Characteristics and Distribution of Extremity Vascular Injuries in a Wartime Military Cohort

Abstract

Combat-related extremity vascular injuries (EVI) in service members pose a significant challenge to clinicians due to the complex, long-term health care needs of these Veterans after repair and limb salvage. This study determined characteristics of service members, mechanisms of injury and distribution of vascular injuries in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans. Veterans with EVI undergoing an initial attempt at repair were identified using the Department of Defense Trauma Registry, validated by chart abstraction and merged with Veterans Administration data. Our cohort of 527 service members with EVI averaged 25.3 ± 6.5 years old (range, 18-56 years) at time of injury, >95% of the service members were male, and 30% were married. The distribution of race was 82% white, 6% African American and 3% Asian; independently, 10% were of Hispanic ethnicity. Cohort members were enlisted (95%) in the Army (68%) or Marines (28%), and most graduated from high school (84%) with 13% reporting some college. Service members were injured in Operation Iraqi Freedom/Operation New Dawn (66%) and Operation Enduring Freedom (33%). Explosive injury mechanism was most common (63%), with gunshot wounds accounting for 32%; 73% were penetrating versus 27% blunt injuries. The composite Injury Severity Score was 15.9 ± 9.2 (range, 1.0-59.0) with a distribution of 60% mild, 25% moderate, and 15% severe injuries. Abbreviated Injury Scale-Extremities distribution included 12% moderate, 67% serious, and 17% severe. The 527 service members experienced 741 vascular injuries: 246 arterial and 38 venous upper and 317 arterial and 140 venous lower extremity injuries with many Veterans also suffering concurrent soft tissue, bone and nerve injuries. Brachial (43%), radial (24%), and ulnar (21%) arteries and brachial (37%) veins were most frequently injured in the upper extremity (Table I). Superficial femoral (29%), tibial (25%), and popliteal (25%) arteries and superficial femoral (28%) and popliteal (23%) veins were the most common lower extremity injuries (Table II). All 527 service members were alive upon discharge with >99% surviving at 5 years of injury. Sixty-five percent were discharged/medically retired for disability, 52% were diagnosed with PTSD at 5 years of injury, and 82% had traumatic brain injury (TBI) including 14% with moderate, severe or penetrating TBI. EVI caused by explosive mechanism represents a large cause of morbidity with high rates of disability and TBI. Many service members undergo successful vascular repair and all survived their EVI, however, the overall health of this cohort requires complex and holistic care beyond initial surgical repair and stabilization.Table IDistribution of upper extremity vascular injuriesArterial injuriesVenous injuriesLeft132Left18Right114Right20Veterans: 227Veterans: 35Left only: 119Subclavian2Subclavian1Left only: 15Right only: 106Axillary15Axillary9Right only: 19Bilateral: 2Brachial106Brachial14Bilateral: 1Radial58Radial1Ulnar51Ulnar3Hand1Superficial7Unspecified13Unspecified324638 Open table in a new tab Table IIDistribution of lower extremity vascular injuriesArterial InjuriesVenous InjuriesLeft162Left71Right155Right69Veterans: 278Veterans: 119Left only: 134Common femoral11External iliac2Left only: 55Right only: 131Profunda femoral9Common femoral14Right only: 58Bilateral: 13Superficial femoral93Profunda femoral4Bilateral: 6Femoral branch2Superficial femoral39Femoral unspecified24Femoral branch1Popliteal78Femoral unspecified5Tibial/peroneal79Popliteal32Sural1Tibial/peroneal21Dorsalis pedis2Medial plantar1Medial plantar1Saphenous12Unspecified17Unspecified9317140 Open table in a new tab