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27 • Vascular Surgery in the Austere Environment 335
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A
Fig. 27.6 Tetraplegic patient
with a low-velocity gunshot
wound to the side of the face,
causing external carotid artery
and internal jugular vein dis-
B C
ruption. Both the artery and
the vein were ligated.
Fig. 27.7 Syringe suction bottle.
ASSOCIATED NECK INJURIES
In the setting of penetrating neck wounds with a vascular component, one should always look for injuries to the
esophagus and the laryngotrachea. If preoperative radiology is not possible, one can ask the anesthetist to pass
a nasogastric tube to allow easier identication of the
esophagus. Repair of local damage to the esophagus may
be undertaken with a two-layered 3-0 absorbable suture,
using the sternomastoid muscle to buttress the suture line
and to reduce the risk of leakage. This muscle takes its blood
supply from the occipital artery and the superior thyroid
artery branches of the thyrocervical trunk and thus can
be mobilized from the clavicle by dividing the sternal and
clavicular heads. Tracheal injuries can be repaired primarily with an absorbable suture and similarly buttressed with
the sternomastoid muscle. If the tracheal defect is large, it
should be converted into a tracheostomy.
19
OPERATIVE MANAGEMENT OF ZONE III INJURIES
Various techniques for gaining access to the inherently
difcult-to-expose distal internal carotid artery have been
reported. However, methods involving subluxation of the
temporomandibular joint and vertical ramus osteotomy are
often not achievable in the austere environment.
ful technique is to divide the digastric muscle and to partially sublux the mandibular condyle. This is accomplished
by forceful opening of the mouth, kept open by careful
positioning of a self-retaining retractor with swabs over the
molars and a Langenbeck retractor placed under the angle
of the jaw to lift it forward.22 This was the technique used in
one such case that is depicted in Fig. 27.8.
One may be faced with signicant bleeding from a Zone III
injury of the internal carotid artery, where the techniques
described previously may not be possible. In that case, the
only option would be ligation of the internal carotid or
proximal ligation and packing of the area for several days to
20,21
A use-
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A
postoperative care. In some circumstances, appropriate facilities are available, and in these cases a median sternotomy is
the best option. Indeed, if the necessary equipment is available, this exposure is not difcult to perform and provides an
excellent working view of zone I vascular structures.
However, without the benet of either good x-rays or a CT
scan then the difcult decision based on clinical parameters
needs to be undertaken. If the decision has been made to
explore for a zone I injury in such austere settings, then I
would suggest a clamshell maneuver with wide retraction
to allow access into the vessels in the root of the neck. The
gateway to the arch is division of the brachiocephalic vein,
allowing exposure of the arch and its branches. Again,
based on experience alone, it is more preferable to ligate vessels from the arch including the innominate artery rather
than to try and perform a complicated vascular reconstruction. There are obvious downsides in ligation such as distal
ischemia, but is often quite surprising how collateralization
around the shoulder allows for improvement. Consideration
also must be made for fasciotomy of the forearm if this is
performed. There is also the risk of stroke caused by ligation
of the carotid arteries which must, of course, be tempered
by the postoperative facilities available, which in an austere
environment may be extremely limited.
B
Fig. 27.8 Zone III injury of the carotid (A), with the defect repaired
using a vein patch (B).
allow thrombosis of the distal part, accepting the inevitable
40% stroke risk. Proximal ligation and closure of the wound
leaving pressure from a Foley catheter balloon to further
compress the area may be another option as this obviates
the necessity for reopening the wound.
OPERATIVE MANAGEMENT OF ZONE I INJURIES
Penetrating injuries either from fragmentation or gunshot
wound into zone I of the neck are often very difcult to deal
with. Most cases in austere environments are either in extremis or dead on arrival. Resuscitation uids may be in short
supply. However, if the patient is cerebrating and maintains
a systolic blood pressure, a decision based on resources
available must be taken into account before embarking on
surgery.
The classic teaching for zone I injuries of the neck is that
proximal control of the innominate, the subclavian, and the
carotid arteries should be enabled via a median sternotomy,
followed by cervical extension into either side of the neck
(Fig. 27.9). In the austere environment, this approach has to
be tempered with the available resources for preoperative and
Upper Limb Vascular Injuries
SUBCLAVIAN AND AXILLARY VESSEL
The subclavian artery is divided into three parts. Bleeding
from the third part as it passes beyond the rst rib can be
one of the most challenging operations in difcult environments. A supraclavicular incision with division of the clavicular head of the sternomastoid allows exposure of the
internal jugular vein which is the rst landmark. Lateral
to this is the scalenus fat pad which is retracted laterally to
expose the scalenus anterior muscle and the phrenic nerve,
which passes from lateral to medial. Division of the scalenus
anterior muscle allows for exposure of the rst and second
part of the subclavian artery. Excision of the clavicle, which
(contrary to opinion) does not destabilize the shoulder (provided the muscles attached to it are reconstituted
for excellent exposure of the subclavian, proximal carotid,
and axillary arteries, but is rarely needed. Instead, injuries
under the clavicle involving the subclavian axillary can be
dealt with by dividing the clavicle at its midpoint using a
Gigli saw and retraction using orthopedic hooks.
Because of the difculty in successful subclavian artery
reconstruction, I would always ligate the vessel. In most
cases, upper limb circulation is maintained via the rich collateral circulation around the shoulder girdle (Fig. 27.10).
Because of the close anatomical relationship of the
neurovascular structures, the brachial plexus is injured
in about one-third of patients with subclavian or axillary
vascular trauma. In this situation it is necessary to perform a nerve repair, primarily by dissecting the nerve and
suturing the epineural layer with 5-0 Prolene during the
rst exploration.26 Access to the axillary artery is achieved
by using an infraclavicular incision made from the deltopectoral groove to the lateral two-thirds of the clavicle.
This exposure requires splitting the bers of the pectoralis
23,24
) allows
25
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A
Fig. 27.9 (A–C) Pulsatile swelling in zone
I and zone II of the neck due to a gunshot
B C
wound with median sternotomy to gain
proximal control of the carotid artery.
A B
Fig. 27.10 (A) Gunshot to zone I of the neck. (B) Removal of the clavicle and ligation of the subclavian artery.
major muscle and dividing the pectoralis minor muscle as
it attaches to the coracoid process. Straightforward and
quick to perform, this is the method of choice in nearly all
cases of penetrating arm injuries to gain proximal control
before isolating the damaged vessels (Fig. 27.11). Further
exposure of the axillary artery can be performed very rapidly by dividing the origins of the pectoralis major and pectoralis minor muscles (Fig. 27.12). Pectoralis major can
be divided about 2 cm from its attachment to the humerus
and retracted inferomedially. The underlying pectoralis
minor muscle is then divided near its insertion on the coracoid process and is retracted. This allows exposure of the
whole of the axillary artery up to the lower border of the
teres major.
Because the axillary vessels are usually soft, lateral repair
will narrow the vessel and better results are obtained if a
vein patch or an interposition graft using autologous
long saphenous vein is employed. However, if repair is not
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Fig. 27.11 (A and B) Exposure of
the infraclavicular axillary artery
for proximal control.
A B
Fig. 27.12 Complete exposure of the axillary artery.
possible, the extensive collateral circulation around the
axillary artery means that ligation is an option (with an
acceptance of a risk of ischemic sequelae of 25% to 30%).
Primary ligation of a vein in the upper limb is usually well
tolerated because of lower hydrostatic pressure within the
superior vena cava associated with erect posture, smaller
minute volume blood ow, and extensive collaterals (Figs.
27.13 and 27.14).27 A fasciotomy is always performed
when managing extremity vascular trauma in the austere
domain. The forearm contains the following three compartments: the volar compartment, dorsal compartment, and
mobile wad containing the brachioradialis; the extensor
carpi radialis brevis; and the extensor carpi radialis longus. The carpal tunnel should be opened or released during
upper extremity fasciotomy in most cases.
BRACHIAL AND FOREARM VESSELS
In contrast to the axillosubclavian arterial segment, ligation of the brachial artery results in amputation in nearly
Fig. 27.13 Arteriogram performed 2 weeks after a gunshot wound to
the axillary artery causing thrombosis.
half of cases, and therefore ow should be reestablished
(particularly if the injury lies in the proximal vessel above
the origin of the profunda brachii).28 Direct suture repair
should never be performed in the brachial artery because
of the potential to narrow the vessel. Instead, short-section
resection and primary end-to-end anastomosis, vein patch
angioplasty, or application of reversed saphenous vein
interposition graft is preferable. The use of shunts is often
warranted. Though thrombosis may occur, limb-threatening sequelae are not always apparent. This author has had
two cases, both transferred from eld hospitals deep in hostile territory, where the non–vascular-trained surgeon had
elected to place shunts into the brachial artery. Both cases
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Fig. 27.14 This child had a gunshot wound to the axilla and necessitated the ligation of the axillary artery just above the border with teres
major muscle; no vascular sequelae followed. Fig. 27.15 Slings made out of surgical gloves and shunts form naso-
gastric tubes.
had a long transfer time of 4 to 5 days. When explored, the
shunts were occluded although the arms and were well
perfused with good radial and ulnar Doppler signals. The
shunts were removed and the brachial artery ligated in
each patient, with no troublesome consequences. One possibility is that slow occlusion over a period of days may have
allowed collaterals to open with no loss of end perfusion.
It is this author's preference to place a temporary vascular shunt when managing an extremity with a combined
orthopedic and vascular injury. This strategy is employed
to reduce the warm ischemic time before application of an
external xator. Any sort of sterile plastic tubing can be
used, and different sizes of nasogastric tube or intravenous
uid sets will sufce to ensure diameter match is consistent
with the vessel concerned. For upper extremity injuries,
slings can be manufactured or improvised using a wristband in a surgical glove (Fig. 27.15). When fashioning a
shunt, one should ensure that it is slightly smaller than the
artery and should cut carefully so that it is unlikely to damage the intima. The shunt should be secured in the intravascular position with a double silk suture tied on the outside
of the vessel. Having shunted the vessel (and following
application of the external xator) the long saphenous vein
can be harvested and prepared as a reversed vein interposition graft. The vascular shunt may then be removed and the
vein interposed and grafted.
Umbilical vein catheters are a vital piece of equipment
in the austere setting and have many uses. Placed via the
lumen of the vein graft and then into the distal artery, this
type of catheter serves to stent open the anastomosis while
suturing it with individual 5-0 Prolene. This maneuver
reduces the risk of narrowing the anastomosis and may
also reduce the number of sutures. After the anastomosis is complete, heparinized saline (5000 U/500 mL) can
be injected down the catheter to reduce the risk of distal
thrombosis. The catheter can then be withdrawn and
attention paid to the proximal anastomosis. By ensuring
that one of the side-tributary stumps of the vein graft is
kept long during harvesting, this portal can also be used to
reintroduce the catheter into the vein lumen and then into
the proximal artery for administration of heparin ush.
The proximal anastomosis can be completed around the
catheter before its removal, and the long side tributary can
be ligated. In Fig. 27.16, there were no slings available or
arterial clamps and the umbilical catheter acted as means
of occluding the arterial ow, held in place by a pair of
forceps.
Single vessel injury in the forearm need not be repaired
but can be ligated. However, repair is mandatory if either
the radial or ulnar artery was previously ligated as is so
common in machete wounds (Fig. 27.17). When both radial
and ulnar arteries are injured, the ulnar artery should be
repaired as it is usually the dominant vessel.
Abdominal Vascular Injuries
On opening the abdomen for exsanguinating abdominal
vascular trauma, the surgeon must perform the following
three tasks: (1) identify the zone of bleeding, (2) obtain
proximal and distal control, and (3) achieve hemostasis
with or without restoration of critical ow. From a trauma
point of view, the abdomen is divided into three zones
(Fig.27.18). In general, hematomas due to blunt injury in
zones II and III are not disturbed. All hematomas in zone I
are explored, as are expanding hematomas in zones II and
III. Zone I can be divided into supramesocolic and inframesocolic areas by the transverse mesocolon. Proximal control
can be very challenging, but knowledge of techniques such
as the Cattell-Braasch maneuver29 for inferior vena cava
(IVC) injury and the left-sided medial visceral rotation (Mattox maneuver) for supramesocolic aortic injury is mandatory if the patient is to have a chance of survival.
Successful application of surgical technique is not the
sole determinant of outcome. Most patients with signicant
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A B
CD
Fig. 27.16 (A–D) A series of photographs showing the insertion of a shunt before external fixator and the author's method of protecting the anastomosis, as well as the final definitive result.
I
IIII
III
Fig. 27.17 A machete wound to the forearm.
intraabdominal hemorrhage require a massive transfusion
and postoperative ventilation. Even then, the chance of
avoiding a fatal outcome is low.
blood loss of 6 L or more, mortality can approach 100%.32
This is the context for the difcult nature of decisions facing surgeons working in a resource-limited environment.
30,31
If there is a cumulative
Fig. 27.18 Zones of the abdomen.
27 • Vascular Surgery in the Austere Environment 341
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Fig. 27.19 (A and B) Left visceral rotation in order to obtain exposure of the supramesocolic aorta.
A B C
Fig. 27.20 (A–C) Through-and-through gunshot wound with injury to the inferior vena cava approached by performing the Cattell-Braasch maneuver.
Knowing that massive intraabdominal bleeding is likely to
end up in patient mortality, the surgeon may be faced with
the decision of whether to initiate treatment or, instead,
to triage the patient to an “expectant” category. Resources
that are expended in trying to save a potentially futile situation may be wasted, but one may face signicant pressure
to attempt salvage from the patient's family members and
from the attending hospital staff. In these difcult scenarios,
it is best to try to save the life but also to set clear limits and
recognize nonsalvageable situations in order to stop care
and conserve resources.
In Fig. 27.19, the patient suffered a fragment injury from
a rocket-propelled grenade to the abdomen. In this case,
a left anterolateral thoracic incision was made in order to
apply an aortic clamp before opening the abdomen. A left
medial visceral rotation (Mattox maneuver) was performed,
and clamps were applied to the supraceliac aorta in an
attempt to control the hemorrhage. Although aortic control was achieved, the liver was badly macerated, and the
patient succumbed to hemorrhage and shock.
In Fig. 27.20, the Cattell-Braasch maneuver is demon-
strated exposing the IVC, which was bleeding consequent
to a gunshot wound. More often than not hemorrhage from
the vena cava is partly constrained by retroperitoneal tissues,
reducing the opportunity for immediate exsanguination. In
the illustrated case, the injury track included the anterior
and posterior walls of the stomach, the anterior and posterior
wall of the third part of the duodenum, and the vena cava,
resulting in a large zone I hematoma. The Cattell-Braasch
maneuver was performed in this scenario to gain proximal
and distal control of the IVC. Hemostasis was secured with
swabs (sponges)-on-sticks, applied proximal and distal to the
venous injury, which was eventually repaired with a lateral
running 3-0 Prolene suture. In more difcult circumstances,
ligation of the IVC would have been a justiable option.
Resuscitative Thoracotomy
Some eld hospitals that I have worked in are on the frontline. This means that patients are presented via a scoop and
run policy to the emergency department, sometimes minutes after being wounded by a bullet or fragment, which in
turn means that patients who would have died on thebattleeld are now surviving and being presented to the trauma
team. Exsanguinating hemorrhage often results in patients
being brought in extremis, having “bled out” because of
their injuries and requiring external cardiac massage.
Immediate decisions in these circumstances must be made.
These decisions are sometimes very difcult, emotions run
high, and the rule of the gun takes president over the rule of
the law and occasionally one is forced to operate. However,
a clear understanding of the outcome must be at the forefront of the operating surgeon’s mind.
342 SECTION 4 • The Management of Vascular Trauma
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Fig. 27.21 (A and B) A one-shot arteriogram.
If a patient having cardiopulmonary resuscitation (CPR)
due to a single penetrating wound to the heart causing a
pericardial tamponade is to have a chance of survival,
a resuscitative thoracotomy must be performed within
10 minutes. Wounds that cause blood on the oor from a
penetrating injury to the limbs have a chance of survival
if the resuscitative thoracotomy is performed within 5 minutes of CPR. Those who have a blunt injury having CPR will
not survive.
A resuscitative thoracotomy requires a left anterolateral
thoracotomy, opening up of the pericardial sac to conrm
whether the heart is full or empty, a clamp on the distal
thoracic aorta, and a large central line in the subclavian or
internal jugular for resuscitation uids. If a patient has lost
so much blood that they require CPR, it means that they have
most likely lost around 4 L of blood. That means that to even
begin the resuscitation eight units of blood are required.
In my opinion, a further eight units are then required for
the procedure and following that, a further eight units are
required over the next few hours. This amounts to around
24 units of blood per patient who requires a resuscitative
thoracotomy. Unless the blood bank is well-stocked, it is
usually futile to begin resuscitating a patient who presents
with exsanguinating to hemorrhage in the austere environment as most blood banks contain 2 to 4 units of blood.
Lower Limb Vascular Injuries
The diagnosis of extremity vascular trauma, including the
utility and effectiveness of continuous-wave Doppler and
other imaging modalities, is detailed in Chapters 7 and 8.
To review, patients with hard signs of vascular injury mandate immediate operative intervention, whereas patients
without hard signs but with suspicious injury patterns
should be monitored with an especially high index of
suspicion. Lower extremity injury patterns known to be
associated with vascular trauma include displaced medial
tibial plateau fractures, distal femoral shaft fractures, and
gunshot wounds in proximity to lower limb neurovascular structures. In these instances, the patient should be
examined not once but over a period of time using a combination of physical examination and noninvasive pressure
measurements using a handheld Doppler. Continuouswave Doppler alone and in conjunction with measurement
of pressure ratios (i.e., IEI or ankle-brachial pressure index
[ABPI]) have a sensitivity and specicity of greater than
33,34
95%.
Specically, an IEI or ABPI of 0.9 or greater is
normal and suggests that no further diagnostic studies or
interventions are needed. An IEI or ABPI of less than 0.9
is an indication for arteriography, if the facilities are available, or for operative exploration.
35
If available, contrast arteriography is also useful in the
setting of a reduced IEI in patients with multiple candidate
sites of injury along the vascular axis (i.e., penetrating
wounds at multiple levels of the extremity). This can be performed in the operating theater using local anesthetic and
a cut-down on the common femoral artery. Once the artery
is exposed, an umbilical vein catheter can be introduced via
limited arteriotomy. Modern day micropuncture catheters
(4 or 5 Fr) are also useful for this maneuver and may obviate
the need for an open operative exposure. Once the catheter
is positioned in the common femoral artery, an x-ray plate is
wrapped in a sterile drape and positioned beneath the area
of interest on the injured lower extremity before injection of
20 mL of contrast (usually 50% Hypaque) down the catheter. Exposure should be timed to occur as the surgeon is
administering the last 2 mL of contrast (Fig. 27.21).
36
In general, ligation above the trifurcation of the tibial
arteries should be avoided in order to reduce the likelihood
of severe limb ischemia and amputation. Ligation of the
common femoral artery increases the risk of amputation
by 50% and the risk of limb loss associated with popliteal
artery ligation is 75%. As such, the proximal and midlevel
lower extremity axial arteries should be repaired if at all
possible.29 The redundant nature of tibial artery circulation
to the leg and foot means that uninterrupted ow through
one of the three vessels is all that is required to maintain
limb viability and salvage. In other words, it is generally
acceptable to ligate or leave unrepaired two of the three
tibial vessels as long as one remaining vessel is uninjured
throughout its length.
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AA B CBC
Fig. 27.22 A gunshot injury to the groin. (A) Initial extraperitoneal exposure of the external iliac artery to gain proximal control. (B) Arterial and venous
shunting to maintain perfusion, followed by fasciotomy. (C) Twelve hours later, the definitive procedure was performed using the long saphenous vein
from the other leg to repair the femoral artery and femoral vein.
Once the lower extremity vascular injury has been identied, proximal and distal control should be achieved. Operating in virgin territory and staying out of the hematoma is
the preferred technique in most cases. For common femoral
artery injuries, this requires either division of the inguinal
ligament or an extraperitoneal approach to the external
iliac artery to gain proximal control (Fig.27.22). Below the
hematoma, the vessels are isolated and clamped. In routine developed-world practice, Fogarty catheters are used
to ensure good inow and backow and to remove thrombus. If Fogarty catheters are not available and if thrombus
seems to be present (manifested by poor inow), the clamp
is applied more proximally in an area of good pulsation and
a small arteriotomy is made below this level. An umbilical
catheter may then be inserted and the thrombus washed
out by attaching the spigotted end to a syringe and infusing
copious amounts of heparinized saline until one is condent that the artery is clear of thrombus. This action can
be performed on the distal outow vessel as well. It is very
important to close the small arteriotomy carefully so as not
to cause any intimal injury. This author has used this technique on several occasions to be condent in securing optimal inow and backow from the distal vessel.
Once the vascular injury site has been controlled and the
bleeding stopped, it is important to take stock of the situation. Questions that may be particularly relevant in an austere setting include: How much blood has been lost? How
long ago did the injury occur? What resources (i.e., surgical tools, blood bank) are available? What is the physiology of the patient? In the austere setting, the surgeon may
not have access to sophisticated blood-serum analysis but
can assume that the patient who has lost 1 L or more of
blood from an arterial injury is physiologically unwell. In
these situations, this author makes liberal use of damage
control vascular techniques, including use of a temporary
vascular shunt to preserve blood ow and to limit extremity ischemia time. In cases of combined arterial and venous
trauma, one may use a shunt in both the artery and the
vein because maintenance of venous outow may contribute to arterial patency. Shunting the vein rst also reduces
venous bleeding once arterial ow has been reestablished.
Following control of the vascular injury and placement
of a temporary vascular shunt or shunts, the situation
should be reassessed. In all cases, but especially those in an
austere setting, the surgeon should consider whether it is
necessary to complete the denitive operation during that
setting or to defer reconstruction until the patient is physiologically improved. Having the shunt in place also allows
one to assess whether vascular reconstruction is even necessary as the shunt can be temporarily occluded and distal
limb perfusion can be assessed with the continuous-wave
Doppler. In some instances in which collateral circulation
has been preserved, there may be an arterial signal in the
leg or foot distal to the manually occluded shunt. In these
cases, it may be that arterial repair can be delayed for a
period of time or even indenitely. Ligating the axial artery
and leaving the leg and foot relatively ischemic but viable
may be the appropriate damage control maneuver in some
cases in the austere setting. In these instances, the leg and
foot can be monitored with repeat IEI measurements and
assessment for clinical signs of ischemia. Revascularization
can then be performed at an interval period of time if ischemia worsens, although this may be deferred for weeks or
longer if collateral circulation is signicant.
This author has frequently left a shunt in place for
24 hours and brought the patient back to the operating theater the following day. Vascular shunts have been used for
many years to maintain perfusion of injured limbs during
transfer to other facilities and have been known to remain
patent for up to 54 hours.
37–40
Temporary shunts permit
time for a fuller appreciation and surgical treatment of the
injury, allowing for the complete débridement of nonviable
soft tissue before committing to denitive vascular procedure. Shunting also allows for the proper consideration of
denitive soft-tissue coverage options, using muscle or a fasciocutaneous ap to cover the vascular reconstruction. In
this way, one may avoid the situation in which a perfectly
good vascular repair has been performed only for the reconstruction to span a soft-tissue defect that has no support or
possibility of soft-tissue coverage.
The long saphenous vein from the extremity contralateral to the injury is the preferred conduit for denitive
vascular repair. Although the saphenous vein from the
injured extremity can be used, if there is a concomitant
venous injury in the limb, that saphenous vein may provide
an element of venous return making its harvest ill-advised.
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A B
Fig. 27.23 (A and B) Consider primary amputation as the procedure of choice in a resource-limited environment.
Major veins of the lower limb should be repaired with the
same care as arterial injuries. The femoropopliteal vein
is usually repaired rst to allow for venous return before
repairing any artery injury. Ligation of major veins in the
lower limbs (external iliac, common femoral, supercial
femoral) results in signicant edema in 50% of patients
compared with 7% after repair.27 There may also be an
argument for the necessity of popliteal vein reconstruction
to prevent limb loss.41 However, this should be considered in
the context of the physiology of the patient and operative
time required. If deemed inappropriate, ligation of lower
extremity venous injury may have to be performed as a matter of damage control.
The absolute indications for fasciotomy include prolonged ischemia time, combined arteriovenous injury, complex injuries (including bone and soft tissue), and crush
injury. However, in the austere environment, prophylactic
fasciotomy should be routine because time scales cannot
be assumed and preoperative information (i.e., injury timing, circumstances) is frequently misleading. Furthermore,
it is unlikely, in the resource-limited environment, that the
surgeon will be able to closely monitor and reassess the
patient in whom there is a concern for the development of
compartment syndrome. Ideally, the fasciotomy should be
performed before the orthopedic and vascular procedures.
There are some who doubt whether routine fasciotomy is
necessary, citing the risk of infection and long-term consequences. However, routine fasciotomy is this author's standard practice, especially in the austere setting.
In summary, in the setting of a mangled extremity in
which there is a fracture and a major vascular injury, this
author's preferred order of management is as follows: (1)
exploration and control (proximal and distal) of the injury,
(2) performance of fasciotomy, (3) placement of a temporary vascular shunt, (4) débridement of soft-tissue wounds,
(5) external xation of the fracture, and (6) harvest of long
saphenous vein and denitive vascular repair after the
patient is physiologically improved. The vascular reconstruction should then be covered by muscle and the wounds
dressed with uffed-up gauze held in place by a light crepe
bandage. The wounds should not be touched by anyone
other than the surgeon, and, after 5 days, the patient should
be returned to the operating theater, the dressings removed,
and the wound closed by delayed primary closure or split
skin graft.
42
FUTILITY OF TREATMENT
When dealing with extremity vascular trauma in the austere environment, it is not always easy to make the right
decision in regard to limb salvage. Signicant risk of mortality and morbidity follows a failed attempt at limb salvage.
There are at least ve scoring systems available to assist
one in making the decision as to whether to amputate the
extremity or to perform a limb-saving procedure.43 However,
reports suggest that these scoring systems are not reliable44;
and, moreover, there are no scoring systems that relate to
the austere environment.
In the author's opinion, limb salvage in the austere environment should be considered only if the following ve conditions are met:
1. There was less than 6 hours' time from point of injury.
2. There was less than 30% soft-tissue loss.
3. Bone shaft is in continuity. If fractured, the ends are xed
in continuity with external xation.
4. Major nerve damage is easily repairable (i.e., less than 2
to 3 cm segmental loss).
5. Vascular reconstruction is able to be covered with viable
and available soft tissue.
In the author's experience, if these conditions are not
present and the surgeon is in a signicantly resource-limited environment, primary amputation is the procedure of
choice (Fig. 27.23).
Soft-Tissue Injury
The management of the soft-tissue defect associated with
vascular trauma is important to consider. Misdirected
attempts to preserve local tissue for vascular coverage can
lead to inadequate débridement, wound sepsis, and more
extensive secondary débridement resulting in further exposure of the repaired vessel at the base of a necrotic and
contaminated wound. The common sequel in this unfortunate situation is delayed and often life-threatening hemorrhage from an exposed and disrupted vascular anastomosis,
necessitating emergency ligation. This is a disaster and
leads to outcomes no better than those observed more than
60 years ago during the World War II. If the initial vascular
operation is not performed properly, the problem is merely
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