The Era of Vascular Surgery in a War Country

Abstract

The objective of this presentation is to reflect on the limited choices for vascular reconstruction in Yemen, which is under war and siege; to emphasize the challenges for vascular surgeons to conduct such a risky and complicated operation with the lack of vascular instruments and materials needed; and to point out that an immensely critical and almost amputated upper limb of a young man could be saved despite the limited facilities. A 25-year-old man presented with acute ischemia after massive bleeding. While he was operating a factory machine, his left hand slipped into the sharp spiral processing machine, and the hand was dissected like minced meat from the palm up to the elbow, with massive loss of skin, muscles, and soft tissues. The initial decision was above-elbow amputation. The computed tomography angiogram showed a defect of the brachial artery from 5 cm above the elbow joint to 2 cm before the radio-ulnar bifurcation and a variant anomaly of the blood arteries with trifurcation of the radial, ulnar, and the origin of the common interosseous artery. The vascular intervention started immediately to reduce the ischemia time with a brachia-trifurcation autologous bypass with the basilic vein in reversed technique and muscle-flap coverage for the distal anastomosis due to lack of skin and soft tissue, then followed by orthopedics fracture fixation. Because of the multi injury of the radial artery at the wrist joint, we decide to ligate the radial artery and let the blood supply of the hand with the ulnar artery alone. After 63 days of inpatient treatment with multiple washouts; unfortunately in Yemen, we do not have basic devices such as a vacuum-assisted closure device of a wound VAC; therefore, we had to do every second-day washout at the operation theater. However, if that device was available, we would have conducted an intraoperative dressing with silver foam every 7 days. Vascular trauma in a war country leads to a catastrophic endpoint and represents a significant cause of morbidity and mortality following injury. Ligation of vascular injury remains the first choice for many surgeons for the initial treatment strategy, especially for minor or distal vascular injuries, but unfortunately for femoral or brachial arteries, injury management is with the amputation of the limb. Despite the limitation of surgical facilities, we managed to save the patient's massively traumatized hand.