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Table 32.1 Modern Classification of Acute Limb Ischemia Related to Vascular Trauma
Level Category Sub-Category Basic Treatment Strategy Alternate Approach
I Compensated (viable) — Repair/Ligation/Conservative
II Uncompensated (threatened) Early
Critical [late]
III Irreversible Early
Late
Matched definitions from the Rutherford’s classification of acute limb ischemia are noted in brackets.
a
In case of blunt trauma
b
At specialized trauma centers or at role 3 medical treatment facilities.
NA, Not applicable; RRT, renal replacement therapy; TS, temporary shunt.
Modified from Vadim Kornilov (1971).
TS/repair
TS/repair + fasciotomy
TS + fasciotomy + RRT
Amputation
a
b
Stent/Stent-graft repair
NA
and, very recently, formal angiography u sing a mobile
c-arm are liberally used for vascular injury diagnosis. Nonetheless, computed tomography is not freely available at role
2E. Modied Kornilov’s classication of acute limb ischemia
(primarily found in 1967 and released in 19712) is now
used for limb evaluation and decision-making concerning
vascular treatment strategy according to new interventional capabilities (Table 32.1).
Specific Treatment Strategies
Injured major artery ligation decreased from 31% in SWA
to 16% in the CO-NC and is now considered an option only
for critically unstable patients. The use of TS increased from
17% in SWA to 25% in CO-NC and to about 40% in CO-S
for common or local damage control (Fig. 32.1). Among
64 shunted patients, 20% of shunts thrombosed within
12 hours, 30% within 12 to 24 hours, and 50% remained
patent for more than 24 hours.3 The average rate of shunt
thrombosis was about 40% (less for femoral and more for
popliteal arteries). In addition to improvised TSs (plastic
tubes), the Pruitt F3 carotid shunt is now widely used for
intraoperative limb perfusion. No patients were strategically
evacuated with an in-dwelling shunt. Type of arterial repair
was distributed equally between lateral suture, end-to-end
anastomosis, and autologous vein grafting.
Among vascular injury patients treated in the SWA, 88%
of patients survived, 33% returned to duty, and 43% of
patients recovered with either good or satisfactory results.
During the CO-NC, the rate of secondary amputations did
not exceed 4% to 5%. Infectious complications occurred in
12.4% of patients with vascular injuries. Total mortality
amounted to between 7.6% and 9.4% in the CO-NC. More
than half of all vascular patients (57.4%) returned to duty.
Signicant updates in CCC were achieved during the
CO-S. An advanced resuscitative team provided prehospital blood and plasma transfusion during tactical evacuation (crossmatching was performed en-route); the team
was also equipped with a resuscitative endovascular balloon occlusion of the aorta (REBOA) kit (no prehospital usage registered). Open vascular exposure and repair
were performed in most cases according to hemodynamic
status. Severe vascular injury, especially associated with
bone fractures, underwent TS followed by a formal repair
Fig. 32.1 A plastic improvised temporary shunt is inserted into the
common femoral artery for intraoperative limb perfusion 7 hours after
blunt occlusive arterial injury (blast mechanism). The patient was admitted with undetectable blood pressure, underwent REBOA, explorative
laparotomy, pelvic packing, external fixation of pelvic fractures, and
marginally threatened limb ischemia was then recognized. Immediate
temporary shunting, angiography, wide lower leg fasciotomy followed
by autologous vein grafting saved the limb with excellent function.
REBOA, Resuscitative endovascular balloon occlusion of the aorta.
using an autologous vein graft. During the CO-S, for the
rst time in Russian history, endovascular techniques were
used in a combat zone. The rst cases of successful REBOA4
and uoroscopy-free upper extremity endovascular revascularization5 at role 2 conrmed the effectiveness of endovascular techniques in austere environments (Fig. 32.2).
As a result, only exceptionally rare secondary amputations
and mortalities were registered at role 2 and again at role 5.
Strategies to Sustain and Train
the Next Generation of Trauma
Surgeons
Military vascular surgeons from the Kirov Military Medical Academy, and Central and Regional Military Hospitals
have been directly involved in the coordination of surgical
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Fig. 32.2 A vascular team (left) and an orthopedic team (right) have
simultaneous surgery on both severely injured hands (due to blast injury).
Multiple closed fractures of both hands, a partial amputation of the right
forearm, and absent right upper extremity pulses (axillary artery injury)
were diagnosed. Using a combination of gentle catheter-wire manipulation and serial radiographs (no c-arm available), the lesion was traversed
via the brachial artery and access to normal subclavian artery obtained.
A Fluency Stent Graft (6 × 100 mm) was then deployed, followed by a
completion angiogram, which demonstrated restoration of extremity
perfusion. This is the first case of successful upper extremity endovascular
revascularization in an austere environment.
care during the conicts, which has signicantly improved
vascular care outcome. The assignment of vascular surgeons to frontline medical facilities has led to a new generation of surgeons skilled in the care of combat vascular
injury. It turned out, however, that vascular cases were
the most challenging, and the deployment of a vascular surgeon was absolutely necessary. To educate young
military surgeons, a 3-day SMART-course (including
dry lab, live tissue, and cadaver training) was established
in the Kirov Military Medical Academy and extended with
endovascular (SMART.REBOA) and advanced vascular
(SMART.ANGIO) modules.
Conclusion
Russian military experience demonstrates a gradual reduction of vascular injury-related mortality from 12% during
the SWA to 7.6% in the CO-NC and further during the ongoing operations. While maintaining the practice of the best
post-WWII achievements, prehospital care improvements,
modern imaging modalities, damage control vascular techniques, and endovascular capabilities have allowed vascular care to the wounded to be optimized.
Surgical experience gained has allowed for improvements
in medical care for civilian practice. Routine CT angiography, REBOA, urgent angioembolization even for unstable
patients, and the rst steps in extracorporeal membrane
oxygenation use for trauma are now part of the civilian
trauma system. A newly constructed emergency hybrid
operation room in the Military Medical Academy and rst
experience with endovascular surgery in a combat zone
encourages us to remember the words of Nikolai Pirogov:
“For surgery, a new era would come if it were possible to
quickly and accurately stop blood circulation in a large
artery, without exposing or ligating it.” (1866).
References
1. Samokhvalov IM, Reva VA, Fomin NF, Rasmussen TE. Contributions
of the surgeon Nikolai Korotkov (1874–1920) to the management
of extremity vascular injury. J Trauma Acute Care Surg. 2016;80(2):
341–346.
2. Samokhvalov IM, Pronchenko AA, Reva VA. International perspec-
tives: Europe. Russia. In: Rasmussen TE, Tai NRM, eds. Rich's Vascular
Trauma. 3rd ed. Philadelphia: Elsevier; 2016:301–308.
3. Samokhvalov IM, Zavrazhnov AA, Kornilov EA. Results of usage of
temporary prosthetics in cases of combat injuries of extremities. Voen
Med Zh. 2006;327:29–33, [Russian].
4. Reva VA, Petrov AN, Samokhvalov IM. First Russian experience with
endovascular balloon occlusion of the aorta in a zone of combat operations. Angiol Sosud Khir. 2020;26(2):61–75.
5. Reva VA, Morrison JJ, Samokhvalov IM. Successful uoroscopy-free
extremity endovascular revascularization in an austere environment.
J Endovasc Resusc Trauma Management. 2019;3(3):133–138.
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Serbia
LAZAR B. DAVIDOVIC and MIROSLAV MARKOVIC
Introduction
For many centuries a simple ligation was the main treatment option in patients with vascular injury. The rst signicant series of vascular reconstructions applied for the
treatment of vascular injuries was published by Serbian
surgeon Vojislav Soubbotich at the beginning of the 20th
century.1 Namely, during the Balkan wars between 1912
and 1913, 60 false traumatic aneurysms and 17 traumatic arteriovenous stulas were treated by himself and
his coworkers. In about 40% of cases some kind of vascular
reconstruction was performed; they included 15 end-toend anastomoses, making an exciting surgical step forward
at that time. More than three decades later, in the series of
2471 arterial injuries from the Second World War, DeBakey
and Simeone reported only 81 repairs, including three endto-end anasthomosis.2 Commenting on this, Norman Rich
said: “It is ironic that nearly 40 years passed before similar
successful efforts were achieved during the latter part of the
Korean conict (1952–53).”
Less than 100 years after Soubbotich’s time, at the end
of the 20th century, the former Yugoslavia experienced civil
war, closely followed by the North Atlantic Treaty Organisation (NATO) bombing of Serbia. Due to these unpleasant
facts, a whole generation of vascular surgeons, including
the authors of this chapter, had the opportunity to treat
a signicant number of war-related vascular injuries. In
addition, a signicant number of civil vascular injuries
have been treated in our hospital over the past few decades.
What have we learned?
3
Lesson 1: War Versus Civil Vascular
Trauma
Common opinion is that the management of vascular injuries inicted during war is fundamentally different to those
acquired during peace. However, that is not necessarily the
case. Besides natural disasters (earthquakes, etc.), trafc,
industrial, and agricultural trauma, as well as the increasing frequency of terrorist attacks, and even sport injuries,
can all be accompanied by severe damage to blood vessels
(Fig. 33.1).
The insignicant differences regarding the early outcome between war and peacetime vascular injuries was
also presented in our study published in 2005.4 That study
compared 273 civil and 140 war-related vascular injuries.
According to univariate analysis, out of 54 included variables, only failed revascularization, associated nonvascular
injuries, secondary operation, explosive injury, war injury,
arterial contusion, popliteal artery injury, and delayed
treatment signicantly increased the amputation rate
after repair of the injured peripheral arteries. However,
multivariate logistic regression analysis of the previous
eight variables showed that only failed revascularization,
associated nonvascular injuries, and secondary operation
signicantly increased the amputation rate after arterial
vascular repair.
Lesson 2: Strategy During
Management of Vascular Trauma
Throughout history, the management of vascular trauma
has included three phases: life-saving, extremity- saving,
and saving of functional extremity.5 It can be assumed that
the order of these main objectives is still used in the modern
approach to vascular injury, which is why primary bleeding control, rapid transportation of the injured person, adequate diagnosis, and timely vascular repair are necessary.
Lesson 3: Primary Bleeding Control
The rst step in the successful management of vascular
trauma is to control primary bleeding, which is a life-saving procedure. However, if it is not performed adequately,
primary bleeding control can cause additional damage to
already injured arterial vessels. The method used in the initial
approach to primary hemostasis signicantly inuences the
extent of the subsequent vascular reconstruction. However,
in a crisis, rst aid is often driven by only one objective: stop
the bleeding at all costs. Unfortunately, vascular surgeons
often have to pay the price for these crisis-driven methods of
achieving hemostasis as can be seen in Fig. 33.2.
Lesson 4: Vascular Repair or
Primary Amputation?
The rst question that a vascular surgeon has to answer
before the treatment of vascular trauma even begins is
whether there is any point in doing vascular repair. According to current guidelines, the indications for primary amputation in the case of vascular trauma include: bone fracture
with loss of continuity of more than 6 cm in length; massive
soft tissue damage and loss; prolonged limb ischemia; severe
nerve destruction; major vein obstruction; and extensive calf wounds associated with small vessels injury.
Even though these indications are quite clear, the decision
regarding primary amputation following vascular trauma
is quite difcult, especially in young patients (Fig. 33.3).
5,6
Lesson 5: Diagnosis
A minor surface wound can often conceal serious vascular injury. How does one recognize and not miss a vascular
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A
lesion when the “hard signs” of vascular trauma (external
arterial bleeding, acute limb ischemia, absent distal pulses,
expanding hematoma, false aneurysm, and bruit/thrill over
the area of injury) are not present? We use a simple diagnostic algorithm for penetrating wounds of the extremi-
4,7,8
ties.
Firstly, digital subtraction angiography (DSA) or
multidetector computed tomography (MDCT) angiography
is indicated in all cases with “soft” signs of vascular trauma
(history of severe bleeding, diminished distal pulses, small
nonexpanding hematoma, injury to anatomically related
nerve, and anatomic proximity of wound to a major vessels).9 In addition, we also perform DSA or MDCT angiography in all hemodynamically stable patients with hard signs
of vascular injuries. These procedures are essential in conrming or excluding the presence of arterial trauma. Additionally, they show the location, extent, and complexity of
the injury. DSA or MDCT angiography ndings can suggest
the surgical approach as well as the type of vascular repair
needed. However, in our experience, lesser vascular lesions
can be omitted on initial MDCT angiogram. Whenever the
initial MDCT nding does not correlate with the clinical presentation, it should be checked with conventional angiography (i.e., DSA) during the observation period. Finally, in
our opinion, only hemodynamically unstable patients with
hard signs of vascular injuries require immediate surgical
exploration without additional diagnosis.
4,7,8
Lesson 6: Vascular Repair
In relation to arterial vascular repair, the following are
important: the selection of the repair procedure; the choice
of vascular graft; the treatment of associated venous injuries; the presence of associated or other complex injuries;
and nally, the approach to prolonged limb ischemia.
The simplest methods of injured vessel repair are lateral
suture or end-to-end anastomosis. However, they can be only
performed in cases where the defect between the edges of the
injured vessel is not too long (less than 2 cm). Otherwise, a
graft interposition or bypass procedure is indicated. Autologous saphenous vein is the material of choice for the repair
of injured peripheral vessels. Prosthetic grafts are a necessity
when the reconstruction of great vessels is indicated.
Lesson 7: Venous Injury
The repair of an injured vein improves the patency of an
already repaired artery, and minimizes swelling of the
extremity and development of compartment syndrome, as
well as long-term chronic venous insufciency. For these
reasons, the repair of injured iliac, femoral, popliteal, and
subclavian veins in all hemodynamically stable patients is
recommended.
be repaired with panel or spiral venous grafts, which require
B
additional preparation time (Fig. 33.4).
4,7
However, large and mid-sized veins should
Fig. 33.1 (A) This serious leg injury was caused by a so-called “slide
tackle” during a football match. (B) Besides a tibia fracture, the patient
had a false traumatic aneurysm of the popliteal artery. We managed to
save this patient’s leg but he was not able to play football again.
Lesson 8: Complex Injuries
Complex injuries should be treated by an experienced interdisciplinary team consisting of a vascular surgeon and other
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A
B
Fig. 33.2 (A) Too distant proximal ligation of the injured femoral artery for the purpose of primary bleeding control has contributed to the extent of the
lesion by secondary thrombosis. (B and C) Additional damage to the injured anterior tibial artery in this case was caused by numerous, mostly unnecessary, clamps.
specialists.4 A signicant number of patients with injured
peripheral vessels have also associated bone fractures. In
such cases, vascular reconstruction might be compromised
by traction and secondary movement of bone fragments.
Therefore, after proximal and distal bleeding has been controlled and a shunt inserted, bone fracture xation should
precede vascular repair (Fig. 33.5).
At the start of the civil war in the former Yugoslavia,
we used to perform vascular repairs with standard anatomic vascular reconstructions. During follow-up, however,
4,10
C
we realized that in cases with contaminated or infected
wounds, as well as in cases with massive skin destruction and soft tissue loss, anatomic reconstruction was signicantly associated with secondary hemorrhage, usually
resulting in major amputations.
4,10,11
Acknowledging this,
we decided that the anatomic reconstruction of injured
arteries should be avoided in the presence of contaminated
wounds and massive soft tissue damage and loss. In such
cases, extraanatomic procedures provided signicantly better early outcome and limb-saving.
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Lesson 9: Late Revascularization
Late (or delayed) attempts at revascularization after peripheral vascular trauma can result in many serious disorders:
compartment syndrome; muscle contracture and necrosis;
disabling efferent neuralgia; poor functionality; and, eventually, major amputation. Patients with untreated traumatic
A
A
B
Fig. 33.3 (A and B) Angiography shows patent bypass from the
median to distal (retromaleolar) part of the posterior tibial artery. This
was associated with a very complex tibial and fibular fracture with a
long bone defect associated with massive soft tissue loss. Therefore,
functional recovery of the extremity was unlikely. A secondary amputation was performed a few months later, but the authors believe that
a primary amputation would have been the better option in this case.
B
Fig. 33.4 (A and B) Creation of panel saphenous vein graft for repair of
mid- or large-sized injured vein.
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C
A
B
D
E
Fig. 33.5 Humeral fracture with complete dislocation (A) caused the injury of the axillar artery (B). Step 1: Bleeding control and temporary shunt insertion (C). Step 2: Bone fracture stabilization by external fixation (D). Massive skin and muscular destruction are notable. Step 3: Injured axillar artery is
replaced with saphenous vein graft (E). Control digital subtraction angiography. The arrow points at patent saphenous vein graft (F). Step 4: Reconstruction of soft tissue defect using vascularized muscular flap (G).
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F
Fig. 33.5 (Continued)
Fig. 33.6 Traumatic fistula between femoral artery and vein initially
not recognized and untreated. Consequently, secondary venous varices and swelling of the extremity developed.
G
arteriovenous stulas can develop congestive heart fail-
8,12
ure
(Fig. 33.6).
The most threatening sequelae of late revascularization can be prevented by the use of a temporary vascular
shunt. Use should be considered in cases of prolonged limb
ischemia, in polytraumatized patients, and in patients with
associated orthopedic injuries. If compartment syndrome
occurs, immediate fasciotomy, releasing all four calf compartments, is neccessary.13 Fasciotomy is rarely indicated in
the upper extremity.
Lesson 10: Early Complications
After Vascular Repair
We have found stenosis, thrombosis, and infection to be
the most frequent and severe early complications following vascular repair.
common in cases of small arterial repair (crural arteries,
etc.) and also when reconstruction is performed by an inexperienced vascular surgeon. The oblique shape of an ideal
end-to-end anastomosis prevents stenosis and provides better early and long-term patency. This technique was originally described by Alexis Carrel more than a century ago.
Residual distal thrombosis can compromise an adequately performed proximal reconstruction of the injured
artery. For this reason, exploration of distal arteries using a
Fogarty catheter, before the repair, is mandatory.
In the case of arterial contusion, an abundant resection
of the damaged artery is necessary prior to reconstruction
(Fig. 33.7). Inadequate arterial débridement is a common
cause of arterial thrombosis during the early postoperative
4,10
period.
Inadequate débridement of damaged/necrotic tissue and
vascular repair in the presence of contamination, as in
cases with massive soft tissue damage and loss and primary
skin closure, increases the incidence of early infection and
secondary hemorrhage after vascular trauma treatment.
4,10,11
Anastomotic stenosis is especially
4,10
4,8
14
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A
C
Fig. 33.7 (A) Blunt trauma of the shoulder followed by contusion of the axillar artery. (B) Digital subtraction angiography findings. (C) Intraoperative
findings. (D) Opening of the contused arterial segment showed intimal dissection.
In such circumstances, a new, extraanatomic reconstruction should be considered; if it is unfeasible, amputation is
the only remaining and life-saving option.
Lesson 11: Endovascular Repair of
Injured Vessels
Endovascular repair is currently the method of choice in
the treatment of blunt thoracic aorta injuries.15 The open
repair of the injured intrathoracic segment of the supraaortic brunches requires sternotomy or thoracotomy, partial
clamping of the aortic arch, and even extracorporeal circulation.16 All these procedures are avoided if endovascular
repair is used.17 However, it requires relatively hemodynamically stable patients.
Endovascular procedures are the methods of choice
for the treatment of injured internal carotid and vertebral arteries in zone III of the neck, and for the proximal
B
D
segment of the subclavian artery18 (Fig. 33.8). Embolization is the ideal procedure in the case of bleeding from
surgically unapproachable midsized and small arteries
(Fig. 33.9). Endovascular repair can also be employed for
the treatment of early and long-term stenosis after open
repair of an injured artery (Fig. 33.10).
Contraindications to the endovascular repair of penetrating arterial injuries include hemodynamic instability,
extensive vascular injuries, and injuries without sufcient
proximal or distal vascular xation points, as well as arterial
transection. In our opinion, this list could be even longer.
Lesson 12: Pediatric Vascular
Trauma
The main characteristics of pediatric vascular trauma are
arterial vasospasm, a less well-developed collateral circulation, and a smaller total volume of blood with limited
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Fig. 33.8 Endovascular repair (stenting) of a false traumatic aneurysm of the subclavian artery.
A
Fig. 33.9 Combined endovascular treatment of an iatrogenic pseudoaneurysm and fistula between the deep femoral artery and vein.
(A) Pseudoaneurysm and arteriovenous fistula. (B) Embolization of the
pseudoaneurysm. (C) Stenting of the deep femoral artery.
B
C
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