One of the features that distinguish a great surgeon from a good surgeon is the ability to remain calm under pressure, strongly direct a team of providers, and stay focused on the mission at hand. Thoracic vascular injuries can make for good theater and subsequent tall tales when there is a successful outcome, but nowhere is it more critical to be in the “great surgeon” mindset than with the management of these unforgiving injuries. “Control” is the operative term. Despite the divergence of vascular and general surgery in the civilian sector, every combat trauma surgeon needs to have the basic vascular surgery knowledge and skillset to manage these injuries. Consultation with a vascular surgeon or transfer may not be an option.

Military surgeons are routinely trained in nonmilitary environments and, as such, may be unprepared for life on the battlefield. Howard Champion in 2003 described six unique considerations with regard to acute resuscitation in a combat setting: (1) the high energy and lethality of wounding agents; (2) multiple causes of wounding; (3) preponderance of penetrating injury; (4) persistence of threat in tactical settings; (5) austere, resource-constrained environment; and (6) delayed access to definitive care.

The majority (~75%) of survivable chest wounds on the battlefield can be managed with simple tube thoracostomy. Greater than 90% of vascular injuries can be diagnosed based on the history and physical exam findings alone. Hard signs suggesting a vascular injury include pulsatile bleeding, expanding hematoma, palpable thrill, audible bruit, and evidence of ischemia as indicated by pulselessness, pain, pallor, paresthesia, and paralysis in an affected upper or lower extremity or stroke when dealing with injury to the great vessels. Soft signs of vascular injury include a history of moderate hemorrhage at the scene of injury, injury in proximity to a named vessel, decreased but present pulse, non-expanding hematoma, and associated peripheral neurologic deficit. Hard signs do not require a lot of workup – in general they belong in the operating room ASAP!

Classic wounding patterns that should cause one to suspect major thoracic vascular trauma include the presence of hemorrhagic shock, jugular venous distension suggesting SVC syndrome or cardiac tamponade, an expanding hematoma at the base of the neck, or a discrepancy in pulse exam between each upper extremity or between the upper and lower extremities. The trajectory of the penetrating wound should also lend clues to the nature of the injury. Bullets can take somewhat unpredictable courses or ricochet off of bony structures, but they can’t defy the laws of physics. For single projectile wounds, knowing the entrance and exit site greatly assists you in focusing your evaluation on the area at risk. For stable patients with no obvious indication for surgery, CT scan with IV contrast is an excellent tool for evaluating critical structures and also for reconstructing the trajectory of the missile or the location of multiple fragments. It is particularly useful for proven or suspected trans-mediastinal wounds.

A classic primary survey should commence immediately in the emergency department (ED) simultaneously with attempts at resuscitation. In the presence of suspected massive thoracic vascular injury, venous access should be established if possible in the lower extremities or at least in the upper extremity that seems least likely to be involved with the injury.

If the casualty needs to be transferred to a higher echelon of care, for example, from a forward surgical team to a combat support hospital, chest tubes should be placed prior to rotary-wing transfer. These patients are essentially inaccessible during transport in a modern evacuation helicopter, and placement of a chest tube en route can be extremely difficult. If there is concern for exsanguination from chest tube placement, the thoracotomy should have already been initiated, and your decision to transfer was incorrect. The patient described won’t survive transport and needs your expertise now.

If the patient rapidly decompensates in the ED with suspected thoracic vascular injury or if you witness cardiovascular collapse, a resuscitative anterolateral thoracotomy through the fourth or fifth interspace is required. Upon entering the chest, the location of the injury should be identified. Inspect the heart. If the pericardium is tense, you need to incise the pericardium sharply and longitudinally anterior to the phrenic nerve. Deliver the heart out of the pericardium, and begin compressions against the sternum with the palm of your hand if needed. Be gentle!

If there is a lot of blood in the left chest and the patient’s heart appears empty, incise the parietal pleura over the aorta to be able to get a clamp fully across the aorta to the spine, and clamp with an atraumatic clamp. Remember that you are now on a clock so mark the time in your head. You have just less than 30 min to release that clamp, and the more time that passes by, the more risk this patient has of dying from uncontrolled coagulopathy, liver failure, or reperfusion injury. If you get the patient back, continue your resuscitation but get the patient to a place where you can conduct a formal operation.

Patients with suspected thoracic vascular injuries should be prepared for operation with standard surgical approaches in mind and with additional preparations allowing for access of more proximal vascular control. In addition, preparation should be made for recovery of an adequate vein for a reconstructive conduit from an uninvolved extremity. Hence, patients with suspected thoracic vascular injuries should have the entire chest and neck prepped into the field to allow for rapid performance of median sternotomy or thoracotomy, as well as preparation of one or both of the lower extremities to allow for recovery of the greater saphenous vein for conduit. In the chest, the first goal is to stop the bleeding and then perform a definitive repair. If suture won’t fix the problem, a large prosthetic graft or bovine pericardial patch will. It is rare to use saphenous vein for reconstruction in the chest with the exception of elective aortocoronary bypass. We prefer to stock 18 × 9 mm collagen-coated knitted and bifurcated Dacron grafts. The tubes are long enough to repair any aortic injury, and the limbs come in handy and are a perfect size for any great vessel reconstruction that is required. When you arrive at your facility, immediately inspect your current stock and supply level of vascular grafts. The time to discover what you have available (if anything) is not in the middle of one of these cases.

There are several surgical approaches to the thorax, each with key advantages and disadvantages for emergent trauma applications. The surgeon should be familiar with all of them, and the clinical situation should determine the choice of incision. Hemodynamically unstable patients may not tolerate lateral positioning for traditional posterolateral thoracotomy incisions more commonly used for elective thoracic surgery. Compounding the difficulty, the decision for incision may be based upon only a portable chest radiograph, chest tube output, wounding patterns, and mechanism of injury. In emergent scenarios, the surgeon will likely have limited knowledge of potential mediastinal involvement, the projectile’s path, or additional cavitary involvement. With penetrating thoracic trauma, there is also the possibility of injury to adjacent body regions, such as the abdomen and neck to consider. Therefore, the chosen initial thoracic incision must prove versatile in accommodating flexibility to provide exposure to rapidly and effectively treat subsequently identified injuries.

In the stable patient, additional imaging in the form of CT may prove very useful. Armed with better understanding of the location and nature of injury, a better decision regarding optimal therapy can be formulated. In the modern endovascular age, this information may also facilitate the effective utilization of less-invasive adjuncts either alone or in support of open surgical means.

Commonly employed open operative approaches include anterolateral thoracotomy, posterolateral thoracotomy, and even bilateral thoracotomy (or “clamshell thoracotomy ”) and median sternotomy. Each has its own potential benefits and associated limitations.