facilitate the anastomosis (Fig. 22.2). A complete debridement of any disrupted tissue is an essential step of the repair, and sacrifices made to avoid an interposition conduit should be keenly resisted as a comprised repair will not be durable. It cannot be overstated that the complexity and additional operative time required for vein harvest and interposition grafting or bypass, particularly by surgeons who don’t perform these operations regularly, are significant. The time used to tie up, potentially, the only operating table for a lengthy vascular reconstruction , may preclude the definitive management of another patient’s more life-threatening injuries. The final operative plan and estimated time should be communicated early to the entire operative team with contingency bail out plans should a more critically wounded patient arrive.

The saphenous vein is the preferred conduit for military vascular injuries. The poor historical results of prosthetic material when used in contaminated war wounds are the justification for this approach. In my experience, prosthetic grafts placed in larger vessels with good muscle coverage have been used successfully. I have used prosthetic grafts for “clean” subclavian and carotid wounds. However, inferior long-term patency of prosthetic materials and the potential for infection in war wounds and subsequent pseudoaneurysm formation have restricted its widespread use in combat-related extremity wounds. Prosthetic may also be used as a temporary repair, with a plan for subsequent re-exploration and replacement with vein graft if necessary.