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2 • Epidemiology of Vascular Trauma 25
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1. MILITARY CONFLICT
Warfare since the 2000s has lost many of the characteristics that dened previous engagements, such as World
War I (WWI), World War II (WWII), Korea, and Vietnam.
Current conict is a “war among the people,” where “people
in the streets and houses and elds… are the battleeld. Military
engagements can take place anywhere, with civilians around,
against civilians, in defense of civilians. Civilians are the targets,
objectives to be won, as much as an opposing force.”3 As such,
vascular trauma inicted by high-energy military ballistic
projectiles and purpose-built or improvised blast weaponry
can affect two populations-at-risk: combatants and noncombatant (civilians).
Vascular Trauma in Combat Troops
It is important to remember that military combatants represent a specic demographic group. Compared with civilian
injuries, military arterial injury occurred predominantly
in males in their twenties (25 vs. 32 years and 98.7% vs.
82% males, respectively).4 Furthermore, the predominant
mechanisms of injury to US and UK soldiers (Afghanistan)
are either improvised explosive devices (48%) or gunshot
wounds (29%).5 Contemporary data conrms that exsanguination is the major cause of death in fatally wounded
soldiers.
6–9
It is also estimated that 80% of arterial injuries
sustained in combat affect the extremities.10 More than
70% of these are associated with blast injuries.
Vascular injury rates seem only to have increased as warfare has become more sophisticated: allied surgeons in WWI
noted vascular trauma rates of 0.4% to 1.3%11; DeBakey
characterized the vascular injury burden in WWII as affecting 0.96% of all patients; later, in the Korean and Vietnam
wars, the rate of vascular injury was judged to be higher,
at 2% to 3%.
12–16
Coalition militaries engaged in combat
operations in Afghanistan and Iraq have invested substantially in detailed trauma registries in order to capture injury
data. Such databases have been used to characterize miscellaneous injury patterns so that force protection (e.g., body
armor or vehicle design) and treatment protocols can be
continually updated and aligned to contemporary trauma
archetypes. Interestingly, present rates of wartime vascular
trauma conrm a much higher prevalence than in previous
campaigns,
some as high as 7.1%.
17–20
with arterial injury rates being reported by
10
A comparative study of the outcomes of major arterial
injuries in military and civilian populations was undertaken by Markov et al.4 One-quarter of all military arterial
injuries were not amenable to control by tourniquet application or compression (noncompressible arterial injuries
[NCAIs]). Military arterial injuries were shown to have a
lower incidence of NCAIs compared with the civilian populations (28% vs. 61%). These differences were attributed
to a higher rate of blunt trauma to the torso in the civilian
setting, as a result of motor vehicle collisions. Blast injuries
were the predominant mechanism of injury in military
settings (69%), while the civilian population was equally
affected by either blunt or penetrating trauma (50% and
50%, respectively). No difference in mortality was found
between matched military and civilian cohorts where compressible arterial injuries were involved (2% military vs.
4.1% civilian). However, their study suggested that NCAIs
carried a lower mortality in the military setting (4.2% vs.
12.16%). This was potentially attributed to the use of body
armor and implementation of combat casualty care strategy. This includes advanced military resuscitative strategies
and the necessary infrastructures that allow rapid evacuation and prehospital care.
A comprehensive study summarizing recent US military
experience (13,076 cases) analyzed vascular injuries from
the United States Joint Theater Trauma Registry (JTTR)
(2002–09).21 It dened battle-related injuries as those sufciently severe to prevent return to duty into the combat
theater. The specic incidence of vascular injury (“total
incidence injury”) was found to be 12%, while the incidence of injuries requiring surgery (“operative incidence”)
was found to be 9%. The study also identied differences
in vascular injury rates between troops deployed to Iraq
(12.5%) and Afghanistan (9%). Other differences included
causative mechanism, with blast accounting for 74% and
67% of injuries in Iraq and Afghanistan, respectively (with
an overall contribution of 73%). There was no difference
in the anatomical distribution of the injuries, nor the “died
of wounds” (DOW) rate (6.4%) between theaters. Wounds
were principally sustained to the extremities (79%), torso
(12%), and cervical regions (8%). In the torso, the most
commonly injured vessels were the iliac arteries (3.8%), followed by the aorta (2.9%), the subclavian arteries (2.3%),
and the inferior vena cava (IVC) (1.4%). In the neck, 109
carotid injuries accounted for 7% of injuries. It was noted
that the vascular injury burden borne by the extremities
was remarkably similar to that noted by DeBakey in WWII.
In contrast, the higher contemporary rate of cervical and
aortic injury was attributed to increased survivability and
far-shortened medivac times.
Overall, the authors concluded that the rate of vascular
injury in these wars was ve times that previously reported
from Vietnam and Korea. The early reported incidence of
vascular injury was estimated at around 4.4% to 4.8%,
based on data published from US military hospitals in
17,18
Iraq.
However, when this analysis includes nonoperated
cases and vascular injury that was unrecognized on reception, the prevalence can be as high as 7%.18 This marked
increase in vascular injury rates is striking and not entirely
clear. In addition to increased wound survivability, possible
reasons include:
1. the very high rate of blast-related injury etiology in these
campaigns,
2. overestimation of the population-at-risk in earlier
reports (thus deating the denominator), or
3. more accurate capture of “minor” nonoperated vascular
wounds (adding to the numerator).
In a similar but smaller British study, Stannard et al.
scrutinized the records of 1203 UK servicemen injured
through enemy action between 2003 and 2008.20 Unlike
the US JTTR, the British JTTR dataset also included patients
who were killed in action (KIA)—that is, who died before
reaching a medical treatment facility22 (an aspect of injury
burden not scrutinized in US accounts). Characterization of
injury was made from clinical data and from postmortem
examinations conducted by the UK Coroner system. It was
determined that 9.1% of this cohort sustained injuries to
26 SECTION 1 • Setting the Stage
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named vessels. Blast wounds accounted for 54% torsocervical injuries and 76% of extremity wounds, respectively.
Critically, the study showed that more than half of patients
who sustained an injury to a named vessel died before any
surgical intervention could be undertaken. Injury to named
vessels in the thorax and aorta proved almost universally
fatal. Cervical vascular injuries also proved highly lethal,
with 13 of 17 patients affected eventually succumbing.
Two-thirds of the vascular injuries sustained involved the
extremities. Almost half of these patients survived, albeit
with eventual amputations in a signicant proportion. The
limb salvage (primary assisted patency) rate was 84%. This
UK group concluded that while favorable limb-salvage rates
are achievable in casualties able to withstand revascularization, torso vascular injury is not usually amenable to successful surgical intervention.
The rate of lower limb amputation following vascular
injury to the extremities is important, being a major cause
of disability and avoidable mortality. Lower limb arterial
injuries are thought to be caused predominantly by blast
injuries (70%) or gun-shot wounds (30%). The commonest affected vessels in penetrating limb injuries include the
supercial femoral artery, the popliteal artery and the posterior tibial arteries, each being affected in around 20% of
cases.10 Perkins et al. studied 579 injured extremities in
US service members from the wars in Iraq and Afghanistan.23 Their primary amputation rates were 8.5%, with
salvage attempts occurring in 91% of patients. Tissue loss
and damage control were the principal reasons for primary
amputations. Secondary amputations occurred in 15.5%
of limbs. Early secondary amputations were associated by
nonviable or infected tissue, while late ones with poor limb
function. 57% of amputations were transtibial, while 30%
were transfemoral. It is also important to note that 82.7%
of those undertaking limb salvage were amputation free at
10 years. This highlights the signicant threat that military
vascular injuries pose to the lower limbs, but also the value
of attempting limb revascularization within adequately
prepared trauma infrastructures.
10,23
Vascular Trauma among Local National Populations
Few studies have examined the burden and impact of vascular trauma in civilians injured in time of war. The registries of military trauma systems may be biased toward data
collection among their own troops, or in such cases where
information is captured there is usually no data on longterm outcomes due to lack of follow-up in war-aficted
societies. In a study by Clouse et al. analyzing vascular
casualties treated at a Level IIIa US facility in Iraq, 30% were
civilians while and 24% were local national combat
forces.17 Extremity vascular injuries were signicantly more
prevalent in US forces compared with the local population (81% vs. 70%). Vascular injury to the torso was signicantly less common in US forces (4% vs. 13%), but neck
injuries occurred with similar prevalence (14% vs. 17%).
The authors hypothesized that the lack of protective body
armor might increase the nonextremity vessel injury rate
in the Iraqi population. Interestingly, vascular injuries were
noted to be overrepresented in the local nationals: although
40% of those admitted to the facility were of Iraqi origin,
they made up to 51% of the vascular injury cohort.
Deployed military hospitals are primarily congured and
resourced for the care of their own nation’s soldiers, so
understanding the additional burden presented with a large
local national population of injured civilians, insurgents,
and military remains important. In a supplementary report
from the Air Force Theater Hospital in Balad, Iraq,24 it was
determined that the incidence of vascular trauma among
4323 locals treated at the facility was 4.4%. The authors
focused on extremity injuries—which affected 70% of vascular casualties—and observed that the median length of
stay from presentation to denitive wound closure was 11
days. Casualties underwent a median of three operations.
Notably, the age range was 4 to 68 years and included 12
pediatric injuries. Mortality was 1.5% with signicant complications in 14% but despite this a 95% limb salvage rate
was recorded.
This experience matches earlier reports. Sfeir et al.25
described a population of 366 lower limb–wounded vascular cases, sustained by a mixed population of combatant
and noncombatants during the Lebanese civil war over a
16-year period ending in 1990. Two-thirds of patients had
received gunshot wounds. Patients included 118 who had
popliteal arterial injuries, 252 with femoral injuries and
16 who had tibial vessel injuries. The overall mortality rate
was 2.3% with no mortality in the popliteal and tibial injury
group whereas there were nine deaths in the femoral injuries group. The overall amputation rate was 6% (11.7% for
the popliteal injuries group). Mirroring more contemporary
experience, the authors associated failure of limb salvage
with physiological instability, delay in repair (of more than
6 hours from injury), and presence of long bone fracture.
2. CIVILIAN VASCULAR INJURY
The overall impact of vascular trauma in civilian society is
largely unknown in societies without recourse to large population datasets. Even in the United States, which is served
by the National Trauma Data Bank (NTDB),b large-scale
studies are few. Overall, regional variations in incidence and
MOI of vascular trauma occur based on socioeconomic and
political challenges faced by the populations studied. Vascular trauma in the civilian setting is also seen as a major
consumer of hospital resources,
longer hospital stay, greater use of critical care resources,
as well as higher blood transfusion requirements.28 Rapid
access to adequate trauma care facilities is universally
considered to be of major importance in achieving good
outcomes.
26,27
In 2010, Demetriades et al. attempted to characterize the
nature of vascular trauma in 22,089 patients—including
children—drawn from a general trauma population of
more than 1.8 million case les recorded on the NTDB
system.29 Accepting the almost inevitable reporting bias
that accompanies analysis of such retrospective data, it was
determined that the overall incidence of vascular injury
during the study period (2002–06) was 1.6%. Four-fths
of the injured were male, and the average age was 34 years.
26–28
being associated with
a
Level III facility is equivalent to a major trauma center (MTC).
b
NTB: a national trauma registry administered by the American College
of Surgeons and receiving data from more than 900 trauma facilities.
2 • Epidemiology of Vascular Trauma 27
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It was reported that 51% sustained a penetrating mechanism; the top four mechanisms of injury were motor vehicle collisions, rearm injuries, stab wounds, and falls from
height. Just under one-quarter were shocked on admission,
and over half had an Injury Severity Score of more than 15.
Abdominal injuries and chest injuries accounted for more
than 24.8% and 23.8% of the trauma burden, respectively,
with arm and leg injuries accounting for 26.5% and 18.5%.
Adult mortality was 23.2%; vessels associated with the
highest amputation rates were the axillary artery (upper
limb amputation rate of 6.3%) and popliteal artery (lower
limb amputation rate of 14.6%).29 This impressive dataset
summarized national epidemiological data; but what is of
concern to individual trauma and vascular surgeons is the
local epidemiology of vascular injury among their patients,
because this will determine workload, case mix, and
outcome.
Another American cohort of 5858 patients from NTDB
(2012) analyzed traumatic abdominal and pelvic vascular injuries. The overall mortality for this group was 25%.
Blunt trauma accounted for 57% of injuries, while 40%
were caused by penetrating trauma. Those with penetrating injuries were 1.72 more likely to die than those with
blunt trauma. Men had a higher incidence of penetrating
trauma compared with women (48% vs. 17%). This study
highlighted once again the poor outcomes of vascular truncal injuries, especially when associated with penetrating
trauma.
30
Data from a major UK trauma center suggested that
vascular injury occurred in 4.4% of consecutive trauma
admissions between 2005 and 2010.28 Vascular injuries in
this cohort had a 18% death rate, with the highest mortality
being seen in those with blunt injuries to junctional areas.
In this UK-specic cohort, stab wounds were the commonest cause of vascular injury, being ve times more common than gun-shot wounds. However, patients with blunt
injuries were more severely injured. Arterial injuries represented 87% of the vascular trauma, while 13% were venous
in nature. 47% of injuries were central in nature, with 35%
affecting the extremities and 20% junctional areas.
Civilian trauma has also been changed by the fact that terrorism is now no longer an isolated phenomenon associated
with the developing world. An estimated eightfold increase
in terrorist attacks was noted between 2000 and 2014.31
Recent attacks, including the Boston Marathon bombing,32 the Paris attacks,
attacks,
d,34
have provided an evolving picture of terror-
c,33
as well as the recent UK terrorist
related vascular injuries in civilian populations. Many of
these have been associated with a multitude (and often combined) mechanism of injuries, including improvised explosive devices (IED), stabbing, and motor vehicle-induced
injuries. Injury patterns in this population are different
from those seen in military circumstances, as civilians lack
ballistic-proof equipment and communities may not be prepared for these attacks. Different studies of civilian trauma
in Israel (2000–2005) showed that vascular trauma was
more common in terrorist-related compared with non–
terrorist-related scenarios (10% vs. 1%).26 Specically,
c
Paris terror attacks (2015): Charlie Hebdo and Bataclan.
d
UK terror attacks (2017): Manchester Arena bombing, London Bridge
attack, and Westminster Bridge attack.
vascular trauma occurred in 8.6% of explosion casualties
and was associated predominantly with penetrating injuries.27 Individuals with vascular trauma also had a higher
injury severity score and a mortality rate ve times greater
than those with nonvascular trauma (22.9% vs. 4.9%,
respectively). The lower-extremities and head/neck areas
were the most common anatomic regions to suffer vascular trauma (37% and 25%, respectively). Data from the
Boston Marathon bombing also showed that 66% of
patients admitted to hospital had suffered lower extremity
injuries, with 22% undergoing amputation.
These studies concluded that vascular trauma is associ-
ated with poorer outcomes in the civilian population
32
26,27
and that the higher incidence of vascular injuries in terrorrelated scenarios requires integration of a vascular surgeon
as part of the trauma team.
Urban Populations
Inner-city populations in countries such as the United
States and South Africa experience high rates of interpersonal violence, often mediated by low-energy handgun or
bladed weaponry. South Africa has an intentional homicide
rate of 32 per 100,000. In the United States this is 4.8 per
100,000, while in the UK it is considerably less, at 1.7 per
10,000.
35–37
However, there is signicant regional variation
in violence rates even within societies where violent injury
is common. For instance, in South Africa, Limpopo experienced 762 murders in 2009–10, while Gauteng experienced 3444 murders over the same time frame.35 Similarly,
the murder rate in non-suburban US cities is approximately
twice that of suburban areas.36 Of course, the relationship
between urban concentration and population homicide
rates is not universal. Australia has an overall murder rate
of 1.2 per 100,000, yet the homicide rate in the sparsely
populated Northern Territories is 3.96 per 100,000, compared with 0.8 in Victoria State.38 The degree to which
national and urban murder statistics translate to violent
vascular injury is difcult to quantify, but it is unsurprising to note that the majority of classical reports detailing
the burden, type, and outcomes from vascular trauma
come from urban institutions serving inner-city and poorer
populations. As described earlier, population-wide data
garnered from the National Trauma Data Bank suggests
the contemporary overall prevalence of vascular injury in
patients is 1.6%21 whereas that presenting for treatment in
urban areas has been quoted as 2.3% in a New York Level I
trauma center39 and 3.4% in a Level II center in El Paso,
Texas.40 These reports typify the perceived demographic as
almost always male and usually young. Mortality is approximately twice that of nonvascular patients39 and penetrating trauma is overrepresented in vascular patients, with the
El Paso authors recording a 40% penetrating injury mechanism in vascular patients against a rate of 10% in the general trauma population.
The largest US single center study of vascular trauma to
date was published in 1988 and emanated from Houston.41
It typies the experience of many large inner-city urban
trauma facilities and was undertaken with the aim of deriving epidemiological conclusions that would guide traumacenter and health logisticians. The study encompassed a
30-year period, describing 5760 cardiovascular injuries
in 4459 patients. The authors set themselves the task of
28 SECTION 1 • Setting the Stage
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accounting for the entire vascular injury cohort, rather
than restricting themselves to specic vessels, utilizing
multiple corroborative documentary sources rather than
a single registry. Their study conrmed that the burden
of vascular trauma in the city was being borne by young
men (86% male, average age 30 years), 90% of whom had
been injured by rearms (gunshot wound 51.5%; shotgun injury 6.8%) or knives (31.1%). The study once again
demonstrated that the wound pattern in civilian circumstances, even where ballistic penetrating injury is the norm,
does not follow that seen in wartime. Torso and neck injuries accounted for two-thirds of all injuries treated, while
lower extremity injuries (including the groin) comprised
only a fth. Whereas very few soldiers with injuries to the
large vessels of the abdomen are seen by military surgeons,
trauma to the abdominal vasculature accounted for 33.7%
of the total vascular injury cohort seen in Houston—a fact
attributed to the maturation of the city’s Emergency Medical Services. Trends in epidemiological factors—including
changes in the local population, changes in local crime
patterns (noting the increased burden of trauma that
accompanied criminal narcotic activity), and provision of
health-care infrastructure—were carefully described. The
authors noted a sixfold surge in vascular trauma, with 163
and 1069 injured patients in the rst and last respective 5
years of the study period, although as they did not detail the
denominator data (total number of trauma patients treated
for each time period), it was not possible to assess for trends
in the proportion of patients with vascular trauma. Furthermore, trauma scores, physiology, and crude outcome
measures such as mortality were not given, thereby limiting
characterization of case mix and reducing the utility of this
impressive dataset for the purposes of comparison. Despite
these drawbacks, this classic study serves as template for
other investigators seeking to describe vascular trauma epidemiology among their communities.
42
South Africa urban centers have reported a number of
large series of vascular injuries pertaining to individual vessels and bodily regions,43 though overall burdens of impact
are less clear. Data from Sydney and Perth in Australia have
reported vascular trauma rates of 1% to 1.8% with penetrating trauma mechanisms contributing up to 42% of
44,45
cases.
size the relative rarity of noniatrogenic vascular trauma in
the general and university hospital setting alike
Reports from individual centers in the UK empha-
46–48
; however, the rates of vascular trauma among certain inner-city
populations may approach those seen in North American
centers. In 2011, a 6-year study in the lead trauma center for London determined that 256 patients (4.4%) out
of 5823 trauma admissions sustained vascular injury.28
Penetrating trauma caused 135 vascular injuries (53%),
while the remainder resulted from blunt trauma patients,
who were more severely injured (median Injury Severity Score [ISS] 29) compared with those with penetrating
trauma (median ISS 11) and had greater mortality rates
(26% vs. 10%) and higher limb amputation rates (12% vs.
0%). These differences remained when comparing injuries
in each anatomical zone. Blunt vascular trauma patients
were twice as likely to require massive blood transfusions
(47% vs. 27%) and had a vefold longer hospital stays
(median 35 days vs. 7 days) when compared with patients
with penetrating vascular trauma. Recent development of
a national trauma registry and trauma systems approach
in the UK National Health Service will allow better plotting
of the impact of vascular trauma, especially with regard to
inner-city “hot spots.”
49
Rural Populations
Large vascular series are dominated by urban centers,
but non-urban and rural populations have discrete epidemiological injury profiles and patients who have bespoke
requirements, particularly regarding timely access to
vascular care. Endeavors by North American researchers studying trauma systems serving rural populations
have shed light on injury patterns in these more isolated
settings.
In 1982, Koivunen et al. reviewed 89 Missourians, onethird of whose injuries were farm related, and found that
the delay between injury and arrival at the center averaged 3.4 hours. Their study also found that 82% of the
injuries involved extremities, and 35% of the injuries were
ligated, with an overall amputation rate of 16.4% and a
mortality rate of 5.6%. The complication rate associated
with vascular repair was 12.4%. The authors noted that
the majority of complications and all deaths and amputations were in patients suffering trauma from farm, industrial, and motor-vehicle accidents.50 In the largest North
American series to date, Oller examined 1148 vascular injuries suffered by 978 patients reported from eight
trauma centers in a largely rural state. Over the course
of the study, vascular trauma accounted for 3.7% of all
trauma cases entered on the trauma registry. The amputation rate was 1.3% among those with extremity injuries,
which accounted for 47% of the total cohort. The authors
reached broadly similar conclusions to the Missouri group
with respect to rural vascular injury patients—four-fths
of whom were transferred in from peripheral facilities—in
that these patients were older, had a higher incidence of
blunt trauma, had longer inpatient admissions, and had
higher mortality rates (14.2%). They argued that, for optimum care, trauma services catering to rural patients with
vascular injuries must congure their systems to enable
prompt identication, resuscitation, and early transport
of vascular injury patients to major trauma centers for
denitive care.
51
Lifestyle and Socioeconomic Factors
Obesity. Obesity is an ever-growing problem in developed
societies and one associated with poor outcome in polytrauma
patients.
52–55
Simmons et al. studied 115 patients with lowerextremity vascular injuries over a 5-year period ending in
2005 and dichotomized the group by a body mass index
(BMI) of 31 or more.54 Interestingly, they found that obese
patients in general exhibited no difference in amputation
rate or mortality, although a BMI of greater than 40 was
not associated with a favorable outcome.
Ethnicity. A study by Moreira et al.56 identied racial
disparities in mortality outcomes after arterial trauma.
They suggested that minority populations sustaining vas cular arterial injuries have a higher rate of adjusted mortality
compared with Caucasian victims. A different study by
Hicks et al. also suggested that older Afro-Caribbean victims
(>65 years) of vascular trauma “were nearly ve times more
likely to experience death or amputation after vascular trauma
2 • Epidemiology of Vascular Trauma 29
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than their Caucasian counter-parts.”57 This may be related to
access to adequate trauma facilities, although Moreira’s
study suggested that the use of open and endovascular
techniques was similar across the different groups studies.
Poverty. In North America, poverty is increasingly recognized
as a determinant of outcomes from trauma.
58–60
It is unclear
to what extent these factors are intrinsic drivers of outcome
and to what extent they represent summary descriptors
of multiple competing and compounding subfactors. In
order to answer this, Crandall sought a more homogeneous
trauma grouping and thus examined the fate of patients
with lower-extremity vascular injury to investigate the
impact of race and insurance status.61 Using a large NTDB
population of 4928 patients, the authors found that those
who were of Latino, African American, Asian American, or
Native American origin had a signicantly higher odds ratio
of death (1.45), as did the uninsured cohort (1.62). The
African American and Latino cohorts made up 51.1% and
19%, respectively, of penetrating vascular patients, but
these groups only contributed 12.1% and 10.5% to the
blunt-injury cohort. When the outcomes were stratied by
mechanism of injury, no difference was found with respect
to mortality in bluntly injured patients, whatever their
insurance status or race. Penetrating trauma patients who
were uninsured had signicantly worse mortality, but race
only trended toward statistical signicance in the prediction
models studied.
3. TRAUMA AT THE EXTREMES OF AGE
Pediatric Trauma
Pediatric vascular trauma is a rare phenomenon, accounting for less than 2% of pediatric hospital admissions.62 Nevertheless, it has a large potential for long-term functional
consequences. Therapy in this patient group, whether
surgical or conservative, requires the surgeon to take into
account the developmental needs of the child. Interestingly, the majority of vascular arterial injuries in this group
appear to be treated by vascular rather than pediatric surgeons. This highlights potential clinical and training challenges as non–pediatric-trained vascular surgeons have to
adapt adult techniques to children in the absence of subspecialist training, national guidelines, or long-term outcomes
63,64
data.
Specic challenges are posed by children receiving care
in war zones, where sophisticated armed conict occurs in
the proximity of civilian populations. Over 4000 children
were treated in US Military Hospitals in Iraq and Afghanistan between 2002 and 2011,64 of which 3.5% had a vascular injury. The majority of these were boys (79%) who
had suffered penetrating trauma (95.6%), predominantly
to the limbs (38% upper and 28% lower limbs) or the
torso (25.4%). Blast injuries (58%) and gunshot wounds
(37%) were the predominant mechanism of injury. Fortunately, limb salvage rates were 95%. Nevertheless, the
consequences of these injuries need careful consideration,
as almost 1 in 10 children died. Of the children that died
the majority (71.4%) had sustained vascular injuries to the
chest, abdomen, or pelvis. These included trauma to the
major abdominal vessels or injuries to the hepatic and mesenteric arteries leading to nonsurvivable visceral ischemia.
This offers a unique perspective of the outcome differences
in pediatric vascular injuries in the context of armed conict, where the pediatric vascular injury rate is almost six
times higher than in the civilian setting (3.5% vs. 0.6%).
In the civilian population, vascular injury rates are similarly low in children
atric trauma.62 The predominant mechanism of vascular
injury in children is penetrating trauma.
65–70
accounting for 0.6%–1% of pedi-
69,70
In the United
29,64
States, this is associated with rearm trauma and motor
vehicle collisions (MVC) (36.9% and 34%, respectively).62
Upper limb trauma was most frequent anatomic site of vascular injury (35%). Mortality in this patient group was associated with shock at presentation and penetrating injuries.
In a 12-year-long study by Klinker et al.,70 1.1% of all
trauma admissions in patients younger than 18 years were
associated with vascular injury. The prevalence of vascular trauma with blunt injury was 0.4%, whereas that with
penetrating trauma was 4.5%. Notably, there were as many
wounds caused by glass injury as there were by gunshots.
The burden of extremity vascular trauma resulted in a 10%
overall amputation rate, most of whom had mangled extremities secondary to train or lawnmower accidents. Mortality
reached almost 10% (frequently associated with head injury),
but unlike pediatric vascular injury in armed conict, there
was a virtual absence of thoracic aortic injury in this cohort.
70
Barmparas et al. analyzed pediatric vascular injury
among 251,787 US National Trauma Data Bank patients
15 years of age or younger29 and compared them with
an adult vascular trauma patient cohort. The prevalence
of pediatric vascular injury was noted to be 0.6% against
an overall rate of 1.6%. Pediatric patients had lower ISS
scores with a high, but less frequent, incidence of penetrating injury (41.8% vs. 51.2%). There were clear differences
in injury patterns. In contrast to adults, pediatric patients
exhibited signicantly more blunt and penetrating upper
extremity vascular injuries but sustained less penetrating chest and abdominal vascular injuries. The upper arm
bore the brunt of pediatric vascular injury; brachial vessel trauma occurred in 13.2%, with forearm vessel injury
in 22%. The incidence of blunt thoracic aortic injury was
much lower in children, involving 8.9% of all blunt pediatric vascular trauma cases versus 26.1% in bluntly injured
adults, with a linear relationship between age and incidence of aortic injury. Mortality was signicantly lower in
the pediatric cohort when compared with adults (13.2%
vs. 23.2%)—a difference that persisted even after correcting for compounding differences such as ISS, low GCS, and
mechanism. There was no difference in the frequency of
lower-extremity amputation between adult and pediatric
patients (9.1% in children vs. 7.5% in adults). The authors
drew attention to the fact that, despite the survival advantage observed in pediatric patients, the rate of penetrating
injury was sobering and a fth of children who had been
shot died from their injuries.
In summary, the incidence of pediatric vascular injury
is thankfully low. Nevertheless, this represents a high-risk
area of surgical practice, where vascular surgeons may
encounter unfamiliar clinical circumstances.
Geriatric Trauma
There have been fewer studies of the epidemiology of vascular injury in geriatric patients. Patients over the age of 65
30 SECTION 1 • Setting the Stage
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represent a relatively small proportion (7.6%) of all individuals suffering traumatic vascular injury. The mechanism
of injury in this population is predominantly blunt trauma,
sustained in the majority of cases by MVCs and falls (59.2%
and 14.0%, respectively, compared with 23.6% and 3.6% in
individuals <65 years of age).71 Despite the relatively rare
occurrence of vascular injury, these individuals do pose
signicant clinical challenges due to the associated burden
of occlusive vascular disease, stiffer vasculature, less resilient physiology, and concurrent polypharmacy. Additionally, geriatric patients display higher ISS scores compared
with the nongeriatric adult population sustaining vascular
trauma. Cumulatively, these factors are reected in a mortality rate that is four times higher in the geriatric vascular
trauma patient compared with the adult one. Anatomically,
vascular injury in patients over 65 predominantly affected
the thoracic vasculature (40%) with 33% displaying damage to the thoracic aorta. Other differences in injury pattern
included higher rates of penetrating neck and arm injury
and more blunt chest and abdominal vascular injuries. The
authors described a linear increase in thoracic aortic injuries
with increasing age and a corresponding decrease in injuries to the forearm vessels and femoropopliteal axis. Interestingly, no signicant difference in amputation rates was
described between older (2.5%) and younger (3.0%) patient
cohorts in terms of overall, upper limb, or lower limb injury
patterns. The younger patient cohort was signicantly more
likely to undergo fasciotomy (9.6% vs. 2.8%), although the
authors were unable to account for this. Overall mortality
was signicantly higher in the older cohort when compared
with younger adults (43.5% vs. 21.6%). Being over 64
years was associated with an odds ratio of death of 3.9 after
adjusting for sex, ISS, low GCS, presence of shock, mechanism of injury, and body region of injury. Unsurprisingly,
older patients had longer intensive care unit stays, although
overall inpatient length of stay of 10.2 days did not differ
signicantly compared with the younger cohort.
4. IATROGENIC VASCULAR INJURY
Vascular surgeons are increasingly encountering vessel
trauma resulting from inadvertent iatrogenic misadventure during open surgery or endovascular intervention.
This may represent the chief cause of vascular trauma in
peaceful countries where percutaneous cardiac, neurological, and endovascular therapies are practiced. One European review of the burden of iatrogenic vascular trauma
estimated incidence of 35% to 42%.72 However, even in
developing countries, this may account for a signicant
proportion of the vascular injury workload.73 The advent
of coronary angiography and angioplasty has created a
new niche of traumatic vascular injuries, mainly related to
bleeding and pseudoaneurysm formation in the iliofemoral
segment. Traditional injury patterns resulting from high
femoral punctures led to noncompressible bleeding from
the external iliac artery in the pre-peritoneal and retroperitoneal spaces. Low-puncture sites are similarly associated
with arteriovenous stula formation.74 With the advent of
micropuncture access and a shift to radial approaches to
the coronary vessels, a new generation of iatrogenic iliac
injuries have arisen. These are associated with large bore
access for endovascular reconstructive procedures, such as
endovascular aneurysm repair (EVAR), thoracic endovascular aneurysm repair (TEVAR), and transcatheter aortic
valve replacement (TAVI). Newer iatrogenic injuries are
also associated with failed percutaneous closure devices
and heavy-duty cannulation for ECMO. Future challenges
confronting the trauma vascular surgeon may also result
from the rapid insertion of REBOA catheters.
Arterial complications associated with retrograde catheterization of the common femoral artery carry a major
complication rate under 1%.
74,75
Minor complication (e.g.,
puncture site hematoma) have been reported in up to
12.5% of patients,76 although the majority of studies report
these in less than 10% of cases.77 Variation in this complications rate depends on whether vascular catheterization is diagnostic in nature or followed by an intervention
using a large bore device (10-fold difference in complication
rate).78 Irrespective of incidence, femoral and external iliac
injuries carry nontrivial morbidities, leading to increased
hospital stay (2.7 vs. 4.5 days)79 and increased blood transfusion requirement (39%). Furthermore, one study suggested that retroperitoneal bleeding from femoral arterial
punctures is associated with a 6.6% rate of mortality.80 In
addition, major femoral bleeding in the context of percutaneous coronary intervention has been associated with an
increased 30-day mortality, as well as a decreased long-term
survival.
79
Overall, the incidence of femoral arterial puncture site
bleeding is thought to have reduced over time. A large
series reports a reduction from 8.4% to 3.5% over a 10-year
period.79 This may be associated with a large number of
factors, including color Doppler ultrasound–guided access,
transition to a radial approach in coronary catheterization,
and the replacement of post-procedural manual compression with vascular closure devices (VCD). Nevertheless,
as coronary intervention is increasingly performed through the radial approach, a degree of deskilling should be
expected when radial operators attempt unavoidable femoral access. This may lead to a future rise in the prevalence
of groin complication. In the context of transfemoral catheterization for coronary interventions, risk factors for complications include female gender, the presence of peripheral
arterial disease, and left-sided punctures.
75
Less common complications of femoral arterial access
include pseudoaneurysms (0.1%–0.2% for diagnostic procedures; 3.5%–5.5% for interventional procedures),81 AV
stula formation (<1%),82 and arterial dissections (0.2%).75
Vascular rupture is usually associated with angioplasty
and stenting in the context of balloon overination, device
oversizing, and intrinsic arterial pathology, such as arteritis or inltrating calcied plaque.74 Although rare (0.1%),
this can have catastrophic consequences, especially when
occurring in the aortoiliac segment.
In Sweden, where repairs for vascular trauma constitute
1.3% of all emergency and elective vascular workloads, a
review of national vascular registry data revealed that iatrogenic etiology accounted for 48% of all vascular injuries,
with penetrating trauma and blunt trauma accounting for
29% and 23%, respectively.83 The most commonly injured
vessel was the right femoral artery, in keeping with complications from endovascular interventions. As expected the
iatrogenic group was older, with a median age of 68 and had
a higher incidence of comorbid conditions such as cardiac
2 • Epidemiology of Vascular Trauma 31
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disease (58%) and renal dysfunction (18%) than patients
injured by noniatrogenic etiologies. Mortality was approximately double that of noniatrogenic patients (4.9% vs.
2.5%). The authors noted that iatrogenic vascular trauma
had increased over the 1993–2004 study period by 150%
and attributed this to the increased uptake of endovascular
procedures. Two small but recent studies from both provincial and tertiary referral vascular centers in England, where
71% to 73% of all vascular injuries were found to be iatrogenic in nature,
48,84
echoed these results. Both studies found
worse outcomes in the iatrogenic group compared with the
noniatrogenic cohorts, with patients undergoing noncardiac or peripheral vascular interventions faring the worst
following their iatrogenic injury.
Vascular trauma following ECMO is often associated with
the large 16 to 20 Fr cannulas used for accessing the common femoral artery. These increase the risk of thromboembolic events, especially in women and those with peripheral
arterial disease. The rate of ECMO-related lower limb ischemia is thus reported as being anything between 10% and
70%85, while local complications (dissections, pseudoaneurysms, or retroperitoneal bleeds) occur in 7% to 14% of
patients.86 While the risk-benet balance of this intervention is justiable, vascular surgeons should be aware of this
new cohort of patients requiring adaptation of their vascular trauma skills.
Vascular closure devices have provided advances in reducing time to hemostasis and facilitating early ambulation
after percutaneous arterial puncture.87 Although generally
considered to be safe, VCDs have nevertheless created additional opportunities for arterial damage if improperly used.
In a combined cohort of coronary and peripheral interventions, VCDs were shown to have a complication rate of 3.9%
(2.2% major and 1.7% minor complications) and a device
failure rate of 7.8%.88 These are not infrequent errors which
can lead to bleeding, as well as femoral artery occlusion.
Differences in vessel-closure technologies between various
devices, operator experience, re-do interventions and atheromatous vessels walls all play a role in arterial damage
following VCD use. It is important to note however that a
Cochrane review found no differences in vascular injuries
between VCD use and manual compression.87 Furthermore,
the complication prole of VCDs is superior to the traditional
alternative of manual compression alone.
78
Venous iatrogenic injury is most commonly encountered
in the placement of central venous catheters (CVC). It is estimated that 5 million CVCs are inserted annually.89 Considering that 2% of CVC suffer from misplacement (even with
ultrasound guidance) these result in a signicant number
of venous injuries.
90–92
Furthermore, CVCs are seen as training procedures, consequently being placed by practitioners
with a various degree of experience. While the majority of
CVC-associated venous injuries are related to puncture site
hematomas, insertion of lines in the internal jugular and
subclavian veins can be associated with inadvertent puncture of adjacent major arteries or mediastinal structures,
leading to potentially noncompressible arterial hemorrhage.
Inferior vena cava lters are a second major area of
venous injuries, with complications occurring during
insertion and retrieval, as well as during use (IVC penetration). Access site bleeding has been reported in 6% to 15%
of patients.93 Caval perforation is a second lter-associated
complication, made worse by concomitant anticoagulation
or damage to other organs in the pericaval space, such as
the duodenum.94 Prompt removal of IVC lters remains
therefore the wisest strategy for vascular surgeon wishing
to avoid caval trauma.
Venous angioplasty poses a nal category of venous
injury. This is often related to the treatment of central venous
or upper limb venous stenosis. Post-procedural bleeding due
to vein rupture is reported as occurring in 2% to 6% of cases,
with the highest morbidity associated with intrathoracic
venous rupture that cannot be externally compressed.
95,96
In summary, the broad advances in endovascular technology, often deployed by nonvascular or training physicians, can create a multitude of vascular injuries which
can result in noncompressible hematomas, formation of AV
stulae, and pseudoaneurysms, as well as vessel rupture.
While the incidence of these injuries is thankfully low, their
occurrence has a veritable traumatic etiology with all its
associated catastrophic outcomes. This makes endovascular iatrogenic injury a worthy target of the skills specic to
the vascular trauma surgeon.
Summary
Vascular injury remains a costly consequence of contemporary trauma burden—both in human and material metrics. Current trauma epidemiology conrms that this injury
type remains a global blight. The contribution of vascular
injury to mortality and morbidity is relatively well understood within discrete populations, such as the coalition
forces ghting in Afghanistan and Iraq (12%). Incidentally,
this represents a much higher rate than that encountered
in historical armed conicts, such as Korea and Vietnam.
However, granularity of data for the same injury types in
the civilian populations is much lower due to a lack of systematic data collection and analysis.
It is important to note that the incidence and prevalence
of vascular trauma is not well investigated worldwide.
Available data suggests that the prevalence of vascular
trauma is lower in civilian trauma cohorts, who exhibit different patterns of injuries from military populations. Iatrogenic trauma is an evolving niche for the vascular surgeon,
which remains in a dynamic state as a result of technological innovation and novel applications of endovascular techniques. Pediatric and geriatric vascular trauma pose further
population-specic challenges to the trauma-vascular surgeon. Vascular surgical care is particularly challenging in
children that have been the victims of armed conict. Consequently, if vascular injury is to be managed in a holistic
manner, robust trauma systems and systematic collection
of metadata is needed in order to obtain accurate epidemiological knowledge. More importantly, if this data is to
be analyzed in a context-adjusted manner, an understanding of social, political and economic circumstances is mandatory. These will ultimately inform resource utilization,
system design and trauma prevention strategies that will
impact favorably on patient outcomes.
References
1. Merrill RM. Introduction to Epidemiology. 5th ed. London: Jones and
Bartlett Publishers; 2010.
32 SECTION 1 • Setting the Stage
https://t.me/medicina_free
2. Caps MT. The epidemiology of vascular trauma. Semin Vasc Surg.
1998;11:227–231.
3. Smith General Sir Rupert. The utility of Force, London, 2005, Allen
Lane.
4. Markov NP, DuBose JJ, Scott D. Anatomic distribution and mortality
of arterial injury in the wars in Afghanistan and Iraq with comparison to a civilian benchmark. J Vasc Surg. 2012;56(3):728–736.
5. Tubb CC, Oh JS, Do NV, etal. Trauma care at a multinational United
Kingdom-Led Role 3 Combat Hospital: resuscitation outcomes from a
multidisciplinary approach. Mil Med. 2014;179(11):1258.
6. Holcomb JB, McMullin NR, Pearse L, et al. Causes of death in U.S.
Special Operations forces in the global war on terrorism 2001–2004.
Ann Surg. 2007;245:986–991.
7. Champion HR, Bellamy RF, Roberts CP, et al. A prole of combat
injury. J Trauma. 2003;54:S13–S19.
8. Kelly JF, Ritenour AE, McLaughlin DF, etal. Injury severity and causes
of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. J Trauma. 2008;64:S21–S26.
9. Bellamy RF. The cause of death in conventional land warfare: implica-
tions for combat casualty care research. Mil Med. 1984;149:55–62.
10. Sharrock AE, Tai N, Perkins Z, etal. Management and outcome of 597
wartime penetrating lower extremity arterial injuries from an international military cohort. J Vasc Surg. 2019;70(1):224–232.
11. Bowlby A, Wallace C. The development of British surgery at the front.
Brit Med J. 1917;1:705–721.
12. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War
II: an analysis of 2471 cases. Ann Surg. 1946;123:534–579.
13. Hughes CW. The primary repair of wounds of major arteries: an anal-
ysis of experience in Korea in 1953. Ann Surg. 1955;141:297–303.
14. Hughes CW. Arterial repair during the Korean War. Ann Surg.
1958;147:555–561.
15. Rich NM, Hughes CW. Vietnam vascular registry: a preliminary
report. Surgery. 1969;65:218–226.
16. Rich NM, Baugh JH, Hughes CW. Acute arterial injuries in Vietnam:
1,000 cases. J Trauma. 1970;10:359–369.
17. Clouse WD, Rasmussen TE, Peck MA, etal. In-theater management of
vascular injury: 2 years of the Balad vascular registry. J Am Coll Surg.
2007;204(4):625–632.
18. Sohn VY, Arthurs ZM, Herbert GS, et al. Demographics, treatment,
and early outcomes in penetrating vascular combat trauma. Arch
Surg. 2008;143:783–787.
19. Fox CJ, Gillespie DL, O’Donnell SD, etal. Contemporary management
of wartime vascular trauma. J Vasc Surg. 2005;41:638–644.
20. Stannard A, Brown K, Benson C, etal. Outcome after vascular trauma
in a deployed military trauma system. Br J Surg. 2011;98:228–234.
21. White JM, Stannard A, Burkhardt GE, etal. The epidemiology of
vascular injury in the Wars in Iraq and Afghanistan. Ann Surg.
2011;253:1184–1189.
22. AAP-6, NATO Glossary of terms and denitions 2010. North Atlantic
Treaty Organisation NATO Standardisation Agency, 2010.
23. Perkins ZB, Yet B, Glasgow S, etal. Long-term, patient-centered out-
comes of lower-extremity vascular trauma. J Trauma Acute Care Surg.
2018;85(1S Suppl 2):S104–S111.
24. Peck M, Clouse D, Cox M, etal. The complete management of extrem-
ity vascular injury in a local population: a wartime report from the
332nd Expeditionary Medical Group/Air Force Theater Hospital,
Balad Air Base. J Vasc Surg. 2007;45:1197–1205.
25. Sfeir RE, Khoury GS, Kenaan MK. Vascular trauma to the lower extrem-
ity: the Lebanese war experience. Cardiovasc Surg. 1995;3(6):653–657.
26. Heldenberg E, Givon A, Simon D, etal. Civilian casualties of terror-
related explosions: The impact of vascular trauma on treatment and
prognosis. J Trauma Acute Care Surg. 2016;81(3):435–440.
27. Heldenberg E, Givon A, Simon D, etal. Terror attacks increase the risk
of vascular injuries. Front Public Health. 2014;30(2):47.
28. Perkins ZB, De’Ath HD, Aylwin C, etal. Epidemiology and outcome of
vascular trauma at a British Major Trauma Centre. Eur J Vasc Endovasc
Surg. 2012;44(2):203–209.
29. Barmparas G, Inaba K, Talving P, et al. Pediatric vs adult vascu-
lar trauma: a National Trauma Databank review. J Pediatr Surg.
2010;45:1404–1412.
30. Talbot E, Evans S, Hellenthal N, et al. Abdominal and pelvic vas-
cular injury: a National Trauma Data Bank study. Am Surg.
2019;85(3):292–293.
31. Sharrock AE, Remick KN, Midwinter MJ. Combat vascular injury:
inuence of mechanism of injury on outcome. Injury. 2019;50(1):
125–130.
32. Gates JD, Arabian S, Biddinger P, et al. The initial response to the
Boston marathon bombing: lessons learned to prepare for the next
disaster. Ann Surg. 2014;260(6):960–966.
33. Lesaffre X, Tourtier JP, Violin Y, et al. Remote damage control during
the attacks on Paris: lessons learned by the Paris Fire Brigade and evolutions in the rescue system. 2017;82(6S suppl 1):S107–S113.
34. Gulland A. It wasn’t a medical miracle – we made our own luck: les-
sons from London and Manchester terror attacks. BMJ. 2017;19:358.
35. http://www.saps.gov.za/statistics/reports/crimestats/2011/categories/
murder.pdf. Accessed November 2011.
36. http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-
in-the-u.s.-2010/tables/10tbl01.xls. Accessed December 2011.
37. http://www.unodc.org/unodc/en/data-and-analysis/homicide.html.
Accessed November 2011.
38. Recorded crime victims. 4510.0. Australian Bureau of statistics
2009.
39. Loh S, Rockman C, Chung C, etal. Existing trauma and critical care
scoring systems underestimate mortality among vascular trauma
patients. J Vasc Surg. 2011;53:359–366.
40. Galindo RM, Workman CR. Vascular trauma at a military level II
trauma center. Curr Surg. 2000;57:615–618.
41. Mattox K, Feliciano DV, Burch J, etal. Five thousand seven hundred
sixty cardiovascular injuries in 4459 patients: epidemiologic evolution 1958 to 1987. Ann Surg. 1989;209:698–705.
42. Bongard F, Dubrow T, Klein S. Vascular injuries in the urban battle-
ground: experience at a metropolitan trauma center. Ann Vasc Surg.
1990;4:415–418.
43. Bowley D, Degiannis E, Goosen J, et al. Penetrating trauma in
Johannesburg, South Africa. Surg Clin N Am. 2002;82:221–235.
44. Gupta R, Rao S, Sieunarine K. An epidemiological view of vascular
trauma in Western Australia. Aust NZ J Surg. 2001;71:461–466.
45. Sugrue M, Caldwell E, D’Amours S, etal. Vascular injury in Australia.
Surg Clin N Am. 2002;82:211–219.
46. Golledge J, Scriven MW, Fligelstone LJ, etal. Vascular trauma in civil-
ian practice. Ann R Coll Surg Engl. 1995;77:417–420.
47. Magee TR, Collin J, Hands LJ, etal. A ten year audit of surgery for vas-
cular trauma in a British teaching hospital. Eur J Vasc Endovasc Surg.
1996;12:424–427.
48. De’Ath HD, Galland RB. Iatrogenic and non-iatrogenic vascular
trauma in a district general hospital: a 21-year review. World J Surg.
2010;34(10):2363–2367.
49. Stannard A, Brohi K, Tai N. Vascular injury in the United Kingdom.
Perspect Vasc Surg Endovasc Ther. 2011;23:27–33.
50. Koivunen D, Nichols WK, Silver D. Vascular trauma in a rural popula-
tion. Surgery. 1982;91:723–727.
51. Oller D, Rutledge R, Thomas C, et al. Vascular injuries in a rural
state: a review of 978 patients from a state trauma registry. J Trauma.
1992;32:740–746.
52. Byrnes MC, McDaniel MD, Moore MB, etal. The effect of obesity on
outcomes among injured patients. J Trauma. 2005;58:232–237.
53. Hoffmann A, Lefering R, Gruber-Rathmann M, et al. The impact of
BMI on polytrauma outcome. Injury. 2011. https://doi.org/10.1016/j.
injury.2011.05.029.
54. Simmons JD, Duchesne JC, Ahmed N, et al. The weight of obesity in
patients with lower extremity vascular injuries. Injury. 2010. https://
doi.org/10.1016/j.injury.2010.04.025.
55. Brown CV, Neville AL, Rhee P, etal. The impact of obesity on the out-
comes of 1153 critically injured blunt trauma patients. J Trauma.
2005;59:1041–1052.
56. Moreira CC, Farber A, Rybin D, etal. Racial differences in treatment
approaches and mortality following arterial trauma. Vasc Endovascu-
lar Surg. 2015;49(7):180–187.
57. Hicks CW, Canner JK, Zarkowsky DS. Racial disparities after vascular
trauma are age-dependent. J Vasc Surg. 2016;64(2):418–424.
58. Rosen H, Saleh F, Lipsitz S, etal. Downwardly mobile: the accidental
cost of being uninsured. Arch Surg. 2009;144:1006–1011.
59. Dozier KC, Miranda Jr MA, Kwan RO, et al. Insurance coverage is
associated with mortality after gunshot trauma. J Am Coll Surg.
2010;210:280–285.
60. Maybury RS, Bolorunduro OB, Villegas C, etal. Pedestrians struck by
motor vehicles further worsen race- and insurance-based disparities
in trauma outcomes: the case for inner-city pedestrian injury prevention programs. Surgery. 2010;148:202–208.
61. Crandall M, Sharp D, Brasel K, et al. Lower extremity vascular inju-
ries: increased mortality for minorities and the uninsured? Surgery.
2011;150:656–664.
2 • Epidemiology of Vascular Trauma 33
https://t.me/medicina_free
62. Eslami MH, Saadeddin ZM, Rybin DV, etal. Trends and outcomes of
pediatric vascular injuries in the United States: an analysis of the
National Trauma Data Bank. Ann Vasc Surg. 2019;56:52–61.
63. Bonasso PC, Gurien LA, Smith SD, et al. Pediatric vascular trauma
practice patterns and resource availability: a survey of American
College of Surgeon-designated pediatric trauma centers. J Trauma
Acute Care Surg. 2018;84(5):758–761.
64. Villamaria CY, Morrison JJ, Fitzpatrick CM, et al. Wartime vascular
injuries in the pediatric population of Iraq and Afghanistan: 2002-
2011. J Pediatr Surg. 2014;49(3):428–432.
65. Whitehouse WM, Coran AG, Stanley JC, et al. Pediatric vascular
trauma: manifestations, management, and sequelae of extremity
arterial injury in patients undergoing surgical treatment. Arch Surg.
1976;111:1269–1275.
66. Meagher Jr DP, Defore WW, Mattox KL. Vascular trauma in infants
and children. J Trauma. 1979;19:532–536.
67. Myers SI, Reed MK, Black CT, etal. Noniatrogenic pediatric vascular
trauma. J Vasc Surg. 1989;10:258–265.
68. De Virgilio C, Mercado PD. Noniatrogenic pediatric vascular trauma: a
ten-year experience at a level I trauma center. Am Surg. 1997;63:781–
784.
69. Linda M, Harris MD. Hordines John. major vascular injuries in the
pediatric population. Ann Vast Surg. 2003;17:266–269.
70. Klinkner DB, Arca MJ, Lewis BD, et al. Pediatric vascular inju-
ries: patterns of injury, morbidity, and mortality. J Pediatr Surg.
2007;42(1):178–182. discussion 182–3.
71. Konstantinidis A, Inaba K, Dubose J, et al. Vascular trauma in
geriatric patients: a national trauma databank review. J Trauma.
2011;71(4):909–916.
72. Fingerhut A, Leppaniemi AK, Androulakis G, etal. The European
experience with vascular injuries. Surg Clin North Am. 2002;82:
175–188.
73. Igun GO, Nwadiaro HC, Sule AZ, Ramyil VM, Dakum NK. Surgical
experience with management of vascular injuries. West Afr J Med.
2001;20:102–106.
74. Ge BH, Copelan A, Scola D, et al. Iatrogenic percutaneous vascular
injuries: clinical presentation, imaging, and management. Semin
Intervent Radiol. 2015;32(2):108–122.
75. Dencker D, Pedersen F, Engstrøm T, etal. Major femoral vascular access
complications after coronary diagnostic and interventional procedures: a Danish register study. Int J Cardiol. 2016;202:604–608.
76. Rae IM, Uddin MM, Ossei-Gerning N, et al. Patients undergo-
ing PCI from the femoral route by default radial operators are at
high risk of vascular access-site complications. EuroIntervention.
2014;9(10):1189–1194.
77. Dariushnia SR, Gill AE, Martin LG. Quality improvement guidelines
for diagnostic arteriography. J Vasc Interv Radiol. 2014;25(12):1873–
1881.
78. Arora N, Matheny ME, Sepke C, et al. A propensity analysis of
the risk of vascular complications after cardiac catheterization
procedures with the use of vascular closure devices. Am Heart J.
2007;153(4):606–611.
79. Doyle BJ, Ting HH, Bell MR, etal. Major femoral bleeding complica-
tions after percutaneous coronary intervention: incidence, predictors, and impact on long-term survival among 17,901 patients
treated at the Mayo Clinic from 1994 to 2005. JACC Cardiovasc Interv.
2008;1(2):202–209.
80. Bhatty S, Cooke R, Shetty R. Femoral vascular access-site complica-
tions in the cardiac catheterization laboratory: diagnosis and management. Interv. Cardiol. 2011;3(4):503–514.
81. Hirsch AT, Haskal ZJ, Hertzer NR. ACC/AHA 2005 Practice Guide-
lines for the management of patients with peripheral arterial disease
(lower extremity, renal, mesenteric, and abdominal aortic). Circula-
tion. 2006;113(11):e463–e654.
82. Kelm M, Perings SM, Jax T. Incidence and clinical outcome of iatro-
genic femoral arteriovenous stulas: implications for risk stratication and treatment. J Am Coll Cardiol. 2002;40(2):291–297.
83. Rudström H, Bergqvist D, Ogren M, etal. Iatrogenic vascular injuries
in Sweden. A nationwide study 1987–2005. Eur J Vasc Endovasc Surg.
2008;35:131–138.
84. Bains SK, Vlachou PA, Rayt HS, etal. An observational cohort study
of the management and outcomes of vascular trauma. Surgeon.
2009;7(6):332–335.
85. Pillai AK, Bhatti Z, Bosserman AJ, et al. Management of vascular
complications of extra-corporeal membrane oxygenation. Cardiovasc
Diagn Ther. 2018;8(3):372–377.
86. Roussel A, Al-Attar N, Alkhoder S, et al. Outcomes of percutane-
ous femoral cannulation for venoarterial extracorporeal membrane
oxygenation support. Eur Heart J Acute Cardiovasc Care. 2012;1(2):
111–114.
87. Robertson L, Andras A, Colgan F, etal. Vascular closure devices for
femoral arterial puncture site haemostasis. Cochrane Database Syst
Rev. 2016;7:3.
88. Klein-Wiele O, Baliota M, Kara K, etal. Safety and efcacy of clip-based
vs. suture mediated vascular closure for femoral access hemostasis:
a prospective randomized single center study comparing the StarClose and the ProGlide device. Catheter Cardiovasc Interv. 2018;91(3):
402–407.
89. Ryder M. Peripheral access options. Surg Oncol Clin N Am.
1995;4(3):395–427.
90. Takasugi JK, O’Connell TX. Prevention of complications in perma-
nent central venous catheters. Surg Gynecol Obstet. 1988;167(1):
6–11.
91. Hull JE, Hunter CS, Luiken GA. The Groshong catheter: initial expe-
rience and early results of imaging-guided placement. Radiology.
1992;185(3):803–807.
92. Morris SL, Jaques PF, Mauro MA. Radiology-assisted placement
of implantable subcutaneous infusion ports for long-term venous
access. Radiology. 1992;184(1):149–151.
93. Joels CS, Sing RF, Heniford BT. Complications of inferior vena cava l-
ters. Am Surg. 2003;69(8):654–659.
94. Grewal S, Chamarthy MR, Kalva SP. Complications of inferior vena
cava lters. Cardiovasc Diagn Ther. 2016;6(6):632–641.
95. Aruny JE, Lewis CA, Cardella JF, etal. Quality improvement guidelines
for percutaneous management of the thrombosed or dysfunctional
dialysis access. J Vasc Interv Radiol. 2003;14(9 Pt 2):S247–S253.
96. Korneld ZN, Kwak A, Soulen MC, Patel AA. Incidence and manage-
ment of percutaneous transluminal angioplasty-induced venous
rupture in the “stula rst” era. J Vasc Interv Radiol. 2009;20(6):
744–751.
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https://t.me/medicina_free
Systems of Care in
the Management of
Vascular Injury
DONALD H. JENKINS, DOUGLAS M. POKORNY, and PHILIP M. EDMUNDSON
Trauma Systems Overview
Managing severe injuries requires the timely intervention
of multidisciplinary teams, as well as the coordination of
prehospital care and resuscitation begun at the point of
injury. Fundamentally, trauma systems save lives by rapidly
delivering critically injured patients in optimal condition
to specialist surgical teams. The delivery of these patients
to specialized trauma centers has repeatedly demonstrated
signicant reductions in mortality compared with nonspecialist centers.
A regional trauma system is a public health model that
seeks to optimize outcomes among injured patients for a
dened population.2 A true trauma system treats trauma as a
disease entity. The system covers the whole patient pathway,
from prehospital care, transportation, and the acute management of injury through the reconstruction and rehabilitation phases. Included in this public health approach is a
responsibility for injury prevention in order to actively reduce
the burden of disease in the population. This approach also
includes a strong commitment to system-wide data collection and analysis, which is utilized for performance improvement across the entire spectrum of patient care.
A trauma system goes beyond simply designating one
hospital as a “Level I trauma center” conjoined with bypass
protocols that send all injured patients to this institution.
While this model may improve care for the severely injured,
it has the potential to worsen outcomes for less seriously
injured patients treated at the same center. Patients with
mild to moderate injuries—who constitute 85% of all
trauma patients—will suffer from de-prioritization within
an overloaded hospital. Systems that comprehensively
address the needs of patients within a given area (so-called
“inclusive trauma systems”) incorporate all acute hospitals in a region and have been shown to produce better
outcomes for a patient population.
sive system are designated according to their capabilities
and institutional commitments. In the United States, levels of capability are designated with a system from level I
to level IV. In the United Kingdom, centers are designated
as major trauma centers (MTCs), which manage severely
injured patients, and trauma units (TUs), which manage
mild and moderately injured patients. Other countries and
military entities have similar tiered levels of care.
Patients with vascular injuries are among the prime
beneciaries of the organized delivery of trauma care. The
prompt resuscitation and early delivery of patients with
active hemorrhage or ischemic limbs to a multidisciplinary
1
3,4
Hospitals in an inclu-
vascular-trauma service can save lives and limbs. Additionally, there tends to be considerable overlap in the personnel,
expertise, resources, and infrastructure required to deliver
complex trauma care and complex vascular care. These
synergies can improve outcomes for both trauma and nontrauma emergency vascular patients alike.
Key Components of a Trauma
System
The purpose of a regional trauma system is to reduce death
and disability following injury, while ensuring efcient use
of resources and personnel. Not all hospitals can be staffed
and equipped to manage all injuries. Major trauma patients
must be identied early in their clinical course and directed
to denitive care in a exible and error-tolerant system that
can deliver high quality clinical outputs. Key facets of a
trauma system therefore include the following:
1. A prehospital care system that is closely integrated into
the trauma system, with dened protocols to expedite
patient triage
2. A regional trauma coordinating system integrating
prehospital and hospital care to identify and deliver
patients to a place of denitive care quickly and safely
with proper notication to the hospital team
3. A network of hospitals with dened capability and
capacity, and with predetermined transfer agreements
for optimizing casualty ow
4. Specialized and designated regional trauma centers
that have responsibility for the management of injured
patients in the region
5. Acute rehabilitation services to improve outcomes and
restore casualties back to productive roles in society
6. A continuous process of system evaluation, governance, and performance improvement across the
trauma network
7. Ongoing training and education for all healthcare
professionals involved in the care of injured patients
8. An active injury prevention program to reduce the
burden of injury for the population that the trauma
system serves
9. A responsibility toward research into trauma and its
effects, to continuously improve care and outcomes
following injury
10. A system-wide plan for response to disaster and mass
casualty incidents
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