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• Surgical Trainee’s Perspective 5
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n Do Not:
n Fail to assess penetrating injuries of the neck for pres-
ence of tracheal and esophago-pharyngeal injury,
through rigorous surgical exploration at the time of
vascular repair and combination of rigid esophagoscopy + esophagography + tracheo-laryngoscopy if
any doubt exists.
n Fail to repeat CTA 7 to 10 days after injury for nonop-
eratively managed patients to assess for resolution or
progression
Subject: Upper Extremity and
Junctional Zone Injuries (Chapter 21)
GENERAL
n Upper limb vascular trauma can lead to life-threatening
hemorrhage and tissue ischemia, neuropathy and ischemia reperfusion injury.
n Junctional trauma may require control from within the
chest; is technically challenging to manage and may be
associated with gross shock.
n Where possible, injuries to the subclavian artery (SCA)
can be managed with covered stents.
SURGICAL APPROACH
n Junctional penetrating trauma may present with a com-
bination of upper limb signs (loss or function, reduced
pulse through to obvious ischemia), local signs (pulsatile
periclavicular hemorrhage or expanding hematoma),
chest signs (massive hemothorax).
n A variety of surgical approaches exist for management
of junctional injury:
n Ligation of the SCA or axillary is unlikely to lead to limb
loss or crippling ischemia due to collaterals but may
result in functional impairment; repair or shunting is
advised if possible. Brachial artery injuries should be
repaired.
n Injuries to single forearm arteries may be ligated if there
is good ow in the intact remaining vessel veried intra-
operatively via Doppler.
SURGICAL TACTICS
n Do:
n Prep widely considering all possible approaches for
proximal and distal control. Include the hand and
forearm to allow for intraoperative Doppler interrogation and possible fasciotomy.
n Be cognizant of critical structures (brachial plexus,
vagus, phrenic nerves).
n Use CTA to conrm site of probable junctional vascu-
lar injury if the patient is stable.
n Make liberal use of shunts for complex injuries,
especially where conjoined orthopedic xation is
anticipated.
n Remember to perform forearm fasciotomy if compart-
ment syndrome is anticipated (Chapter 21, Box. 21.1
and Fig. 21.15).
n Do Not:
n Use limb viability trauma scoring systems (Chapter 21,
Tables 21.2 and 21.3) as an absolute driver of deci-
sion-making, but instead as a cue/prompting measure to consider all elements contributing to injury
burden.
n Hesitate to gain the second opinion of a colleague
when considering amputation.
n Cover a dominant vertebral artery when stenting
the SCA, or fail to follow-up on patients with covered
stents (where long-term outcomes are unknown).
Location Approach Adjuncts
Right proximal
SCA
Left proximal
SCA
Mid-distal SCA,
Proximal
axillary
Distal axillary,
Proximal
brachial
Mid-distal
brachial
Ulnar, radial Longitudinal forearm
SCA, Subclavian artery.
Median sternotomy Supraclavicular extension,
Anterolateral
thoracotomy
Supraclavicular incision
(divide sternocleidomastoid and anterior
scalene)
Lateral infraclavicular
incision (split pec
major, divide pec
minor)
Incision over medial
bicipital groove
incision
resection of clavicular
head
Extend with median ster-
notomy and supraclavicular incision (may be
referred to as trapdoor
incision)
Clavicular resection,
infraclavicular incision
Lateral extension onto arm
S-shaped extension over
antecubital crease to
expose distal brachial
artery
Subject: Blunt Thoracic Aortic
Injury (Chapter 17)
GENERAL
n Blunt thoracic aortic injury (BTAI) typically occurs in the
aorta distal to the origin of the left subclavian artery, and
ranges from intimal tear only (minimal aortic injury) to
pseudoaneurysm and complete transection (with lethal
and unconstrained hemorrhage). CTA is the standard
diagnostic tool.
n Most cases that survive to reach surgical care can be
temporized through vigorous blood pressure control
(beta blockade) and careful monitoring while arrange-
ments are optimized for denitive management or other
more life-threatening injuries addressed.
n In general, goal SBP <120 mm Hg
n Esmolol drip is most commonly used due to rapid
onset, ease of titration
n Aortic endovascular stenting (thoracic endovascular
aortic repair (TEVAR); Chapter 17, Figs. 17.9, 17.10)
has become a prevailing mode of treatment, with open
6 • Surgical Trainee’s Perspective
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or hybrid repairs reserved for injuries involving the aortic arch or where endovascular resources are limited.
SURGICAL APPROACH
n Open repair is accomplished by the clamp and sew
approach via left posterolateral thoracotomy and distal
perfusion of the aorta to reduce the chance of spinal
cord ischemia (Chapter 17, pp. 5–7, Fig. 17.8).
n Proper sizing of stents is key in preventing TEVAR-related
complications (Chapter 17, Table 17.3 and Figs. 17.11–
17.13). Bird’s neck deformity can be avoided by using
new generation devices that allow for the curvature of
the aorta in young patients.
n Most patients tolerate covering of the origin of the left
subclavian well. Carotid-subclavian bypass can be
undertaken for patients who develop subclavian steal.
SURGICAL TACTICS
n Do:
n Base the timing of denitive management on the
nature and extent of the BTAI lesion, other associated
injuries, and facility expertise.
n Consider conservative management (with early CTA
follow-up) for patients with minor lesions (intimal
tear, small pseudoaneurysm).
n Consider screening for blunt cardiac injury with elec-
trocardiogram (EKG) monitoring.
n Do Not:
n Fail to ensure that all TEVAR patients are submitted to
life-long surveillance programs to ensure stent complications are identied.
Subject: Cardiac, Great Vessel and
Pulmonary Injuries (Chapter 16)
GENERAL
n Surgery is infrequently needed for thoracic injury;
patients with penetrating injuries to the heart and great
vessels usually do not reach the surgeon alive.
n The most common indications for thoracotomy are
hemorrhage from the lung, major arterial injury in the
arch or root-of-neck vessels, or a penetrating cardiac
wound.
SURGICAL APPROACH
n Any penetrating injury between the nipples from
the sternal notch to xiphoid process (known as the
“cardiac box”) or encompassing the left chest, should be
evaluated for potential cardiac injury.
n Site large-bore access venous access sites on the
contralateral side to any injury, and consider using the
common femoral veins.
n Critically shocked patients with evidence of massive
hemothorax (chest x-ray appearance, immediate drainage of 1200–1500 mL of blood via tube thoracostomy);
or cardiac tamponade (diagnosed on US); or visible
hemorrhage from the root of the neck should undergo
emergent endotracheal intubation in the ER and transfer
expeditiously to the OR for surgery.
n Where physiology becomes agonal, perform EDT (left
anterolateral thoracotomy or clamshell thoracotomy if
suspected right-sided injury) (Chapter 16, pp. 4–6, Figs.
16.1–16.4) with the aim of:
n Conrming the diagnosis.
n Performing pericardiotomy if tamponade is present.
n Via longitudinal incision in the pericardium above
the left phrenic nerve.
n Controlling hemorrhage from a wound to the heart,
great vessels, or lung.
n Catastrophic lung hemorrhage may be temporized
with use of hilar clamping or lung twist (Chapter
16, p. 25). These require division of the inferior
pulmonary ligament.
n Clamping the descending thoracic aorta to preserve
circulating volume and perfuse the coronary and
carotid arteries.
n The inferior pulmonary ligament can be taken
down to aid in visualization.
n Undertaking internal cardiac massage.
n Less critically disturbed patients whose physiology stabi-
lizes with resuscitation can be more thoroughly worked
up (CT chest, CTA arch vessels) and then moved to critical care for close observation. Conservative management
should be abandoned if tube thoracostomy output continues (>200 mL/h over 2–4 hours) or if volume requirements become elevated.
SURGICAL TACTICS
n Do:
n Make use of the subxiphoid pericardial window tech-
nique to rule out tamponade during trauma laparot-
omy (Chapter 16, p. 8).
n Match the repair technique to the location of the
heart injury: clamp and suture (permanent monola-
ment) for atria; unpledgeted repair to right ventricle;
pledgeted repair to left ventricle.
n Consider temporizing cardiac injuries in extremis with
skin staples, Foley balloon, or other adjuncts (Chapter
16, Table 16.2).
n Use partial isolation (Satinsky clamp) to deal with
simple penetrating arch injury.
n Use debranching techniques to manage complex injuries
to the branch vessels (i.e., control the injury→sew proxi-
mal end of prosthetic graft onto arch→sew distal end of
graft to cut distal end of the disrupted arch vessel).
n Use lung-sparing techniques (suture, stapled wedge,
tractotomy) when dealing with pulmonary hemor-
rhage (Chapter 16, pp. 25–26).
n Consider endovascular techniques to manage great
vessel injuries.
n Do Not:
n Undertake futile resuscitative thoracotomy (blunt
mechanism of injury [MOI] with no signs of life in ER,
penetrating MOI with no signs of life in the eld).
n Fail to consider packing the chest as a damage control
measure.
n Injure the intercostal arteries arising from the pos-
terior aspect of the thoracic aorta when applying a
cross-clamp.
• Surgical Trainee’s Perspective 7
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n Lose sight of location of coronary arteries and inad-
vertently ligate or disrupt coronary arteries while
attempting to repair a cardiac injury.
n Forget to get postop echocardiography to evaluate for
valvular injury post cardiac repair.
Subject: Aortic, Iliac and Visceral
Arterial Injuries (Chapter 18)
GENERAL
n Wide variety of presentation with potential for rapid
deterioration and exsanguination.
n Vascular injuries in the abdomen are categorized accord-
ing to anatomical location, dened within three retroperitoneal zones: zone I – midline, zone II – lateral, zone
III – pelvic (Chapter 18, Fig. 18.1).
n CTA is the gold standard investigation for stable casu-
alties; exploratory laparotomy for unstable patients
(i.e., no or short-lived response to initial resuscitation).
SURGICAL APPROACH
n Skin preparation and draping should take account of
the potential need for left anterolateral thoracotomy and
vascular control at the groins.
n Evisceration, four-quadrant packing, and sequential
removal of packs removes blood and allows a methodical
start to challenging surgery.
n Any zone I retroperitoneal hematoma will require explo-
ration as there is a high chance of it involving the aorta
or its branches, or the inferior vena cava (IVC). Left or
right medial visceral rotation respectively for aorta
(hematoma biased to left of midline) and IVC (hematoma
biased to right of midline) are the key maneuvers to
expose the injury, though consideration should be given
to obtaining supraceliac aortic control in very unstable
patients beforehand (Chapter 18, Figs. 18.2–18.4).
n Large zone I hematomas that are present in the supra-
colic compartment may be better controlled through
clamping of the thoracic aorta via left anterolateral
thoracotomy.
n Zone II and zone III hematomas may be managed more
judiciously, with exploration reserved for ongoing bleeding (expanding hematoma or the presence of physiological instability). Some also include penetrating trauma as
an indication, particularly for pelvic hematoma where
the iliac vessels may have been injured.
SURGICAL TACTICS
n Do:
n Do consider preplacement of a REBOA catheter
prelaparotomy to enable rapid aortic control should
this be required.
n Branches of the celiac artery can be ligated proxi-
mally with low risk of end-organ ischemia; injury to
the peripancreatic superior mesenteric artery (SMA)
should be repaired or shunted in order to avoid catastrophic mid-gut infarction. Approach the celiac via
the lesser sac or left medial visceral rotation; approach
the SMA via the lesser sac (with stapled division of the
pancreas in-extremis), via left medial visceral rotation
or via the root of the small bowel mesentery. The inferior mesenteric artery can be ligated. Injuries to the
renal arteries usually result in ligation and probable
nephrectomy.
n Mobilize the cecum or sigmoid colon to visualize the
common and external iliac vessels, avoiding the ureter, and be prepared to achieve distal control at the
groin if unfavorable pelvic anatomy is present.
n Do Not:
n Fail to consider endovascular treatment of pelvic ves-
sel injury (covered stent) if the situation permits (i.e.,
consider operating in a hybrid room if possible).
n Fail to consider preperitoneal packing as a means to
temporize pelvic bleeding associated with pelvic fractures prior to embolization.
n Fail to consider the likelihood of abdominal compart-
ment syndrome and the advantage of temporary laparostomy to prevent this and allow assessment of visceral
viability at a subsequent planned relook procedure.
Subject: Inferior Vena Cava, Portal
and Mesenteric Venous Injuries
(Chapter 19)
GENERAL
n As with injury to the aorta and its branches, injuries to
the IVC, portal vein, and mesenteric vessels are highly
lethal.
n CTA is the investigation of choice, with hematomas
around the ascending colon and duodenum fairly spe-
cic for IVC injuries as well as caval lling defect.
n Resuscitative thoracotomy or zone I REBOA are valid
means of controlling aortic inow in order to manage
the critically deteriorating patient.
n Selected patients, without hemodynamic disturbance,
and where the hematoma is small-to-moderate on CT
scan, may be monitored and observed; assuming there is
no other reason to pursue laparotomy (e.g., blunt injury;
or, if penetrating, no violation of peritoneum or signs of
peritonism).
SURGICAL APPROACH
n Cava:
n Utilize right medial visceral rotation (Chapter 19,
Fig. 19.2), with extensive kocherization of the duo-
denum, for infra- and suprarenal IVC and control.
Use digital pressure or careful application of swabs/
sponges on sticks to occlude the IVC either side of an
injury rather than attempting encirclement with risk
to the lumbar vessels.
n Retrohepatic injuries to the cava, heralded by dark
blood continuously welling up from behind the liver,
should be managed via manual compression of the liver
against the cava and thence appropriate packing and/
or clamping of the portal triad (Pringle maneuver).
8 • Surgical Trainee’s Perspective
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n If this fails to control bleeding, the laparotomy inci-
sion should be extended to the right chest via right
anterolateral thoracotomy, with control of the suprahepatic IVC from within the pericardium, prior to full
mobilization of the liver, and exposure of the injured
retrohepatic cava. Alternatively, seek to place occlusion balloons in the cava via percutaneous means to
isolate the liver prior to mobilization.
n Portal Vein
n Approach by clamping the portal triad proximal to
the injury, taking down the hepatic exure of the
colon, and performing a wide Kocher maneuver, then
releasing the clamp to facilitate digital control of the
injury and gentle dissection of the vein away from the
hepatic artery and common bile duct to allow injury
denition and placement of vessel loops.
n Be prepared to divide the neck of the pancreas (to
the left of the SMA/superior mesenteric vein [SMV])
using a linear cutter stapler in order to expose the
most proximal portion of the portal vein if proximal
control is not achievable otherwise.
n Superior Mesenteric Vein
n Injuries are associated with central hematoma at the
base of the small bowel mesentery (at the fusion of
the peritoneum overlying junction of the transverse
colon mesentery).
n Medial visceral rotation from the right with kocher-
ization allows the operator to place a hand behind the
mesentery containing the injured vein. This allows for
application of digital control and dissection of the vessel/
clamping/repair, or ligation prior to hematoma entry.
SURGICAL TACTICS
n Do:
n Consider getting aortic control before opening a large
central hematoma.
n Handle the portal vein and SMV carefully; they are
thin-walled and tear easily.
n Anticipate the splanchnic sequestration effects of
portal vein or SMV ligation and ensure aggressive volume resuscitation in the postoperative period. Plan for
early relook laparotomy to assess for potential bowel
infarction.
n Do Not:
n Expect to see contrast extravasation on the initial CT
abdomen in venous injury.
n Ligate the suprarenal IVC – this is not tolerated and
will lead to acute renal failure.
n Spend too much time attempting complex repair of
the portal vein – damage control adjuncts such as
ligation or shunting should be considered early to
avoid extensive bleeding.
Subject: Lower Extremity Vascular
Trauma (Chapter 22)
GENERAL
n The lower limb is the most frequent site of arterial injury
in both civilian and military trauma.
n Documenting a complete lower extremity neurovascular
examination prior to intervention assists in determination of injury pattern as well as evaluation of possible
postoperative complications.
n High energy mechanisms of injury, especially explosions,
result in complex multisegmental injury with disruption
of soft tissue, bone, and skin.
n Limb salvage and vascular reconstruction must only be
considered in the context of the totality of injury and
associated physiological disturbance. Interventions that
save life and restore homeostasis should be prioritized
accordingly.
n The presence of a vascular injury can be discerned from
hemorrhage, ischemia, or signs found on CTA. The
latter, as a preprocedural investigation, is especially
useful in situations where several levels of vascular
damage may be present (shotgun injury, multiple long
bone fracture).
n Warm ischemic time is very important and must be
carefully monitored, driving urgency of revascularization. Aim to restore perfusion within 3 hours of injury –
although classic teaching is 6 hours, recent data
indicates this is too long.
n Primary amputation is a difcult decision to undertake –
a second opinion, obtained from an experienced colleague brought to the OR for this purpose can help in
decision-making.
SURGICAL APPROACH
n Proximal tourniquet for control of ongoing hemorrhage
until proximal control is achieved via exposure of vessels
above the injury zone, with subsequent distal control
and thence entry into the hematoma and evaluation of
the injury. Prep tourniquet into eld to allow for intraoperative manipulation.
n Injuries at the groin may not be amenable to tourni-
quet control; sponge-stick or digital control of external
hemorrhage should be maintained while a retroperitoneal approach is used to effect access to the external
iliac artery (EIA). A curvilinear skin incision, from the
mid-inguinal point superior to the anterior superior
iliac spine, can be employed, dividing aponeurosis of the
external oblique, splitting the underlying bers of the
internal oblique and transversus abdominis, reaching
the preperitoneal plane, and developing this medially to
reach the EIA.
n In general, standard vascular axial exposures (mid-
inguinal, anteromedial thigh, medial calf; Chapter 22,
pp. 9–13) can be used to deal with injuries to the common, profunda and supercial femoral arteries, and the
popliteal and posterior tibial vessels. There should be no
hesitation in extending these incisions proximally or distally as the situation dictates.
n The orthodox preliminaries of injury denition,
evaluation of inow and backow, and Fogarty
catheter thrombectomy of upstream and downstream
vessels are required before considering whether the
patient requires a shunt or immediate denitive
repair.
n Ensure adequate healthy tissue coverage over any shunt/
repair after the wound is appropriately débrided.
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SURGICAL TACTICS
n Do:
n Consider coil embolization for the treatment of
CTA-identied bleeds emanating from branches of the
profunda.
n Bias toward use of end-to-end interposition with great
saphenous vein for short defects, or formal by-pass for
longer defects. The latter option, combined with vessel
exclusion, is ver y applicable for popliteal ar tery injuries
and avoids surgical division of medial knee ligaments.
n Repair the popliteal and common femoral veins, if
possible, in order to avoid the morbidity of ligation.
n Avoid ligation of the external iliac, supercial femoral,
or popliteal artery when possible due to high risk of
limb loss.
n Default to four-quadrant calf fasciotomy unless:
n Ischemia time <2 hours
n Lower limb hourly observations (pain, tissue
laxity, perfusion, pulses) can be assured in the
postoperative period, with concurrently available surgical capacity for rapid fasciotomy should
compartment syndrome develop. Pain out of proportion to examination and/or pain with passive
motion are commonly rst signs of compartment
syndrome.
n Do Not:
n Zealously repair single calf vessel injuries if there is
good evidence of foot perfusion from the uninjured
vessels.
n Fail to verify that all four compartments were opened
during calf fasciotomy.
n anterior/lateral – visualize and palpate septum
between the two compartments ensuring both
opened via H-type incision
n deep posterior – visualization of the posterior tibial
neurovascular bundle
n Injure the supercial peroneal nerve during the lat-
eral incision or the great saphenous vein during the
medial incision.
n Be falsely reassured by a normal compartment
pressure – this can be used as an adjunct in diagnosis
but not unilaterally to rule out compartment
syndrome.
Subject: Soft-Tissue and Skeletal
Wound Management in the Setting
of Vascular Injury (Chapter 26)
to IIIA to IIIC – vascular repair required; Chapter 26,
Table 26.1).
n Options include: primary amputation; defer primary
amputation to a later date once patient has been coun-
selled; or attempt surgical intervention with the aim of
limb salvage (i.e., revascularization, fracture xation,
soft tissue coverage).
n Tailor decisions to individual patient, overall injury bur-
den, and future functional goals.
n Shunts are a key part of the armamentarium in decision-
making concerning sequencing.
n The viability of the distal soft-tissue envelope denes the
level of the amputation, with preservation of viable soft
tissue a critical goal of initial débridement to preserve
options for later stump closure on re-look surgery 2 to 5
days later.
SURGICAL TACTICS
n Do:
n Save detailed wound evaluation for the OR once it is
clear that surgery is required.
n Appraise skin, muscle, and nerve loss as well as a bony
skeleton assessment during evaluation. Check for
degloving injury.
n Work supercial-to-deep and peripheral-to-central
when performing débridement, extending wounds
along fasciotomy (axial) lines where required. Preserve bony fragments that have a contiguous soft
tissue attachment. Liberally irrigate.
n Utilize viable soft tissue to cover vascular repairs,
mobilizing local aps if necessary (e.g., Sartorius ap
for common femoral vessels).
n Plan for later denitive orthopedic xation at the
same time as denitive wound coverage (e.g., the Fix
and Flap approach) to reduce risk of deep infection
and allow for resolution of soft tissue edema.
n Be familiar with the variety of soft tissue coverage
solutions (local and distal fasciocutaneous and muscle aps, free aps (Chapter 26, pp. 8–10).
n Do Not:
n Compromise skin perforators when performing calf
fasciotomy.
n Submit patients to complex soft tissue reconstruction
until they are physiological stable.
n Fail to involve the patient in the discussion regarding
reconstruction options, particularly when considering the place of early amputation.
GENERAL
n Multidisciplinary input that is timely, coordinated, and
coherent is vital in order to achieve good functional outcomes in complex limb trauma in both the civilian and
military settings.
n Secondary, or delayed amputation is part of the
spectrum of treatment options.
SURGICAL APPROACH
n Categorize open lower-limb fractures using the Gustilo-
Anderson system (I–III, where III is subcategorized in
Subject: Management of Pediatric
Vascular Injury (Chapter 25)
GENERAL
n Pediatric vessel size, propensity for spasm and infre-
quency of presentation combine to make management
challenging; 50% iatrogenic.
n Diagnosis is difcult in the shocked child; continuous
wave Doppler and injury extremity index are useful
adjuncts to clinical diagnosis; CT angiography is a main-
stay of localization if Duplex is not available.
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n Abnormal ABI 2 years or younger: < .88, Abnormal
ABI > 2 years: < 0.9 (Chapter 25, p. 2)
SURGICAL APPROACH
n Extremities:
n Standard repair techniques (primary repair, vein
patch angioplasty, interposition grafting with reversed
saphenous vein) should be employed.
n Synthetic grafts are avoided where possible due to
lack of potential for conduit growth and concern for
long-term patency.
n Veins should be repaired to avoid edema, improve
patency of concomitant arterial repairs, and improve
functional outcomes.
n Interrupted sutures permit circumferential anasto-
motic expansion with growth; vessel ends should be
maximally spatulated to the same end.
n Topical papaverine and lidocaine to vessels may
reduce spasm and permit a less technically challenging repair.
n Trunk and neck:
n Blunt carotid vertebral artery injury (BCVI) rarely
benet from surgical exploration. Antithrombotic
medications should be considered based on injury
severity. These should be followed up as per adult
practice to ensure complications do not develop.
n Stent graft repair of arch vessel injury or distal extra-
cranial carotid injury is feasible in older children but
long-term outcomes are unknown and open repair is
the default for blunt thoracic aorta injury.
n The use of intraoperative systemic heparin, and short-
term postoperative anticoagulation is permissible to
prevent vessel thrombosis, as is longer-term antiplatelet
therapy.
SURGICAL TACTICS
n Do:
n Respect the propensity of pediatric vessels to
spasm and employ the gentlest of handling tech-
niques; use vessel loops to achieve control; employ
high-magnication loupes and microvascular
instrumentation.
n Remember to employ long-term imaging follow-up
for any stent grafts to assess for device migration as
vasculature enlarges over time.
n Do Not:
n Delay in achieving the best imaging solution that the
child will tolerate; early liaison with anesthetic and
pediatric colleagues and generation of sedation/anal-
gesia options to permit imaging is advisable.
n Delay in intervening where there is evidence of
ischemic compromise to a limb and simple measures
such as fracture reduction have not restored perfusion.
n Forget that fasciotomy is a vital part of the manage-
ment of pediatric extremity vascular injury and use
this liberally.
SECTION 1
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Setting the Stage
11
1
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The Vascular Injury Legacy
NORMAN M. RICH and KENNETH J. CHERRY
Although the rst crude arteriorrhaphy was performed
more than 250 years ago, it is only within the past 50 years
that vascular surgery has been practiced both widely and
consistently with anticipation of good results. Historically,
it is of particular interest that by the turn of the 20th century, many if not most of the techniques of modern vascular surgery had already been explored through extensive
experimental work and early clinical application. In retrospect, it is therefore almost astonishing that it took nearly
another 50 years before the work of such early pioneers as
Murphy, Goyanes, Carrel, Guthrie, and Lexer was widely
accepted and applied in the treatment of vascular injuries.
However, adoption of the thought processes and practices
of these enlightened surgeons was hampered by the technological limitations of their era and had to await the dramatic advances in graft materials and imaging seen during
the 1950s and beyond.
Since the days of Ambroise Paré in the mid–16th century,
major advances in the surgery of trauma have occurred
during times of armed conict, when it was necessary to
treat large numbers of severely injured patients, often under
far-from-ideal conditions. This has been especially true with
vascular injuries.
Although German surgeons accomplished arterial
repairs in the early part of World War I (WWI), it was not
until the Korean War and the early 1950s that ligation of
major arteries was abandoned as the standard treatment
for arterial trauma. The results of ligation of major arteries
following trauma were clearly recorded in the classic manuscript by DeBakey and Simeone in 1946, who found only 81
repairs in 2471 arterial injuries among American troops in
Europe in World War II (WWII).3 All but three of the arterial repairs were performed by lateral suture. Ligation was
followed by gangrene and amputation in nearly half of the
cases. The pessimistic conclusion reached by many was
expressed by Sir James Learmonth, who said that there was
little place for denitive arterial repair in the combat wound.
Within a few years, however, in the Korean War, the possibility of successfully repairing arterial injuries was established conclusively, stemming especially from the work of
Hughes, Howard, Jahnke, and Spencer. In 1958, Hughes
emphasized the signicance of this contribution in a review
of the Korean experience, nding that the overall amputation rate was lowered to about 13%, compared to the
approximately 49% amputation rate that followed ligation
in WWII.
American surgeons, who represented most of the major
surgical training programs in the United States, treated
more than 7500 vascular injuries. In 1969, Rich and
Hughes reported the preliminary statistics from the
Vietnam Vascular Registry, which was established in 1966
at Walter Reed General Hospital to document and follow all
12
4
During the Vietnam hostilities, more than 500 young
1,2
servicemen who sustained vascular trauma in Vietnam.5
An interim Registry report that encompassed 1000 major
acute arterial injuries showed little change from the overall
statistics presented in the preliminary report.6 Considering
all major extremity arteries, the amputation rate remained
near 13%. Although high-velocity missiles created more
soft-tissue destruction in injuries seen in Vietnam, the
combination of a stable hospital environment and rapid
evacuation of casualties (similar to that in Korea) made
successful repair possible. Injuries of the popliteal artery,
however, remained an enigma, with an amputation rate
remaining near 30%.
In the past 50 years, civilian experience with vascular trauma has developed rapidly under conditions much
more favorable than those of warfare. Results are better
than those achieved with military casualties in Korea and
Vietnam.
Initial Control of Hemorrhage
Control of hemorrhage following injury has been of prime
concern to man since his beginning. Methods for control
have included various animal and vegetable tissues, hot
irons, boiling pitch, cold instruments, styptics, bandaging,
and compression. These methods were described in a historical review by Schwartz in 1958.7 Celsus was the rst
to record an accurate account of the use of ligature for
hemostasis in CE 25. During the rst three centuries, Galen,
Heliodorus, Rufus of Ephesus, and Archigenes advocated
ligation or compression of a bleeding vessel to control hemorrhage.
Ancient methods of hemostasis used by Egyptians about
1600 BCE are described in the Ebers’ papyrus, discovered by
Ebers at Luxor in 1873.7 Styptics prepared from mineral or
vegetable matter were popular, including lead sulfate, antimony, and copper sulfate. Several hundred years later during the Middle Ages in Europe, copper sulfate again became
popular and was known as the hemostatic “button.” In
ancient India, compression, cold, elevation, and hot oil
were used to control hemorrhage, while about 1000 BCE,
the Chinese used tight bandaging and styptics.
The writings of Celsus provide most of the knowledge of
methods of hemostasis in the rst and second centuries CE.7
When amputation was done for gangrene, the prevailing
surgical practice was to amputate at the line of demarcation
to prevent hemorrhage. In the rst century CE, Archigenes
was apparently the rst to advocate amputating above the
line of demarcation for tumors and gangrene, using ligature of the artery to control hemorrhage.
Rufus of Ephesus (rst century CE) noted that an artery
would continue to bleed when partially severed, but when
completely severed, it would contract and stop bleeding
1 • The Vascular Injury Legacy 13
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within a short period of time.7 Galen, the leading physician
of Rome in the second century CE, advised placing a nger
on the orice of a bleeding supercial vessel for a period of
time to initiate the formation of a thrombus and the cessation of bleeding. He noted, however, that if the vessel were
deeper, it was important to determine whether the bleeding
was coming from an artery or a vein. If coming from a vein,
pressure or a styptic usually sufced, but ligation with linen
was recommended for an arterial injury.
Following the initial contributions of Celsus, Galen, and
their contemporaries, the use of ligature was essentially forgotten for almost 1200 years in Western medicine. A tension developed between traditional church teachings and
enlightened thought, perhaps holding back any advancement in Western medicine or surgery. Use of the knife on
living tissue was considered to be wrong; consequently,
amputation was below the line of ischemic demarcation.
Abu al-Qasim al-Zahrawi, a prominent Arab physician from
Moorish Spain (10th century CE), advocated ligation in his
great work Kitab Al-Tasrif almost 600 years before Paré.
7
Throughout the Middle Ages, cautery was used almost
exclusively to control hemorrhage. Jerome of Brunswick
(Hieronymus Brunschwig), an Alsatian army surgeon,
actually preceded Paré in describing the use of ligatures as
the best way to stop hemorrhage.7 His recommendations
were recorded in a textbook published in 1497 and provided
a detailed account of the treatment of gunshot wounds.
Ambroise Paré, with wide experience in the surgery of
trauma, especially on the battleeld, rmly established the
use of ligature for control of hemorrhage from open blood
vessels. In 1552, he startled the surgical world by amputating a leg above the line of demarcation, repeating the
demonstration of Archigenes 1400 years earlier. The vessels were ligated with linen, leaving the ends long. Paré
also developed the bec de corbin, ancestor of the modern
hemostat, to grasp the vessel before ligating it (Fig. 1.1).7
Previously, vessels had been grasped with hooks, tenaculums, or the assistant’s ngers. He designed articial limbs
and advanced dressing technique. During the siege of Turin
(1536), Paré ran out of oil, which was traditionally used to
cauterize. He mixed egg yolk, rose oil, and turpentine and
discovered this dressing had better outcomes than oil.
In the 17th century, Harvey’s monumental contribution describing circulation of blood greatly aided the
Fig. 1.1 Artist’s concept of the bec de corbin, developed by Paré
and Scultetus in the mid–16th century. It was used to grasp the vessel before ligating it. (From Schwartz AM. The historical development of
methods of hemostasis. Surgery. 1958;44:604.)
understanding of vascular injuries.7 Although Rufus of
Ephesus apparently discussed arteriovenous communications in the rst century CE, it was not until 1757 that
William Hunter rst described the arteriovenous stula as
a pathological entity.8 This was despite the fact that, as early
as the second century CE, Antyllus had described the physical ndings, clinical management (by proximal and distal
ligation), and the signicance of collateral circulation.
9
The development of the tourniquet was another advance
that played an important role in the control of hemorrhage.
Tight bandages had been applied since antiquity, but subsequent development of the tourniquet was slow. Finally, in
1674, a military surgeon named Morel introduced a stick
into the bandage and twisted it until arterial ow stopped.7
The screw tourniquet came into use shortly thereafter. This
method of temporary control of hemorrhage encouraged
more frequent use of the ligature by providing sufcient
time for its application. In 1873, Freidrich von Esmarch, a
student of Langenbeck, introduced his elastic tourniquet
bandage for rst aid use on the battleeld.10 Previously it
was thought that such compression would injure vessels
irreversibly. His discovery permitted surgeons to operate
electively on extremities in a dry, bloodless eld.
Ligation was not without its complications, as British
Admiral Horatio Nelson discovered after amputation of his
right arm after the attack at Tenerife, “A nerve had been
taken up in one of the ligatures at the time of the operation,” causing considerable pain and slowing his recovery.11
Furthermore, the long ligatures meant delayed wound healing. It was Haire, an assistant surgeon at the Royal Naval
Hospital Haslar, who took the risk of cutting sutures short
(rather than leaving them long) to allow suppuration,
necrosis, and granulation before the suture was pulled
away. He observed that “the ligatures sometimes became
troublesome and retarded the cure,” and that cutting them
short allowed stumps to heal in the course 10 days.
In addition to the control of hemorrhage at the time of
injury, the second major area of concern for centuries was
the prevention of secondary hemorrhage. Because of its
great frequency, styptics, compression, and pressure were
used for several centuries after ligation of injured vessels
became possible. Undoubtedly, the high rate of secondary
hemorrhage after ligation was due to infection of the
wound, often promoted by dressing choices or infection
spread by well-meaning attendants. Although John Hunter
demonstrated the value of proximal ligation for control of a
false aneurysm in 1757, failure to control secondary hemorrhage resulted in the use of ligature only for secondary
bleeding from the amputation stump.12 Subsequently, Bell
(1801) and Guthrie (1815) performed ligation both proximal and distal to the arterial wound with better results than
those previously obtained.
13,14
Some of the rst clear records of ligation of major arteries were written in the 19th century and are of particular interest. The rst successful ligation of the common
carotid artery for hemorrhage was performed in 1803 by
Fleming, but was not reported until 14 years later by Coley
(1817), because Fleming died a short time after the operation was performed.15 A servant aboard the HMS Tonnant
attempted suicide by slashing his throat. When Fleming
saw the patient, it appeared that he had exsanguinated.
There was no pulse at the wrist and the pupils were dilated.
14 SECTION 1 • Setting the Stage
Brachial artery
Figure-of-eight suture
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It was possible to ligate two superior thyroid arteries and
one internal jugular vein. A laceration of the outer and
muscular layers of the carotid artery was noted, as well as
a laceration of the trachea between the thyroid and cricoid
cartilages. This allowed drainage from the wound to enter
the trachea, provoking violent seizures of coughing,
although the patient seemed to be improving. Approximately 1 week following the injury, Fleming recorded: “On
the evening of the 17th, during a violent paroxysm of
coughing, the artery burst, and my poor patient was, in an
instant, deluged with blood!”
15
The dilemma of the surgeon is appreciated by the following statement: “In this dreadful situation I concluded that
there was but one step to take, with any prospect of success;
mainly, to cut down on, and tie the carotid artery below
the wound. I had never heard of such an operation being
performed; but conceived that its effects might be less formidable, in this case, than in a person not reduced by hemorrhage.”15 The wound rapidly healed following ligation of
the carotid artery, and the patient recovered.
Ellis (1845) reported the astonishing experience of successful ligation of both carotid arteries in a 21-year-old
patient who sustained a gunshot wound of the neck while
he was setting a trap in the woods in 1844, near Grand
Rapids, Michigan, when he was unfortunately mistaken
for a bear by a companion.16 Approximately 1 week later,
Ellis had to ligate the patient’s left carotid artery because of
hemorrhage. An appreciation of the surgeon’s problem can
be gained by Ellis’ description of the operation: “We placed
him on a table, and with the assistance of Dr. Platt and a
student, I ligatured the left carotid artery, below the omohyoideus muscle; an operation attended with a good deal of
difculty, owing to the swollen state of the parts, the necessity of keeping up pressure, the bad position of the parts
owing to the necessity of keeping the mouth in a certain
position to prevent his being strangulated by the blood, and
the necessity of operating by candle light.”
16
There was recurrent hemorrhage on the 11th day after
the accident, and right carotid artery pressure helped control the blood loss. It was, therefore, necessary also to ligate
the right carotid artery 4½ days after the left carotid artery
had been ligated. Ellis remarked: “For convenience, we had
him in the sitting posture during the operation; when we
tightened the ligature, no disagreeable effects followed; no
fainting; no bad feeling about the head; and all the perceptible change was a slight paleness, a cessation of pulsation
in both temporal arteries, and of the hemorrhage.”16 The
patient recovered rapidly with good wound healing and
returned to normal daily activity. There was no perceptible
pulsation in either supercial temporal artery.
16
The importance of collateral circulation in preserving viability of the limb after ligation was well understood
for centuries, as identied by Antyllus nearly 2000 years
ago.9 The fact that time was necessary for establishment of
this collateral circulation was recognized. Halsted (1912)
reported cure of an iliofemoral aneurysm by application of
an aluminum band to the proximal artery without seriously
affecting the circulation or function of the lower extremity.17 Asepsis had been recognized, and the frequency of
secondary hemorrhage and gangrene following ligation
promptly decreased as an understanding of transmission
of infectious disease and its management was developed
through Pasteur and Lister. Subsequently, Halsted (1912)
demonstrated the role of collateral circulation by gradually,
completely occluding the aorta and other large arteries in
dogs by means of silver or aluminum bands that were gradually tightened over a period of time.
18
Early Vascular Surgery
About two centuries after Paré established the use of the ligature, the rst direct repair of an injured artery was accomplished. This event more than 250 years ago is credited as
the rst documented vascular repair. Hallowell, acting on
a suggestion by Lambert in 1759, repaired a wound of the
brachial artery by placing a pin through the arterial walls
and holding the edges in apposition by applying a suture
in a gure-of-eight fashion about the pin (Fig. 1.2).19 This
technique (known as the farrier’s stitch) had been utilized
by veterinarians but had fallen into disrepute following
unsuccessful experiments. Table 1.1 outlines early vascular
techniques.
Unfortunately, others could not duplicate Hallowell’s
successful experience, almost surely because of the multiple problems of infection and lack of anesthesia. There
was one report by Broca (1762) of a successful suture of a
longitudinal incision in an artery.20 However, according to
Shumacker (1969), an additional 127 years passed following the Hallowell-Lambert arterial repair before a second
instance of arterial repair of an artery by lateral suture in
man was reported by Postemski in 1886.
Laceration
Fig. 1.2 The first arterial repair performed by Hallowell, acting on a
suggestion by Lambert in 1759. The technique, known as the farrier’s
(veterinarian’s) stitch, was followed in repairing the brachial artery
by placing a pin through the arterial walls and holding the edges in
apposition with a suture in a figure-of-eight fashion about the pin.
(Drawn from the original description by Mr. Lambert, Med Obser and Inq
1762;2:30–360.)
Table 1.1 Vascular Repair Before 1900
Technique Year Surgeon
Pin and thread 1759 Hallowell
Small ivory clamps 1883 Gluck
Fine needles and silk 1889 Jassinowsky
Continuous suture 1890 Burci
Invagination 1896 Murphy
Suture all layers 1899 Dörfler
Adapted from Guthrie GC. Blood Vessel Surgery and its Applications.
New York: Longmans, Green and Co; 1912.
20
Pin
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