Papers Presented to the Peripheral Vascular Surgery Society—Winter Meeting
Upper Extremity Vascular Injury: A Current In-Theater Wartime Report from Operation Iraqi Freedom

https://doi.org/10.1007/s10016-006-9090-3Get rights and content

Past wartime experience and recent civilian reports indicate upper extremity (UE) vascular injury occurs less often and with less limb loss than lower extremity (LE) injury. Given advances in critical care, damage control techniques, and military armor technology, the objective of this evaluation was to define contemporary patterns of UE injury and effectiveness of vascular surgical management in UE vascular injury during Operation Iraqi Freedom (OIF). From 1 September 2004 through 31 August 2005, 2,473 combat-related injuries were treated at the central echelon III surgical facility in Iraq. Patients with UE vascular injuries upon arrival were reviewed. Vessels injured were delineated. Therapeutic interventions, early limb viability, and complication rates following vascular repair were recorded. Of casualties treated during the study period, 43 (1.7%) UE and 83 (3.3%) LE vascular injuries were identified. Of the UE injuries, 11 (26%) had been operated on at forward locations and six (14%) had temporary shunts in place upon arrival at our facility. Injury levels included 10 (23%) subclavian-axillary, 25 (58%) brachial, and 10 (23%) distal to the brachial bifurcation. Two patients had multilevel injury. Twenty-eight grafts were placed, and 10 vessel repairs and eight ligations were performed. Two (4.7%) brachial interposition grafts required removal due to infection. Four (9.3%) subacute brachial graft thromboses occurred. Four (9.3%) patients underwent early UE amputation. In this most recent U.S. military evaluation of wartime UE vascular injury, UE injury appears rare, with LE injury twice as frequent. Yet, UE limb loss appears more substantial than noted previously. These findings are likely related to significant tissue destruction occurring with the combined mechanisms of injury sustained in OIF.

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INTRODUCTION

The evolution of extremity vascular injury treatment is intimately related to experience obtained during military conflict. From routine ligation and amputation in the World Wars through the rapid evacuation and successful in-theater use of autogenous reconstruction during Korea and Vietnam, these struggles have provided models for improvement in revascularization and limb salvage.1, 2, 3, 4, 5 The recent operations in support of Operation Iraqi Freedom (OIF) embody the first expanded U.S.

MATERIALS AND METHODS

During 12 consecutive months, from 1 September 2004 through 31 August 2005, 2,473 battle-related injuries were evaluated at the central level III [332nd Expeditionary Medical Group (EMDG)/Air Force Theater Hospital] facility at Balad Air Base, Iraq (Fig. 1). The 332nd EMDG is the first Air Force theater hospital since the Vietnam War. All theater U.S. medical evacuation occurred via Balad Air Base and the 332nd EMDG. Thus, all injured force movement flowed either directly into the 332nd EMDG or

Incidence and Distribution of UE Vascular Injury

During the year-long study period 2,473 battle-related injuries were evaluated at the 332nd EMDG. There were 163 major vascular injures identified, for a rate of 6.6%. The anatomic distribution of major vascular injury is illustrated in Figure 3A, with 126 of the injuries occurring in extremities where limb salvage was attempted. Of these, 43 (34% of extremity vascular injuries, 1.7% of all battle-related injuries) were in the upper extremity (Fig. 3B). Over half (n = 26, 60%) of UE injuries

DISCUSSION

OIF represents the first sizeable U.S. military conflict since Vietnam and, as such, provides an opportunity to revisit vascular injury management during time of war. This report uses the Balad Vascular Registry to depict the in-theater experience with UE vascular injury at the 332nd EMDG/Air Force Theater Hospital at Balad Air Base, Iraq, from September 2004 through August 2005. The development of FSTs and graded echelons of care in conjunction with ever-maturing damage control maneuvers and

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Presented at the Sixteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Park City, UT, January 27–29, 2006.

The views expressed in this report are those of the authors and do not reflect the official policy of the Department of Defense or other departments of the U.S. government.

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