Military Vascular Injuries

Abstract

The management of traumatic combat-related vascular injury can offer special challenges even to experienced surgeons. Recent US conflicts have advanced the practice of vascular trauma surgery on the battlefield and offer important lessons learned for management of similar injury in urban trauma centers. Damage control techniques for complex peripheral vascular injuries when associated with hemodynamic instability may provide an opportunity to save both life and limb. Early initiation of damage control resuscitation concepts is crucial to performing a successful simultaneous vascular reconstruction. A vascular assessment should begin in the admitting area using a handheld continuous wave Doppler device. Do not rely on a pulse exam for a patient in hemorrhagic shock. A CT angiogram may be useful for cervical or truncal vascular injuries to plan the best approach but rarely necessary for the diagnosis of an extremity vascular injury. Prehospital tourniquets should be exchanged for a pneumatic type or better removed in the operating room if the patient is unstable or if additional hemorrhage is expected. Vascular repairs often require massive transfusion; therefore, temporary shunting with delayed repair should be considered at community surgical facilities. A second surgical team can save time by placing external fixation and performing saphenous vein harvests or fasciotomy. Finally, a saphenous vein interposition graft is durable when there is adequate muscle coverage; otherwise a longer bypass tunneled out of the zone of injury should be chosen to prevent desiccation or delayed rupture.