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1 • The Vascular Injury Legacy 15
Aneurysmal pockets
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With the combined developments of anesthesia and
asepsis, several reports of attempts to repair arteries
appeared in the latter part of the 19th century. The work
of Jassinowsky, who is credited in 1889 for experimentally
Femoral artery
proving that arterial wounds could be sutured with preservation of the lumen, was later judged by Murphy in 1897
as the best experimental work published at that time.
21,22
In 1865, Henry Lee of London attempted repair of arterial
Femoral vein
Anterior
Posterior
lacerations without suture.23 Glück, in 1883, reported 19
experiments with arterial suture, but all experiments failed
because of bleeding from the holes made by the suture needles.24 He also devised aluminum and ivory clamps to unite
longitudinal incisions in a vessel, and it was recorded that
the ivory clamps succeeded in one experiment on the femoral artery of a large dog. Von Horoch of Vienna reported
on the anterior and
posterior surface of
B
the femoral artery
six experiments, including one end-to-end union, all of
which thrombosed.23 In 1889, Bruci sutured six longitudinal arteriotomies in dogs; the procedure was successful
in four.20 In 1890, Muscatello successfully sutured a partial transection of the abdominal aorta in a dog.20 In 1894,
A
Heidenhain closed by catgut suture a 1-cm opening in the
axillary artery made accidentally while removing adherent
carcinomatous glands.25 The patient recovered without any
circulatory disturbance. In 1883, Israel, in a discussion of
a paper by Glück, described closing a laceration in the common iliac artery created during an operation for perityphlitic abscess.
24,26
The closure was accomplished by ve silk
sutures. However, from his personal observations, Murphy
(1897) did not believe it could be possible to have success in
this type of arterial repair.22 In 1896, Sabanyeff successfully
closed small openings in the femoral artery with sutures.
The classic studies of J.B. Murphy of Chicago (1897) con-
20
C
tributed greatly to the development of arterial repair and
culminated in the rst successful end-to-end anastomosis
of an artery in 1896.22 Previously, Murphy had carefully
reviewed earlier clinical and experimental studies of arterial repair and had evaluated different techniques extensively in laboratory studies. Murphy attempted to determine experimentally how much artery could be removed
and still allow an anastomosis. He found that 1 inch of a
Fig. 1.3 (A–C) The first successful clinical end-to-end anastomosis of
an artery was performed in 1896. Sutures were placed in the proximal
artery, including only the few outer coats; three sutures were used to
secure the final repair. (From Murphy JB. Resection of arteries and veins
injured in continuity—end-to-end suture-experimental clinical research.
Med Record. 1897;51:73.)
calf’s carotid artery could be removed and the ends still
approximated by invagination suture technique because
of the elasticity of the artery. He concluded that arterial
repair could be done with safety when no more than 3/4
inch of an artery had been removed, except in certain
locations, such as the popliteal fossa or the axillary space,
where the limb could be moved to relieve tension on the
repair. He also concluded that when more than half of the
artery was destroyed, it was better to perform an end-toend anastomosis by invagination rather than to attempt
Hospital in Chicago on September 19, 1896, approximately
2 hours after wounding. There was no hemorrhage or
increased pulsation noted at the time. Murphy rst saw the
patient 15 days later, October 4, 1896, and found a large
bruit surrounding the site of injury. Distal pulses were
barely perceptible. When demonstrating this patient to
students 2 days later, a thrill was also detected. An operative repair was decided on. Because of the historical signi-
cance, the operation report is quoted:
repair of the laceration. This repair was done by introducing sutures into the proximal artery, including only the
two outer coats, and using three sutures to invaginate the
proximal artery into the distal one, reinforcing the closure
with an interrupted suture (Fig. 1.3).
22
In 1896, Murphy was unable to nd a similar recorded
case involving the suture of an artery after complete division, and he consequently reported his experience (1897)
and carried out a number of experiments to determine the
feasibility of his procedure. Murphy’s patient was a
29-year-old male shot twice with one bullet entering the
femoral triangle. The patient was admitted to Cook County
Operation, October 7, 1896. An incision ve inches long was
made from Poupart’s ligament along the course of the femoral
artery. The artery was readily exposed about one inch above
Poupart’s ligament; it was separated from its sheath and a
provisional ligature thrown about it but not tied. A careful
dissection was then made down along the wall of the vessel to
the pulsating clot. The artery was exposed to one inch below
the point and a ligature thrown around it but not tied: a careful
dissection was made upward to the point of the clot. The artery
was then closed above and below with gentle compression
clamps and was elevated, at which time there was a profuse
16 SECTION 1 • Setting the Stage
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hemorrhage from an opening in the vein. A cavity, about the
size of a lbert, was found posterior to the artery communicating with its caliber, the aneurysmal pocket. A small aneurysmal
sac about the same size was found on the anterior surface of the
artery over the point of perforation. The hemorrhage from the
vein was very profuse and was controlled by digital compression. It was found that one-eighth of an inch of the arterial
wall on the outer side of the opening remained, and on the
inner side of the perforation only a band of one-sixteenth of
an inch of adventitia was intact. The bullet had passed through
the center of the artery, carried away all of its wall except the
strands described above, and passed downward and backward
making a large hole in the vein in its posterior and external side
just above the junction of the vena profunda. Great difculty
was experienced in controlling the hemorrhage from the vein.
After dissecting the vein above and below the point of laceration and placing a temporary ligature on the vena profunda, the
hemorrhage was controlled so that the vein could be sutured.
At the point of suture the vein was greatly diminished in size,
but when the clamps were removed it dilated about one-third
the normal diameter or one-third the diameter of the vein above
and below. There was no bleeding from the vein when the clamps
were removed. Our attention was then turned to the artery.
Two inches of it had been exposed and freed from all surroundings. The opening in the artery was three-eighths of an inch
in length; one-half inch was resected and the proximal was
invaginated into the distal for one-third of an inch with four
double needle threads which penetrated all of the walls of the
artery. The adventitia was peeled off the invaginated portion for
a distance of one-third of an inch: a row of sutures was placed
around the edge of the overlapping distal end, the sutures penetrating only the media of the proximal portion; the adventitia
was then brought over the end of the union and sutured. The
clamps were removed. Not a drop of blood escaped at the line
of suture. Pulsation was immediately restored in the artery
below the line of approximation and it could be felt feebly in the
posterior tibial and dorsalis pedis pulses. The sheath and connective tissue around the artery were then approximated at the
position of the suture with catgut, so as to support the wall of
the artery. The whole cavity was washed out with a ve percent
solution of carbolic acid and the edges of the wound were accurately approximated with silk worm-gut sutures. No drainage.
The time of the operation was approximately two and one-half
hours, most of the time being consumed in suturing the vein.
The artery was easily secured and sutured, and the hemorrhage
from it readily controlled. The patient was placed in bed with the
leg elevated and wrapped in cotton.
22
The anatomic location of the injuries, the gross pathology involved, and the detailed repair contributed to Murphy’s historically successful arterial anastomosis. Murphy
mentioned that a pulsation could be felt in the dorsalis pedis
artery 4 days following the operation. The patient had no
edema and no disturbance of his circulation during the
reported 3 months of observation.
22
Subsequently, Murphy (1897) reviewed the results of
ligature of large arteries before the turn of the century.22
He found that the abdominal aorta had been ligated 10
times, with only 1 patient surviving for 10 days. Lidell
reported only 16 recoveries after ligation of the common
iliac artery 68 times, a mortality of 77%.20 Balance and
Edmunds reported a 40% mortality following ligation of a
femoral artery aneurysm in 31 patients. Billroth reported
secondary hemorrhage from 50% of large arteries ligated
in continuity. Wyeth collected 106 cases of carotid artery
aneurysms treated by proximal ligation, with a mortality
rate of 35%.
In 1897, Murphy summarized techniques he considered
necessary for arterial suture. They bore a close resemblance
to principles generally followed today:
1. Complete asepsis
2. Exposure of the vessel with as little injury as possible
3. Temporary suppression of the blood current
4. Control of the vessel while applying the suture
5. Accurate approximation of the walls
6. Perfect hemostasis by pressure after the clamps are
taken off
7. Toilet of the wound
Murphy also reported that Billroth, Schede, Braun,
Schmidt, and others had successfully sutured wounds in
veins.22 He personally had used ve silk sutures to close an
opening 3/8-inch long in the common jugular vein.
Several signicant accomplishments occurred in vascular
surgery within the next few years. In 1903, Matas described
his endoaneurysmorrhaphy technique, which remained
the standard technique for aneurysms for over 40 years.27
In 1906, Carrel and Guthrie performed classic experimental
studies over a period of time with many signicant results.28
These included direct suture repair of arteries, vein transplantation, and transplantation of blood vessels as well as
organs and limbs. In 1912, Guthrie independently published his continuing work on vascular surgery.14 Following
Murphy’s successful case in 1896, the next successful repair
of an arterial defect came 10 years later when Goyanes used
a vein graft to bridge an arterial defect in 1906.
22,29
Working in Madrid, Goyanes excised a popliteal artery aneurysm
and used the accompanying popliteal vein to restore continuity (Fig. 1.4).29 He used the suture technique developed
by Carrel and Guthrie of triangulating the arterial orice
with three sutures, followed by continuous suture between
each of the three areas. A year later in 1907, Lexer in
Germany rst used the saphenous vein as an arterial substitute to restore continuity after excision of an aneurysm of
the axillary artery.29 In his 1969 review, Shumacker commented that within the rst few years of the 20th century,
the triangulation stitch of Carrel (1902), the quadrangulation method of Frouin (1908), and the Mourin modication
(1914) had been developed.
20
By 1910, Stich had reported more than 100 cases of
arterial reconstruction by lateral suture.30 His review
included 46 repairs, either by end-to-end anastomosis or by
insertion of a vein graft.31 With this promising start, it is
curious that over 30 years elapsed before vascular surgery
was widely employed. A high failure rate, usually by thrombosis, attended early attempts at repair, and few surgeons
were convinced that repair of an artery was worthwhile. In
1913, Matas stated that vascular injuries, particularly arteriovenous aneurysms, had become conspicuous features of
modern military surgery, and he felt that this class of injury
must command the closest attention of the modern military surgeon: “A most timely and valuable contribution to
the surgery of blood vessels resulted from wounds in war.
1 • The Vascular Injury Legacy 17
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Artery
V
A
g
Fig. 1.4 The first successful repair of an arterial defect utilizing a vein
graft. Using the triangulation technique of Carrel with endothelial
coaptation, a segment of the adjacent popliteal vein was used to repair
the popliteal artery. A, Artery; V, vein; g, graft. (From Goyanes DJ. Nuevos
trabajos chirugia vascular. El Siglo Med. 1906;53:561.)
Unusual opportunities for the observation of vascular
wounds inicted with modern military weapons … based
on material fresh from the eld of action, and fully conrmed the belief that this last war, waged in close proximity to well-equipped surgical centers, would also offer an
unusual opportunity for the study of the most advanced
methods of treating injuries of blood vessels.”
27
Matas described Soubbotitch’s experience of Serbian
military surgery during the Serbo-Turkish and SerboBulgarian Wars at the 1913 London International Congress.27 He reported that 77 false aneurysms and arteriovenous stulas were treated. There were 45 ligations, but 32
vessels were repaired, including 19 arteriorrhaphies, 13 venorrhaphies, and 15 end-to-end anastomoses (11 arteries and
4 veins). It is impressive that infection and secondary hemorrhage were avoided. In 1915, Matas, in discussing Soubbotitch’s report, emphasized that a notable feature was the
suture (circular and lateral repair) of blood vessels, and the
fact that it had been utilized more frequently in the Balkan
conict than in previous wars.27 He also noted that, judging
by Soubbotitch’s statistics, the success obtained by surgeons
in the Serbian Army Hospital in Belgrade far surpassed those
obtained by other military surgeons in previous wars, with
the exception perhaps of the remarkably favorable results in
the Japanese Reserve Hospitals reported by Kikuzi.
World War I Experience
During the early part of WWI, with the new techniques
of vascular surgery well established, the German surgeons
attempted repair of acutely injured arteries and were successful in more than 100 cases.31 During the rst 9 months
of WWI, low-velocity missiles caused arterial trauma of
a limited extent. In 1915, however, the widespread use of
high explosives and high-velocity bullets, combined with
mass casualties and slow evacuation of the wounded, made
arterial repair impractical.
In 1920, Bernheim went to France with the specic intent
of repairing arterial injuries.32 Despite extensive prior experience and equipment, however, he concluded that attempts
at vascular repair were unwise. He wrote: “Opportunities
for carrying out the more modern procedures for repair or
reconstruction of damaged blood vessels were conspicuous
by their absence during the recent military activities. Not
that blood vessels were immune from injury; not that gaping arteries and veins and vicariously united vessels did not
cry out for relief by ne suture or anastomosis. They did,
most eloquently, and in great numbers, but he would have
been a foolhardy man who would have essayed sutures of
arterial or venous trunks in the presence of such infections
as were the rule in practically all of the battle wounded.”
32
The great frequency of infection with secondary hemorrhage virtually precluded arterial repair. In addition, there
were inadequate statistics about the frequency of gangrene
following ligation, and initial reports subsequently proved
to be unduly optimistic. In 1927, Poole, in the United States
Army Medical Department History of WWI, remarked that
if gangrene were a danger following arterial ligation, primary suture should be performed, and the patient should be
watched very carefully.
Despite the discouragement of managing acute arterial injuries in WWI, fairly frequent repairs of false aneurysms and arteriovenous stulas were carried out by many
surgeons. These cases were treated after the acute period
of injury, when collateral circulation had developed with
the passage of time and assured viability of extremities. In
1921, Matas recorded that the majority of these repairs
consisted of arteriorrhaphy by lateral or circular suture,
with excision of the sac or endoaneurysmorrhaphy.
33
In 1919, Makins, who served in WWI as a British surgeon, recommended ligating the concomitant vein when it
was necessary to ligate a major artery.34 He thought that this
reduced the frequency of gangrene by retaining within the
limb for a longer period the small amount of blood supplied
by the collateral circulation. This hypothesis was debated
for more than 20 years before it was nally abandoned.
Payr in 1900, Carrel, and the French surgeon Tufer
described temporary arterial anastomoses with silver and
glass tubes that were inserted with some success by Makins
and other WWI military surgeons, but patency was limited
to 4 days, merely allowing some collateral development.
20,34
World War II Experience
Experiences with vascular surgery in WWII were well
recorded in the classic review by DeBakey and Simeone in
1946, analyzing 2471 arterial injuries.3 Almost all were
treated by ligation, with a subsequent amputation rate near
49%. There were only 81 repairs attempted—78 by lateral
suture and 3 by end-to-end anastomosis—with an amputation rate of approximately 35%. The use of vein grafts was
18 SECTION 1 • Setting the Stage
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even more disappointing: they were attempted in 40 cases
with an amputation rate of nearly 58%. That review covered the time period ending in December 1944.
More recently, Barr, Cherry, and Rich35 reported on
research analyzing the original records of WWII military
medical units in the Mediterranean and European theaters, with emphasis on the treatment of vascular injuries subsequent to December 1944 and going through the
War’s end in May 1945. These authors found that there
was a change in practice from ligation to repair. Whereas
DeBakey and Simeone had reported a 3.3% repair rate,
surgeons in the last half year of the War repaired arteries at an increased rate. The Second Auxiliary Surgical
Group repaired 9% of injured vessels, a threefold increase.
Surgeons in the Third Auxiliary Surgical Group repaired
22% of the injured arteries they encountered, a sevenfold
increase. The amputation rate of the Second Auxiliary was
25%, contrasting with the 50% rate noted with ligation.
The 107 cases of repair reported by the Third Auxiliary
was a greater total than the entirety (81) of the DeBakey
and Simeone report through 1944.
A similar shift to repair was not seen in the Pacic theaters.36 Only ve reports of attempted repair came from the
War in the Pacic. The surgeons there were aware of the
need for something other than ligation, but the island battleelds, the vast oceanic distances, the jungle terrain and
climate, the lack of stable supply lines, the lack of established nearby evacuation hospitals, and the lack of rapid
methods of evacuation all contributed to the static nature
of surgery for injured vessels there. It simply was not possible in the Pacic.
The controversial question of ligation of the concomitant
vein remained, though few observers were convinced that
the procedure enhanced circulation. The varying opinions
were summarized by Linton in 1949.
37
A refreshing exception to the dismal WWII experience in
regard to ligation and gangrene was the case operated on by
Dr. Allen M. Boyden—an acute arteriovenous stula of the
femoral vessels repaired shortly after D-Day in Normandy.
The following comments are taken by Boyden from his own
original eld notes (approximately 26 years later in 1970)
and emphasize the value of adequate records, even in military combat:
of Blakemore (Vitallium) tubes, two bulldog forceps, and a
2-mL ampoule of heparin!
The conclusion that ligation was the treatment of choice
for an injured artery was summarized by DeBakey and
Simeone in 1946: “It is clear that no procedure other than
ligation is applicable to the majority of vascular injuries
which come under the military surgeons’ observation. It is
not a procedure of choice. It is a procedure of stern necessity, for the basic purpose of controlling hemorrhage, as
well as because of the location, type, size and character of
most battle injuries of the arteries.”
3
In retrospect, it should be remembered that the average time lag between wounding and surgical treatment
was over 10 hours in WWII, virtually precluding successful arterial repair in most patients. Of historical interest is
the nonsuture method of arterial repair used during WWII
(Fig. 1.5).
1
Saline
Vein
3
4
2
Proximal
Rubber shod
Artery
Kelly clamp
Distal end of
vein placed into
proximal end of artery
Distal
5
clamp
High explosive wound left groin, 14 June 1944, at 2200
hours. Acute arteriovenous aneurysm femoral artery.
Preoperative blood pressure 140-70; pulse 104.
Operation: 16 June 1944, nitrous oxide and oxygen.
Operation: 1910 to 22 hours.
One unit of blood transfused during the operation.
Arteriovenous aneurysms isolated near junction with pro-
funda femoris artery.
Considerable hemorrhage.
Openings in both artery and vein were sutured with ne silk.
Postoperative blood pressure 120-68; pulse 118. Circulation
of the extremity remained intact
until evacuation.
As this case demonstrated Boyden’s interest in vascular surgery, the Consulting Surgeon for the First Army
presented him with half of the latter’s supply of vascular
instruments and material. This supply consisted of two sets
6
Fig. 1.5 The various steps of a nonsuture method of bridging arterial
defects designed during World War II. (1) The Vitallium tube with its
two ridges (sometimes grooves). (2) The exposed femoral artery and
vein, with the vein retracted and clamps placed on a branch. (3) The
removed segment of vein is irrigated with saline solution. (4) The vein
has been pushed through the inside of the Vitallium tube, and the two
ends have been everted over the ends of the tube held in place with
one or two ligatures of fine silk. (5) The distal end of the segment of
the vein is placed into the proximal end of the artery and held there
by two ligatures of fine silk. (6) The snug ligature near the end of the
Vitallium tube is tied to provide apposition of the artery and the vein.
(7) The completed operation, showing the bridging of a 2-cm gap in
the femoral artery. (Modified description of the original drawings from
Blakemore AH, Lord JW Jr, Stefko PL. The severed primary artery in war
wounded. Surgery. 1942;12:488.)
7
1 • The Vascular Injury Legacy 19
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Experiences During the Korean
War
In pleasant contrast to the experiences of WWII, the successful repairs of arterial injuries in the Korean War were
due to several factors. There had been substantial progress
in the techniques of vascular surgery, accompanied by
improvements in anesthesia, blood transfusion, and antibiotics. Perhaps of greatest importance was the rapid evacuation of wounded men, often by helicopter, which often
allowed their transport from time of wounding to surgical
care within 1 to 2 hours. In addition, a thorough understanding of the importance of débridement, delayed primary closure, and antibiotics greatly decreased the hazards
of infection.
Initially in the Korean War, attempts at arterial repair
were disappointing. During one report of experiences at a
surgical hospital for 8 months between September 1951
and April 1952, only 11 of 40 attempted arterial repairs
were thought to be successful, as reported by Hughes in
1959.38 Only 6 of 29 end-to-end anastomoses were considered initially successful, and all six venous grafts failed.
In another report from a similar period of time, only 4 of
18 attempted repairs were considered successful. In 1952,
Warren emphasized that an aggressive approach was
needed, with the establishment of a research team headed
by a surgeon experienced in vascular grafting.39 Surgical
research teams were established in the army, and there
was improvement in results of vascular repairs by 1952.
Signicant reports were published by Jahnke and Seeley in
1953; Hughes in 1955 and 1958; and Inui, Shannon, and
Howard in 1955.
with the US Marines during 1952 and 1953 by Spencer
and Grewe and reported in 1955.43 These surgeons worked
in specialized research groups under fairly stabilized conditions, considering that they were in a combat zone. Brigadier General Sam Seeley, who was chief of the Department
of Surgery at Walter Reed Army Hospital in 1950, had the
foresight to establish Walter Reed Army Hospital as a vascular surgery center, and this made it possible for patients
with vascular injuries to be returned there for later study.
In a total experience with 304 arterial injuries, 269 were
repaired and 35 ligated, as reported by Hughes in 1958.4
The overall amputation rate was 13%, a marked contrast
to that of about 49% in WWII. Because amputation rate is
only one method of determining ultimate success or failure
in arterial repair, it is important to emphasize that Jahnke
revealed in 1958 that, in addition to the lowered rate of
limb loss, limbs functioned normally when arterial repair
was successful.
EXPERIENCE IN VIETNAM
In Vietnam, the time lag between injury and treatment was
reduced even further by the almost routine evacuation by
helicopter, combined with the widespread availability of
surgeons experienced in vascular surgery. In a 1968 study
by Rich, 95% of 750 patients with missile wounds sustained in Vietnam reached the hospital by helicopter.45 This
promptness of evacuation, however, created an adverse
44
4,40–42
Similar work in the navy was done
effect on the overall results, for patients with severe injuries
from high-velocity missiles survived to reach the hospital
but often expired during initial care. These patients would
never have reached the hospital alive in previous military
conicts.
Between October 1, 1965 and June 30, 1966, there
were 177 known vascular injuries in American casualties,
excluding those with traumatic amputation, as reported by
Heaton and colleagues.46 There were 116 operations performed on 106 patients with 108 injuries. These results
included the personal experience of one of us (NMR) at the
2nd Surgical Hospital. The results reported included a shortterm follow-up of approximately 7 to 10 days in Vietnam. In
Vietnam, amputations were required for only 9 of the 108
vascular injuries—a rate of about 8%. Subsequently, following detailed analysis of the Vietnam Vascular Registry by
Rich and colleagues in 1969, and then in 1970, the amputation rate was found to be approximately 13%—identical
to that of the Korean War.
5,6
Almost all amputations were
performed within the rst month after wounding.
The Vietnam Vascular Registry was established at Walter
Reed General Hospital in 1966 to document and analyze all
vascular injuries treated in Army Hospitals in Vietnam. A
preliminary report by Rich and Hughes in 1969 involved
the complete follow-up of 500 patients who sustained 718
vascular injuries (Table 1.2).5 Although vascular repairs
on Vietnamese and allied military personnel were not
included, the Registry effort was soon expanded to include
all American service personnel, rather than limiting the
effort to soldiers.
In 1967, Fisher collected 154 acute arterial injuries in
Vietnam covering the 1965–1966 periods.47 There were
108 arterial injuries with signicant information for the
initial review from Army hospitals. In 1967, Chandler and
Knapp reported results in managing acute vascular injuries in the US Navy Hospitals in Vietnam.48 These patients
were not included in the initial Vietnam Vascular Registry
report, but, after 1967, an attempt was made to include all
military personnel sustaining vascular trauma in Vietnam.
This included active-duty members of the US Armed Forces
treated at approximately 25 Army hospitals, 6 Navy hospitals, and 1 Air Force hospital.
As with any registry, success of the Vietnam Vascular
Registry has depended on the cooperation of hundreds of
individuals within the military and civilian communities. In
the initial report from the Registry, 20 surgeons who had
done more than ve vascular repairs were identied. As can
be seen by the list of more than 500 surgeons within the
front and back covers of the rst edition of this textbook,
many surgeons in every training program in the United
States contributed to the generally good results obtained in
Vietnam.
5
In addition to the surgeons already cited, hundreds of
individuals have been directly contacted through the Registry. The cooperative effort that has been obtained has not
only provided long-term follow-up information for the individual surgeon, but it has also given the names of additional
patients who have previously been missed, and additional
specic information has been added where needed regarding individual patients. A major success in the Registry
effort was obtained at the American College of Surgeons’
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Table 1.2 Management of Arterial Trauma in Vietnam Casualties Preliminary Report from the Vietnam Vascular Registry
Artery End-to-End Anastomosis Vein Graft Lateral Suture Prosthetic Graft Throm-Bectomy Ligation
Common carotid 2 6 (2) 3 (2) 1
Internal carotid 2 1
Subclavian 1
Axillary 6 (3) 12 (3) 2 (3) (1) (3) (1)
Brachial 57 (8) 32 (10) 2 (1) 1 (9) 1 (2)
Aorta 3 (1)
Renal 1
Iliac 1 1 1 (1) (1) (1)
Common femoral 4 (2) 11 (1) 4 (1) 1 (2) (2) (4)
Superficial femoral 63 (5) 37 (14) 7 (7) (4) 2 (6) (4)
Popliteal 31 (5) 28 (13) 6 (4) (10) 2 (4)
Total 165 (23) 127 (43) 29 (17) 2 (8) 3 (33) 6 (16)
a
Numbers in parenthesis represent additional procedures performed after the initial repair in Vietnam and repair of major arterial injuries not initially treated in
Vietnam.
Modified from Rich NM, Hughes CW. Vietnam vascular registry: a preliminary report. Surgery. 1969;65(1):218–226.
Clinical Congress in Chicago in 1970, where 110 surgeons
who had previously performed arterial repairs in Vietnam
signed in at the Vietnam Vascular Registry exhibit. The
Vietnam via Gulf War 1991 to
Afghanistan and Iraq
a
exhibit attempted to represent some of the activities and
presented some of the interim results of the combined effort
of all of the surgeons.
The fact that signicant problems continue to confront
the surgeon managing combat vascular injuries is emphasized by the report by Cohen and co-workers in 1969, which
evaluated a 6-month period of experience in Vietnam.49
The following list represents some of the major remaining
problems:
Since Vietnam, there have been many minor conicts
around the world. In the British Falklands campaign of
1982, despite excellent surgical outcomes for those who
reached eld hospitals, there was little vascular experience. The relative paucity of surgical cases during the multinational Gulf War of 1991 similarly did not inuence
advances in military vascular surgery.
The decade and a half of war that followed the events
of September 11, 2001, resulted in a signicant bur-
1. Arterial injuries associated with massive damage to soft
tissues
2. Major venous obstruction
3. Repeated vascular operations with a viable limb
4. Associated unstable fractures
5. Inadequate tissue débridement
6. Calf wounds with small vessel injury
den of injury including vascular trauma. Studies from
White, Stannard, and, more recently, Patel have shown
that the recorded rate of this injury pattern in modern
combat is 7% to 15%, which is considerably higher than
that reported in previous wars.
50–52
The reasons behind
the increased rate of vascular trauma are discussed in
Chapter 2, but sufce it to say the recent wartime expe-
rience forms the basis for much of the text that fol-
Through the Vietnam Vascular Registry, identication
cards have been sent to the majority of the patients whose
names and records are included in the long-term follow-
1,2,5
up.
The responses from the individual patients through
this media have been extremely encouraging, and the typical response that is frequently received is that the patients
appreciate the fact that “someone still cares.” Nearly 1500
patients have been evaluated by one of the authors (NMR)
in the Peripheral Vascular Surgery Clinic and Registry at
Walter Reed Army Medical Center over the past 50 years.
lows. Providing details on vascular trauma managed in
Afghanistan and Iraq is beyond the scope of this particular chapter; however, strategies such as topical hemostatic
agents, the reemergence of tourniquets, temporary vascular shunts, smarter transfusion and resuscitation strategies,
and even catheter-based endovascular techniques will be
highlighted throughout the text. Finally, the vexing injury
pattern from these wars—that is, vascular disruption with
noncompressible torso hemorrhage—will be redened with
a call for new management strategies.
Preliminary plans are presently being made to maintain
an extended long-term follow-up. This will be important
in determining the long-term results of the repairs and in
Civilian Experience
determining the incidence of such problems as the early
development of arteriosclerosis in the repair sites of these
young men. Personal contact has been made through the
Registry with approximately 300 other surgeons who have
performed vascular repairs in Vietnam, and the support of
these surgeons has been solicited in helping with this longterm follow-up project.
The frequency of arterial injuries in civilian life has
increased greatly in the past decade. This is due to more
automobile accidents, the appalling increase of gunshot
and stab wounds, and the increasing use of therapeutic and
diagnostic techniques involving the cannulation of major
arteries.
1 • The Vascular Injury Legacy 21
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As recently as 1950, most general surgeons had little
experience or condence in techniques of arterial repair.
The experiences in the Korean War, combined with the
widespread teaching of techniques of vascular surgery
in surgical residencies, resulted in a great increase in frequency of arterial repair between 1950 and 1960. This is
well-illustrated in the report by Ferguson and co-authors
in 1961 of experiences with 200 arterial injuries treated in
Atlanta over the 10-year period beginning in 1950.53 The
proportion of patients treated by arterial repair increased
from less than 10% in 1950 to more than 80% in 1959. In
the latter part of the study, ligation was done only for injuries of minor arteries, such as the radial or ulnar, or certain
visceral arteries. The mortality rate was reduced by onethird and the amputation rate by half when two consecutive 5-year periods were compared. The rate of success of
arterial repair improved from 36% to 90%.
In 1964, Patman and associates reported experiences
with 271 repairs of arterial injuries in Dallas.54 In the
past decade, a series of reports from large urban centers
throughout the United States have appeared, all documenting the effectiveness of current techniques of arterial repair.
Reference will be made to these reports in specic discussions in the following chapters. Two large series from the
early 1970s are those of Drapanas and colleagues in 1970
from New Orleans, which included 226 arterial injuries,
and the cumulative report by Perry and associates from Dallas in 1971, which included 508 arterial injuries.
55,56
In 1974, Smith and co-workers reported a survey of
268 patients in Detroit with 285 penetrating wounds of
the limbs and neck.57 There were 127 peripheral arterial
injuries identied. In 1975, Cheek and coauthors reviewed
200 operative cases of major vascular injuries in Memphis
that included 155 arterial injuries.58 Kelly and Eiseman, in
1975 from Denver, found 116 arterial injuries among 175
injuries to major named vessels in 143 patients.59 Hardy
and associates, in 1975, reviewed 360 arterial injuries in
353 patients in Jackson.60 Bole and colleagues, in 1976,
reported 126 arterial injuries in 122 patients in New York
City during 1968–1973.
61
During the Troubles in Belfast in the 1970s and 1980s,
Baros D’Sa combined the skills required of civilian and military vascular surgeons in managing vascular injuries and
developed an international reputation for the use of shunts
in terrorist-induced, complex vascular trauma.
62,63
Conclusion
Advances in the management of vascular trauma have
been driven by the requirements of warfare. This is no less
true now than it was in medieval times. In the last 50 years,
concomitant technological improvements in resuscitation,
anesthesia, and endovascular technologies within the civilian sector have contributed further. The difcult decisions
of when to repair, how to repair, damage-control vascular
surgery, and when to amputate will be covered in the following chapters of this textbook.
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22 SECTION 1 • Setting the Stage
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2
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Epidemiology of Vascular
Trauma
PETER GOGALNICEANU, TODD E. RASMUSSEN, and NIGEL R.M. TAI
Repair the vessel without compromising the lumen
DR. RICHARD LAMBERT (1759)
Lambert’s dictum describes “what” vascular surgeons do.
This has remained constant throughout the centuries.
However, “why” and “how” surgeons do this has changed
drastically from decade to decade. The vascular trauma subspecialty in particular has experienced changing practices
with regard to uid versus blood products resuscitation,
tourniquet use, point-of-care imaging and endovascular
innovations, such as REBOA and the covered stent.
The true purpose of epidemiological study should not
be limited to the listing of injury patterns by mechanism of injury (MOI), anatomical location or geography.
These provide interesting facts but are somewhat articial
academic exercises that have limited clinical applications.
The real purpose of epidemiology is to understand how
society changes and the mechanisms by which human suffering occurs. Epidemiology serves the surgeon by providing an understanding of how injury patterns arise from
the patient’s and the surgeon’s broad social and political
context. More importantly, it allows anticipation of how
different infrastructures can serve to mitigate or exacerbate this harm. Vascular trauma is both catastrophic and
complex. Studying its origins and patterns provides a more
subtle representation of health-care issues, which have a
far greater reach than the routines of the operating room.
Furthermore, the evolution of the vascular surgeon’s armamentarium, from the cauterizing iron to the endovascular
stent, has itself impacted on the landscape of vascular injuries as the range of iatrogenic injuries has grown.
Contemporary drivers of epidemiological change in vascular injury include:
1. Military conict.
2. Civilian trauma and urban unrest, including accidental
injury, terrorism, and gang-related civilian violence.
3. Trauma at the extremes of age.
4. Iatrogenic vascular injury as a result of minimally inva-
sive or endovascular procedures.
Principles of Vascular
Epidemiology
Epidemiology (from the Greek: the study of that which befalls
the people) is dened as the study of the distribution and
determinants of health-related states or events in human
populations, and the application of this study to the prevention and control of health problems.1 The global burden
and impact of trauma as an agent of death and disability is
increasingly well characterized (Table 2.1). However, while
the prevalence and incidence of individual vascular injury
patterns have been well depicted in local situations, the
epidemiological study of vascular trauma is a relatively
underexploited eld.2 Possible reasons for this include the
heterogeneity of the circumstances in which vascular
injury may be sustained, the protean direct and indirect
consequences of vascular trauma to bodily systems, and the
unsuitability of modern scoring methodologies to capture
the specic effects of vascular injury on patient outcome.
In the rst edition of Rich’s Vascular Trauma, Geza de Takats
summarized richness and complexity of traumatic mechanisms of injury as follows:
From time immemorial, hungry or suspicious cavemen,
frustrated and jealous lovers, violent criminals, and, more
recently… machinery and automobiles, have inicted serious
and often irreparable injury on the human body and soul.
Consequently, understanding the historic and contemporary epidemiology of vascular trauma is important.
Box 2.1 lists the generic components of epidemiological
endeavor. With respect to trauma, recognizing the prevalent populations underpins the alignment and targeting
of hospital resources, as well as education of health-care
providers. In essence, this informs the design of trauma
and vascular-care systems. More widely, the standardized and open-access description of the incidence, mechanisms, and demography of traumatic injury empowers
comparison of properly stratified outcomes from injury.
In turn, these aid not only research, but also clinical governance, quality-improvement initiatives, and fair reimbursement for treating hospitals. Subsequently, these
provide knowledge of socioeconomic realities and influence the design and assessment of preventative public
health interventions, thus informing health and social
policy.
If vascular and trauma clinicians are to anticipate
injury patterns, to track changes, and to put into place
effective programs to prevent or to mitigate the effects
of vascular trauma, then the study of injury epidemiology is an essential function of practice. The aim of this
chapter is to provide the context to more-detailed illustrations of specific anatomical injuries given elsewhere
in the text.
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Table 2.1 Summary: Deaths (000s) by Cause, in WHO Regions (a), Estimates for 2010 and 2016.
Cause World (2016) World (2010)
Population
(thousands) 7,461,884 6,140,789
000 % total 000 % total Change (000)
Injuries 297,394 11 290,806 10 6589
A. Unintentional
injuries
1. Road injury 82,538 3 69,837 2 12,701
2. Poisonings 6269 0 8341 0 −2073
3. Falls 38,162 1 30,431 1 7731
4. Fire, heat, and hot substances 10,610 0 12,876 0 −2266
5. Drowning 20,134 1 28,715 1 −8581
6. Exposure to mechanical forces 13,225 0 14,057 1 −832
7. Natural disasters 361 0 670 0 −309
8. Other unintentional injuries 43,860 2 44,567 2 −707
B. Intentional
injuries
1. Self-harm 37,564 1 39,194 1 −1630
2. Interpersonal violence 31,237 1 32,174 1 −938
3. Collective violence and legal
intervention
From the World Health Organization (WHO) Global Health Observatory Data Repository. Accessed May 2019. https://www.who.int/healthinfo/
global_burden_disease/estimates/en/.
215,158 8 209,494 7 5664
82,236 3 81,311 3 924
13,436 1 9943 0 3492
Box 2.1 Core Purposes of Epidemiological
Programs (1)
Identifying risk factors for disease, injury, and death
Describing the natural history of disease
Identifying individuals and populations at greatest risk for disease
Identifying where the public health problem is the greatest
Monitoring diseases and other health-related events over time
Evaluating the efficacy and effectiveness of prevention and
treatment programs
Providing information that is useful in health planning and
decision making for establishing health programs with
appropriate priorities
Assisting in carrying out public health programs
Context and Categorization of
Vascular Trauma
The epidemiological study of vascular injury is hampered by
the protean nature of trauma and the multiple and interrelated factors that determine functional outcome. Examples
include co-injury to critical soft tissue, as well as bony and
neurological structures. This difculty is made more acute
by the lack of uniformity among authors as to appropriate
injury descriptors, outcome metrics, and follow-up periods. Most studies in both the military and civilian domains
offer descriptions of cohorts comprising specic vascular
regions (extremities) or anatomical areas (e.g., calf vessels);
this provides detail at the expense of proper epidemiological perspective. Rates of vascular trauma are conicted by
use of different denitions of population-at-risk, invoking
different denominators, and inating or deating prevalence accordingly. Outcomes are dened differently and with
varying degrees of accuracy. For instance, mortality rates
may variously be built on denitions such as death while
an inpatient, ignoring those who expire before reaching
the hospital. Epidemiology is dependent on data; countries
with mature trauma systems and mandatory data-collection
infrastructures offer a more fruitful perspective on injury
rates and causes. Similarly, while wartime populations often
have higher vascular injury rates than peacetime cohorts,
the presence of detailed injury data (with accurate description of the denominator populations) is directly related to
whether a trauma systems approach to data collection is
deployed by the medical services of the combatant parties.
It is fair to say that countries without a “trauma systems”
approach to injury management are usually unable to
describe the effect of vascular trauma in populations-at-risk.
Because most developing countries fall into such categories,
it is correct to assume that the global burden of vascular
trauma is unknown.
Vascular trauma may be broadly categorized according to:
1. MOI: e.g., iatrogenic, blunt, penetrating, blast, combination injuries
2. Anatomical site of injury: e.g., compressible versus
noncompressible hemorrhage
3. Contextual circumstances: e.g., military versus civilian
Each of these domains may be further stratied, with
military injury being subdivided by patient status (combatant vs. noncombatant) and category of conict (civil war,
counter-insurgency warfare, maneuver warfare). Civilian
injuries may be similarly contextualized by local circumstances (e.g., urban trauma vs. rural trauma).
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