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Background The role of endovascular treatment for vascular trauma, including injury to the subclavian and axillary arteries, continues to evolve. Despite growing experience with the utilization of these techniques in the setting of artherosclerotic and aneurysmal disease, published reports in traumatic subclavian and axillary arterial injuries remain confined to sporadic case reports and case series. Methods We conducted a review of the medical literature from 1990 to 2012 using Pubmed and OVID Medline databases to search for all reports documenting the use of endovascular stenting for the treatment of subclavian or axillary artery injuries. Thirty-two published reports were identified. Individual manuscripts were analysed to abstract data regarding mechanism, location and type of injury, endovascular technique and endograft type utilized, follow-up, and radiographic and clinical outcomes. Results The use of endovascular stenting for the treatment of subclavian (150) or axillary (10) artery injuries was adequately described for only 160 patients from 1996 to the present. Endovascular treatment was employed after penetrating injury (56.3%; 29 GSW; 61 SW), blunt trauma (21.3%), iatrogenic catheter-related injury (21.8%) and surgical injury (0.6%). Injuries treated included pseudoaneurysm (77), AV fistula (27), occlusion (16), transection (8), perforation (22), dissection (6), or other injuries otherwise not fully described (4). Initial endovascular stent placement was successful in 96.9% of patients. Radiographic and clinical follow-up periods ranging from hospital discharge to 70 months revealed a follow-up patency of 84.4%. No mortalities related to endovascular intervention were reported. New neurologic deficits after the use of endovascular modalities were reported in only one patient. Conclusion Endovascular treatment of traumatic subclavian and axillary artery injuries continues to evolve. Early results are promising, but experience with this modality and data on late follow-up remain limited. Additional multicenter prospective study and capture of data for these patients is warranted to further define the role of this treatment modality in the setting of trauma.

Prophylactic fasciotomy has been used as an adjunct to alleviate the compartment syndrome after an ischemia reperfusion injury. It has been purposed that prophylactically treating compartment syndrome will improve neuromuscular recovery of the limb therefore improving functional limb outcome. The purpose of this study is to quantify the neuromuscular recovery of prophylactic fasciotomy in a porcine model of hind limb ischemia.

Background Devastating extremity injuries are prevalent but most often survivable on the modern battlefield. The complexity of these injuries requires advanced methods of reconstruction. This study is designed to validate the feasibility of gracilis myocutaneous flap transplantation via microvascular free tissue transfer in a porcine model. This model will facilitate study of autotransplant physiology as well as vascularized composite allotransplantation as an evolving method for reconstructing previously nonreconstructable injuries. Material and methods A donor gracilis myocutaneous flap is procured from Yorkshire swine. The right external carotid artery and internal jugular vein are prepared as the recipient axis for microvascular anastomoses. Group 1 undergoes immediate microvascular anastomosis with resultant 1-h ischemic period. Group 2 undergoes delayed anastomosis with 3-h ischemic period. Markers of ischemia-reperfusion injury are evaluated after anastomosis and on postoperative days 1, 2, 7, and 14. Results A novel porcine model for microvascular composite tissue transplantation is demonstrated. Ischemia period-dependent elevations in circulating biomarkers (lactate dehydrogenase [LDH], creatine kinase [CK], and aspartate transaminase [AST]) demonstrate the effects of prolonged ischemia. Both groups showed marked LDH elevation without significant statistical intergroup difference ( P = 0.250). The difference in CK and AST levels at 24 h showed strong significance ( P Conclusions A novel method of vascularized gracilis myocutaneous flap transplantation was validated in the Yorkshire swine. Assays for skeletal muscle tissue injury (LDH, CK, and AST) showed ischemia period-dependent response providing assessment of ischemia-reperfusion injury at the cellular level. Subsequent studies will evaluate agents that mitigate ischemia-reperfusion injury and transition these findings to potentiate vascularized composite allotransplantation.

Although a dedicated corps of full-time active-duty and eserve component military physicians now provide most S battlefield medical and surgical care, the military serices have continued to benefit from close collaborations nd interaction with civilian counterparts. In addition to he individual service and facility-specific relationships ith civilian trauma experts and trauma centers described lsewhere, there has been a concerted effort to establish, aintain, and expand programs that promote professional nteractions and exchange of information between military nd civilian surgeons and surgical leadership. These interactions are not new. The history of civilian rofessional medical support for the military can be traced ack nearly a century. In 1916, foreseeing the possibility hat American involvement in the European hostilities of orld War I might become a reality, The Committee of merican Physicians for Medical Preparedness, chaired by

ObjectiveThe purpose of this study was to examine the anatomic distribution and associated mortality of combat-related vascular injuries comparing them to a contemporary civilian standard.DesignThe Joint Trauma Theater Registry (JTTR) was queried to identify patients with major compressible arterial injury (CAI) and noncompressible arterial injury (NCAI) sites, and their outcomes, among casualties in Iraq and Afghanistan from 2003 to 2006. The National Trauma Data Bank (NTDB) was then queried over the same time frame to identify civilian trauma patients with similar arterial injuries. Propensity score-based matching was used to create matched patient cohorts from both populations for analysis.ResultsRegistry queries identified 380 patients from the JTTR and 7020 patients from the NTDB who met inclusion criteria. Propensity score matching for age, elevated Injury Severity Score (ISS; >15), and hypotension on arrival (systolic blood pressure [SBP] 15 compared with civilian matched counterparts (10.7% vs 42.4%; P = .006).ConclusionsMortality of injured service personnel who reach a medical treatment facility after major arterial injury compares favorably to a matched civilian standard. Acceptable mortality rates within the military cohort are related to key aspects of an organized Joint Trauma System, including prehospital tactical combat casualty care, rapid medical evacuation to forward surgical capability, and implementation of clinical practice guidelines. Aspects of this comprehensive combat casualty care strategy may translate and be of value to management of arterial injury in the civilian sector.

Acute colonic perforation is an uncommon but distressing complication of colonoscopic procedures. We describe the successful management of 3 such cases using laparoscopic techniques.

Temporary occlusion of the aorta as an operative method to increase proximal or central perfusion to the heart and brain in the setting of shock is not new.1 Resuscitative aortic occlusion with a balloon was reported as early as the Korean War and has been described in more recent publications.2–5 Despite potential advantages over thoracotomy with aortic clamping, resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma has not been widely adopted. Broader application of this procedure may have lagged because of latent technology, a poorly understood skill set, or anticipated ineffectiveness of the technique. However, the recent evolution of endovascular technology and its clear benefit in managing vascular disease such as ruptured abdominal aortic aneurysm suggest that a reappraisal of this technique for trauma is needed. The objective of this report is to provide a technical description of REBOA. To simplify, this maneuver can be considered in the following five steps each with specific procedural considerations (Table 1)

BACKGROUND The optimal method of vascular control and resuscitation in patients with life-threatening, extrathoracic torso hemorrhage remains debated. Guidelines recommend emergency department thoracotomy (EDT) with aortic clamping, although transabdominal aortic clamping followed by vascular control and direct vascular control (DVC) without aortic clamping are alternatives. The objective of this study is to compare the effectiveness of three approaches to extrathoracic torso hemorrhage in a large animal model. METHODS Adolescent swine (Sus Scrofa) (mean weight = 80.9 kg) were randomized into three groups all of which had class IV shock established by hemorrhage from an iliac artery injury. Group 1: EDT with thoracic aortic clamping (N = 6); group 2: transabdominal supraceliac aortic clamping (SCC; N = 6); and group 3: DVC of bleeding site without aortic clamping (N = 6). After hemorrhage, EDT or SCC was performed in groups 1 and 2, respectively, with subsequent exploration of the bleeding site and placement of a temporary vascular shunt (TVS). Group 3 (DVC) underwent direct exploration of the injury and placement of a TVS. All groups were resuscitated to predefined physiologic endpoints over 6 hours with repeated measures of central and cerebral perfusion and end-organ function at standardized time points. Postmortem tissue analysis was performed to quantify injury to critical tissue beds. RESULTS There was no difference in mortality among the groups and no TVS failures. Central aortic pressure, carotid flow, and partial pressure brain tissue oximetry, all demonstrated increases in EDT and SCC after application of the aortic clamp relative to DVC (p < 0.05). During resuscitation, serum lactate levels were higher in EDT compared with SCC and DVC (6.85 vs. 3.08 and 2.15, respectively; p < 0.05) and serum pH in EDT reflected greater acidosis than SCC and DVC (7.24 vs. 7.36 and 7.39, respectively; p < 0.05). EDT and SCC required more intravenous fluid than DVC (2,166 mL and 2,166 mL vs. 667 mL, respectively; p < 0.05) and more vasopressors were used in EDT and SCC compared with DVC (52.1 μg and 43.5 μg vs. 12.4 μg, respectively; p < 0.05). Brain and myocardial tissue stains demonstrated the same degree of acute ischemic changes in all groups. CONCLUSION Although aortic clamping increases central and cerebral perfusion, DVC results in less physiologic derangement. The optimal method of aortic control would incorporate the benefits of maintained central pressure with less associated morbidity. Clinical studies evaluating DVC are warranted.

Considering the spectrum of combat casualty care, from point of wounding to rehabilitation, prehospital treatment technology has not kept pace with advances in other areas. When responding to the most common cause of potentially survivable but often fatal injury (penetrating truncal trauma),1,2 the medic on today s battlefield has treatment options that are defined by currently available technology. Penetrating truncal injury is often associated with noncompressible torso hemorrhage, the initial management of which is limited to the replacement of intravascular volume in an attempt to avoid ischemia and exsanguination before surgical hemostasis. The importance of injury-induced hypovolemia and the current technological limitations of prehospital resuscitation necessitate the reappraisal of resuscitative fluid strategies that was conducted during this conference. Almost a decade has passed since the last civilian-military fluid conference, and our goal with this symposium is to review data on any new potential fluids, which may offer an advantage over those currently in use. An additional objective of this conference is to aid in the refinement and focus of ongoing research efforts in this field. As the consensus conclusions of this symposium will reveal, freeze-dried plasma (FDP) may be the next generation of improved resuscitation fluids. Although the US Military infused FDP in World War II on the beaches of Normandy, the military does not have this option available today. In the context of this paradox, prehospital fluid replacement with FDP may represent a trip back to the future in the cause of improving the care of the combat casualty.

Background: Noncompressible hemorrhage from central vascular injuries remains the leading cause of preventable death in modern combat. This report introduces a large animal model of noncompressible torso hemorrhage, which permits assessment of the various approaches to this problem. Methods: Yorkshire swine were anesthetized and monitoring devices for central aortic pressure, carotid flow, and intracerebral and transcutaneous brain oximetry were applied. Class IV hemorrhagic shock was induced through an iliac arterial injury and animals were subjected to different vascular control methods including thoracic aortic clamping, supraceliac aortic clamping, direct vascular control, and proximal endovascular balloon occlusion. After vascular control, the injury was shunted, and damage control resuscitation was continued. Serum markers, intravenous fluid volumes, and vasopressor requirements were tracked over a subsequent resuscitation period. Postmortem tissue analysis was performed to compare levels of acute ischemic injury between groups. Results: The protocol for animal preparation, hemorrhage volume, open surgical technique, and posthemorrhage resuscitation was developed using four animals. The endovascular approach was developed using two additional animals. After model development, treatment animals subsequently underwent noncompressible hemorrhage with thoracic aortic clamping, supraceliac aortic clamping, direct vascular control, and endovascular aortic occlusion. Premature death occurred in one animal in the direct vascular control group. Conclusion: This study presents a large animal model of class IV hemorrhagic shock from noncompressible hemorrhage, which permits comparison of various vascular control methods to address this challenging problem. Future studies using this model as the standard will allow further development of strategies for the management of noncompressible hemorrhage.

In the spirit of international exchanges of knowledge with colleagues from all over the world, who are interested in the care and treatment of vascular trauma, we offer selected historical reflections from the western world on vascular trauma. Whereas there are a number of key individuals and a variety of events that are important to us in our writing, we know essentially nothing about what is written by other cultures and, particularly, the Chinese. It is well recognized around the world that Chinese surgeons are among the first to be highly successful in re-plantation of severed extremities, repairing both injured arteries and veins. Also, we recognize that there are contributions in other parts of the world, which are not well known to us collectively. Contributions from the Arabic speaking part of the world come to mind because there is periodic brief reference. We offer our perspective hoping that there will be one or more Chinese surgeons who will offer us the benefit of sharing their perspective on important historical contributions to the managing of vascular trauma outside of the western world, and, particularly, the English speaking literature. Once again, we encourage our colleagues in the Arabic speaking world to provide us with their perspective of the development and management of vascular trauma.

The challenging circumstances that confronted military caregivers during the years of war in Afghanistan and Iraq established the imperative for military-oriented medical research. The burden of injury and illness resulting from this long period of combat operations, and the unique clinical and logistical considerations it engendered provide a compelling rationale for requirement-driven, well-coordinated medical research. Also referred to as “gap” driven and programmed, military trauma research is specifically aimed at providing readily deployable solutions to reduce morbidity and mortality from war-related injury. From a strategic standpoint, the approach taken by military medical research is quite different from that sponsored by other federal research agencies, which typically fund investigator-initiated studies of interest to the scientific community, irrespective of the urgency of the question to society. Importantly, neither these agencies nor private foundations dedicate funding to injury research of the type or severity that can be anticipated in modern warfare including terrorism. Military research has been shown effective in reducing the case fatality rate during combat and has established itself as the centerpiece of the military’s continuously learning health system. 1,2 It has also generated numerous advances that are being translated to improving civilian trauma care. 3 The following paragraphs of this preface and the articles in this supplement provide examples that serve to emphatically answer the question, “Why military medical research?” Between 2005 and 2013, the fatality rate for service personnel injured in Afghanistan decreased by 50% while the severity of injury was increasing. 1,2 The reason for this unprecedented achievement is multifactorial, but two factors stand out. At the height of the wars in Afghanistan and Iraq, the military health system made (1) significant investments in requirement-driven, programmed trauma research, and (2) an extraordinary effort to codify a trauma system that identified emerging needs for research, and rapidly translated results from military research into best clinical practices. The first element was comprised of programmatic research performed by the individual services (Army, Navy, and Air Force) and through the Joint-service, Defense Health Program. The sec

Background: The battlefields of the Global War on Terror have created unique demands on deployed surgical teams. Modern high- energy fragmentation devices often inflict complex head and neck injuries. This series analyzes the role of the head and neck surgical team during 3 separate single explosive events that led to civilian multiple casualty incidents (MCIs) treated at a military theater hospital in Iraq from February to April 2007. Methods: All MCIs occurring between February and April 2008 with triage and treatment at the 332nd Air Force Theater Hospital in Balad, Iraq, were identified and reviewed. Injury Severity Score, admission injury pattern, length of hospital stay, head and neck procedures, non-head and neck procedures, and clinical duties performed by the otolaryngology surgeon were recorded and analyzed. Results: Three MCIs occurring during the period of February to April 2008 were reviewed and described as incidents A, B, and C. A total of 50 patients were involved. Eighteen patients (36%) were treated for head and neck trauma. The average ISS for the non-head and neck trauma group was 15.8 (range, 1-43), whereas the head and neck trauma group average ISS was 23.6 (range, 2-75) (P less than 0.06). The most commonly performed head and neck procedures included repair of facial lacerations, maxillomandibular fixation, and operative reduction internal fixation of facial fractures. The head and neck surgeon also performed airway triage and assisted with procedures performed by other specialties. Conclusions: By reviewing 3 MCIs and the operative log of the involved otolaryngologist, this review illustrates how the otolaryngologist's clinical knowledge base and surgical domain allow this specialist to uniquely contribute in response to a mass casualty incident.

Background The modern era has witnessed an increase in endovascular techniques used by physicians to treat vascular injury and age-related disease. As a consequence, the number of open vascular operations available for general surgical education has decreased dramatically. This changing paradigm threatens competence in vascular injury management achieved during surgical residency. The objective of this study is to sample perceptions on vascular injury treatment in the United States to highlight the need for planning for this important tenant of surgical education. Methods An electronic survey was extended to board-certified surgeons through 3 professional societies, the Peripheral Vascular Surgery Society (PVSS), the Eastern Association for the Surgery of Trauma (EAST), and the American College of Surgeons (ACS). Results A total of 520 respondents were self-categorized as trauma (59%; n = 307), vascular (17%; n = 90), or general (19%; n = 99) surgeons. Respondents reported that general surgeons currently manage less than 10% of vascular injuries at their respective institutions. A 2.5-fold increase in endovascular treatment of vascular injury during the past decade was reported with interventional radiologists now involved in the management of up to 25% of injuries. Few general or trauma surgeons surveyed possessed a catheter-based skill set, although 38% of trauma surgeons expressed great interest in endovascular training. Additionally, a cadre of vascular surgeons (67%) affirmed a commitment to teaching vascular injury management. Conclusions The results of this study confirm a diminished role for non–fellowship-trained surgeons in managing vascular injury. Despite an increased acceptance of endovascular techniques to manage trauma, general and trauma surgeons do not possess the skill set. Collaboration between surgical communities will be especially important to maintain high standards in vascular injury management.

Extremity vascular injury during the current war has been defined by anecdotal description and case series. These reports focused on estimation of short-term limb viability and technical description of commonly used adjuncts. Temporary vascular shunting (TVS) has been advocated in current care structures, yet mostly due to war environments, broader statistical scrutiny is lacking. This study's purpose is to provide perspective on TVS's impact on limb salvage, and estimate longer-term freedom from amputation.Data from the Joint Theater Trauma Registry (JTTR), Balad Vascular Registry (BVR), Walter Reed Vascular Registry (WRVR), electronic medical records, and patient interviews were collected on American Troops sustaining extremity vascular injury from June 2003 through December 2007. Those in whom arterial TVS utilization was identified comprise the TVS group. These were compared with controls with similar injury date and anatomic location managed without TVS. Descriptive statistics were employed establishing overall univariate predictors of amputation and comparison between groups. Proportional-hazards modeling, with propensity score adjustment for systemic injury severity and Level 2 care, characterized risk factors of limb loss and effect of TVS. Freedom from amputation was estimated using Kaplan Meier log-rank methods.Cases and controls consisted of 64 and 61 extremity arterial injuries, respectively. Mean follow-up was 22 months (range: 1-54 months). The TVS group was more severely injured (mean injury severity score [ISS]: 18 [SD = 10] TVS vs. 15 [SD = 10] control, P = .05) and more likely to receive Level 2 care (TVS: 26%; control: 10%, P = .02). Overall, a total of 26 amputations occurred (21%). Penetrating blasts, compared with gunshot wounds, were associated with amputation (30% vs. 6%, P = .002). After propensity score adjustment, use of TVS suggested a reduced risk of amputation (relative risk [RR] = 0.47; 95% confidence interval [CI] [0.18-1.19]; P = .11). Venous repair was associated with limb salvage (RR = 0.2; 95% CI [0.04-0.99], P = .05). Associated fracture (RR = 5.0; 95% CI [1.45-17.28], P = .01), and elevated mangled extremity severity score (MESS) ([MESS 5-7] RR = 3.5, 95% CI [0.97-12.36], P = .06; [MESS 8-12] RR = 16.4; 95% CI (3.79-70.79), P.001) predicted amputation. Amputation-free survival was 78% in the TVS group and 77% in the control group at three years (P = .5).Temporary vascular shunting used as a damage control adjunct in management of wartime extremity vascular injury does not lead to worse outcomes. Benefit from TVS is suggested, but not statistically significant. Injury specific variables of venous ligation, associated fracture, and penetrating blast mechanism are associated with amputation. Amputation-free survival after vascular injury in Operation Iraqi Freedom is 79% at three years. Further studies to statistically define any possible benefits of TVS are needed.

Abdominal aortic aneurysm (AAA) rupture is an event with very high associated morbidity and mortality. Perioperative mortality rates in the United States for open repair of ruptured AAA have averaged around 45% since the late 1980s. Although elective aneurysm repair is four to five times more common than emergent repair, and despite aggressive programs to screen at-risk populations, the incidence of ruptured AAA continues to increase. There is a great need for improvement in early aneurysm detection, which could lead to improved outcomes. However, even with improved methods of detection, due to patient-related factors, a sizeable number of patients with AAA can be anticipated to remain undiagnosed. Improved outcomes with respect to repair of ruptured AAA are therefore vital. Endovascular aneurysm repair (EVAR) has steadily gained in popularity since the first report of its successful application to human patients in 1991 by Parodi et al. Indeed, recent estimates in the United States suggest that elective EVAR is now utilized more commonly than open AAA repair. Because randomized controlled trials (RCTs) have shown perioperative morbidity and mortality advantages for EVAR over open AAA repair in the elective setting, there have been many proponents of using EVAR preferentially for aneurysm patients with the highest mortality, those with rupture. In fact, reports of using EVAR for ruptured AAA can be found in the literature as early as 1994. This chapter will provide an overview of the complications specifically associated with using EVAR for ruptured AAAs. Complications will be categorized into two groups, those that occur in the peri-operative setting (early) and those that occur thereafter (late).

For the first few decades following the development and refinement of carotid endarterectomy in the 1950s through 1970s cerebral arteriography was the sole preoperative diagnostic modality and was considered the gold standard for carotid artery imaging. Cerebral arteriography, however, carries a risk of cerebrovascular events of 4% and permanent neurological deficit of approximately 1%.1 Noninvasive techniques such as oculoplethysmography (OPG), Doppler waveform analysis, and supraorbital directional flow were extensively studied, showed poor or no correlation with arteriography, and were deemed unreliable for surgical decision making.2,3 The Echoflow (Diagnostic Electronic Corp., Lexington, MA), a continuous wave directional Doppler velocity flowmeter that provided a velocity-sensitive color-coded computer-generated image of the extracranial carotid arteries developed in the 1970s was evaluated by several authors and showed merit as a screening tool for carotid stenosis.3, 4, 5, 6, 7 It was not until the development of duplex ultrasonography (DUS) in the 1980s, however, that the supremacy of arteriography for surgical planning was seriously challenged.8, 9, 10, 11, 12 DUS has become the most widely used screening tool for the detection of carotid stenosis, and in the majority of patients preoperative imaging with DUS alone is accurate, safe, and cost effective.9,13, 14, 15, 16

Objective Wounding patterns, methods of repair, and outcomes from femoropopliteal injury have been documented in recent civilian literature. In Operation Iraqi Freedom, as in past conflicts, these injuries continue to be a therapeutic challenge. Therefore, the objective of the current study is to document the pattern of femoropopliteal injuries, methods of repair, and early outcomes during the current military campaign in Iraq. Methods From September 1, 2004, to April 30, 2007, all vascular injuries arriving at the Air Force Theater Hospital (the central echelon III medical facility in Iraq; equivalent to a civilian level I trauma center), Balad Air Base, Iraq were prospectively entered into a registry. From this, injuries involving the lower extremities were reviewed. Results During the 32-month study period, 9289 battle-related casualties were assessed. Of these, 488 (5.3%) were diagnosed with 513 vascular injuries, and 142 casualties sustained 145 injuries in the femoropopliteal domain. Femoral level injury was present in 100, and popliteal level injury occurred in 45. Injuries consisted of 59 isolated arterial, 11 isolated venous, and 75 combined. Fifty-eight casualties were evacuated from forward locations. Temporary arterial shunts were placed in 43, of which 40 (93%) were patent on arrival at our facility. Our group used shunts for early reperfusion before orthopedic fixation, during mass casualty care, or autogenous vein harvest in 11 cases. Arterial repair was accomplished with autogenous vein in 118 (88%), primary means in nine (7%), or ligation in seven (5%). Venous injury was repaired in 62 (72%). Associated fracture was present in 55 (38%), and nerve injury was noted in 19 (13%). Early limb loss due to femoropopliteal penetrating injury occurred in 10 (6.9%). Early mortality was 3.5% (n = 5). Conclusions Femoropopliteal vascular injury remains a significant reality in modern warfare. Femoral injuries appear more prevalent than those in the popliteal region. Early results of in-theater repair are comparable with contemporary civilian reports and are improved from the Vietnam era. Rapid evacuation and damage control maneuvers such as temporary shunting and early fasciotomy assist timely definitive repair and appear effective.

Wartime missile injuries are frequently high-energy wounds that devitalize and contaminate tissue, with high risk for infection and wound complications. Debridement, irrigation, and closure by secondary intention are fundamental principles for the management of these injuries. However, closure by secondary intention was impractical in Iraqi patients. Therefore, wounds were closed definitively before discharge in all Iraqi patients treated for such injures at our hospital. A novel wound management protocol was developed to facilitate this practice, and patient outcomes were tracked. This article describes that protocol and discusses the outcomes in a series of 88 wounds managed with it.High-energy injuries were treated with rapid aggressive debridement and pulsatile lavage, then covered with negative pressure (vacuum-assisted closure [VAC]) dressings. Patients underwent serial operative irrigation and debridement until wounds appeared clean to gross inspection, at which time they were closed primarily. Patient treatment and outcome data were recorded in a prospectively updated database.Treatment and outcomes data from September 2004 through May 2005 were analyzed retrospectively. There were 88 high-energy soft tissue wounds identified in 77 patients. Surprisingly, for this cohort of patients the wound infection rate was 0% and the overall wound complication rate was 0%.This series of 88 cases is the first report of the use of a negative pressure dressing (wound VAC) as part of the definitive management of high-energy soft tissue wounds in a deployed wartime environment. Our experience with these patients suggests that conventional wound management doctrine may be improved with the wound VAC, resulting in earlier more reliable primary closure of wartime injuries.

The recognition of blunt vascular injury has increased in recent years due to an improved understanding of blunt mechanical forces, mechanisms of injury, and awareness that such injuries are often occult. This has been aided by improved quality and expanded availability of noninvasive studies. As a result, outcomes following blunt vascular injury have improved. Compared to penetrating vascular injury and other vascular disease processes, blunt vascular injury has unique features that make it useful to consider as a distinct clinical entity. Manifestations of blunt vascular injury may develop in a delayed fashion and present with more subtle findings, such as a pulse deficit or diminished ankle-brachial pressure index. The objective of this review is to present a brief historical perspective on blunt vascular injury as well as an appraisal of current diagnostic and treatment strategies. Blunt vascular injury will be discussed in distinct anatomic regions, including cervical and upper and lower extremity and evidence-based management strategies developed.

Background Wartime vascular injury management has traditionally advanced vascular surgery. Despite past military experience, and recent civilian publications, there are no reports detailing current in-theater treatment. The objective of this analysis is to describe the management of vascular injury at the central echelon III surgical facility in Iraq, and to place this experience in perspective with past conflicts. Study Design Vascular injuries evaluated at our facility between September 1, 2004 and August 31, 2006 were prospectively entered into a registry and reviewed. Results During this 24-month period, 6,801 battle-related casualties were assessed. Three hundred twenty-four (4.8%) were diagnosed with 347 vascular injuries. Extremity injuries accounted for 260 (74.9%). Vascular injuries in the neck (n = 56; 16.1%) and thoracoabdominal domain (n = 31; 8.9%) were less common. US forces accounted for 149 casualties (46%), 97 (30%) were local civilian, and 78 (24%) were Iraqi forces. One hundred seven (33%) patients with vascular injury were evacuated from forward locations after treatment initiation. Fifty-four (50%) of these had temporary shunts placed. Of 43 proximal shunts placed in-field, 37 (86%) were patent at the time of our assessment. Early amputation rate was 6.6% for those extremity injuries treated for limb salvage. Perioperative mortality was 4.3%. Conclusions This evaluation represents the first in-theater report of wartime vascular injury since Vietnam. Extremity injuries continue to predominate, although the incidence of vascular injury appears to be somewhat increased. Local forces and civilians now represent a substantial proportion of those injured. The principles of rapid evacuation, temporary shunting, and early reconstruction are effective, with satisfactory early in-theater limb salvage.

Objective To describe the treatment of children at an expeditionary military hospital in wartime Iraq. Design Descriptive, retrospective study. Setting The 332nd Air Force Theater Hospital in Balad, Iraq, January 1, 2004, to May 31, 2005. Patients All 85 children (of 1626 total patients) evaluated and treated at the hospital during the study period. Interventions Indicated surgical procedures performed on children. Main Outcome Measures Age, sex, diagnosis, injury, operations, and complications for children during the study period. Results The 85 children (age range, 1 day to 17 years; mean, 8 years) represented 5.2% of all patients. Thirty-four (61%) of the 56 children for whom sex was recorded were male. Injury was the diagnosis for 48 children (56%). Of these, the cause was fragmentation wound in 25 children (52%), penetrating trauma in 11 (23%), burn in 9 (19%), and blunt trauma in 3 (6%). The site of injury was the lower extremity in 18 children (38%), head in 11 (23%), upper extremity in 8 (17%), abdomen in 8 (17%), and chest in 3 (6%). Nontraumatic conditions had congenital, infectious, gastrointestinal, and neoplastic causes. During the study, 134 operations were performed on 63 children. There were 5 deaths. Conclusions Expeditionary military hospitals will encounter both injured and noninjured children seeking medical care. To optimize the care of these children, it will be necessary to provide the proper personnel, training, and equipment.

Background: While the use of vascular shunts as a damage control adjunct has been described in series from civilian institutions no contemporary military experience has been reported. The objective of this study is to examine patterns of use and effectiveness of temporary vascular shunts in the contemporary management of wartime vascular injury. Materials: From September 1, 2004 to August 31, 2005, 2,473 combat injuries were treated at the central echelon III surgical facility in Iraq. Vascular injuries were entered into a registry and reviewed. Location of shunts was divided into proximal and distal, and shunt patency, complications and limb viability were examined. Results: There were 126 extremity vascular injuries treated. Fifty-three (42%) had been operated on at forward locations and 30 of 53 (57%) had temporary shunts in place upon arrival to our facility. The patency for shunts in proximal vascular injuries was 86% (n = 22) compared with 12% (n = 8) for distal shunts (p < 0.05). All shunts placed in proximal venous injuries were patent (n = 4). Systemic heparin was not used and there were no shunt complications. All shunted injuries were reconstructed with vein in theater and early viability for extremities in which shunts were used was 92%. Conclusions: Temporary vascular shunts are common in the management of wartime vascular injury. Shunts in proximal injuries including veins have high patency rates compared with those placed in distal injuries. This vascular adjunct represents a safe and effective damage control technique and is preferable to attempted reconstruction in austere conditions.

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.

Abdominal apoplexy is a clinical entity characterized by spontaneous intraperitoneal hemorrhage from rupture of a visceral vessel. We describe a 34-year-old man who presented with abdominal apoplexy due to rupture of an ileocolic aneurysm. Subsequent biochemical and genetic analysis confirmed the diagnosis of Ehlers-Danlos syndrome type IV based on abnormal production of type III procollagen and a novel mutation in the COL3A1 gene. Patients presenting with abdominal apoplexy should undergo a thorough examination so that the underlying vascular pathology can be identified.

Objective: Aortic inflammation and the genes that regulate the immune response play an important role in abdominal aortic aneurysm pathogenesis. However, the modulating effects of such genetic and other environmental factors on the severity on aneurysm inflammation is not known. The objective of this study was to determine the influence of the human leukocyte antigen (HLA) class II genes, gender, and environmental factors on degree of abdominal aortic aneurysm tissue inflammation. Methods: Aneurysm specimens were obtained at the time of operation from 96 consecutive patients who underwent abdominal aortic aneurysm repair and were graded for degree of histologic inflammation. Multivariate analysis was used to determine the association of genetic and environmental factors with degree of inflammation and to determine the HLA-associated disease risk for aneurysm. Results: Active cigarette smoking and female gender were independently associated with high-grade tissue inflammation identified histologically (odds ratio [OR], confidence interval [CI]: 5.6, 1.6 to 19.3; and 6.0, 1.4 to 26.2, respectively), and a specific HLA allele (DR B1 * 01) was inversely associated with inflammation (OR, CI: 0.2, 0.04 to 0.7). Overall, the HLA-DR B1 * 02 and B1 * 04 alleles were significantly associated with disease risk, more than doubling risk for abdominal aortic aneurysm (OR, CI: 2.5, 1.4 to 4.3; and 2.1, 1.2 to 3.7, respectively). Conclusion: Active cigarette smoking and female gender are significant disease-modulating factors associated with increased abdominal aortic aneurysm inflammation. In addition, the HLA class II immune response genes possess both disease modulating and disease risk properties, which may be useful in early aneurysm detection and surveillance. (J Vasc Surg 2002;35:988-93.)