Upper Extremity Vascular Injury: A Current In-Theater Wartime Report from Operation Iraqi Freedom

Article Outline

• Abstract
• INTRODUCTION
• MATERIALS AND METHODS
• RESULTS
  • Incidence and Distribution of UE Vascular Injury
  • Therapeutic Interventions and Early Complications
• DISCUSSION
• REFERENCES
• Copyright

Past wartime experience and recent civilian reports indicate upper extremity (UE) vascular injury occurs less often and with less limb loss than lower extremity (LE) injury. Given advances in critical care, damage control techniques, and military armor technology, the objective of this evaluation was to define contemporary patterns of UE injury and effectiveness of vascular surgical management in UE vascular injury during Operation Iraqi Freedom (OIF). From 1 September 2004 through 31 August 2005, 2,473 combat-related injuries were treated at the central echelon III surgical facility in Iraq. Patients with UE vascular injuries upon arrival were reviewed. Vessels injured were delineated. Therapeutic interventions, early limb viability, and complication rates following vascular repair were recorded. Of casualties treated during the study period, 43 (1.7%) UE and 83 (3.3%) LE vascular injuries were identified. Of the UE injuries, 11 (26%) had been operated on at forward locations and six (14%) had temporary shunts in place upon arrival at our facility. Injury levels included 10 (23%) subclavian-axillary, 25 (58%) brachial, and 10 (23%) distal to the brachial bifurcation. Two patients had multilevel injury. Twenty-eight grafts were placed, and 10 vessel repairs and eight ligations were performed. Two (4.7%) brachial interposition grafts required removal due to infection. Four (9.3%) subacute brachial graft thromboses occurred. Four (9.3%) patients underwent early UE amputation. In this most recent U.S. military evaluation of wartime UE vascular injury, UE injury appears rare, with LE injury twice as frequent. Yet, UE limb loss appears more substantial than noted previously. These findings are likely related to significant tissue destruction occurring with the combined mechanisms of injury sustained in OIF.

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INTRODUCTION 

The evolution of extremity vascular injury treatment is intimately related to experience obtained during military conflict. From routine ligation and amputation in the World Wars through the rapid evacuation and successful in-theater use of autogenous reconstruction during Korea and Vietnam, these struggles have provided models for improvement in revascularization and limb salvage.¹, ², ³, ⁴, ⁵ The recent operations in support of Operation Iraqi Freedom (OIF) embody the first expanded U.S. military conflict since Vietnam within which assessment of contemporary vascular practices may occur. Modern advances in critical care, damage control techniques, and military armor technology as well as the constant streamlining of in-theater combat care asset structure query the efficacy of these current efforts.

Moreover, despite inherent differences between military and civilian care environments, past wartime experiences in conjunction with ever-increasing numbers of civilian reports indicate extremity injuries continue to constitute the majority of vascular injuries. Upper extremity (UE) vascular injury has traditionally been portrayed as occurring less often and with less limb loss than lower extremity (LE) injury.⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶ Placed within the wartime perspective, arm loss rates due to vascular injury during the World Wars and Korea were relatively stable at 20–30%.¹, ², ³ This was significantly reduced late in Korea and in Vietnam as arm loss dropped to nearly 5% with routine repair.³, ⁴ Therefore, the objective of this evaluation was to define present-day patterns of UE wartime vascular injury and the acute effectiveness of contemporary vascular surgical management in UE injury during OIF.

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MATERIALS AND METHODS 

During 12 consecutive months, from 1 September 2004 through 31 August 2005, 2,473 battle-related injuries were evaluated at the central level III [332nd Expeditionary Medical Group (EMDG)/Air Force Theater Hospital] facility at Balad Air Base, Iraq (Fig. 1). The 332nd EMDG is the first Air Force theater hospital since the Vietnam War. All theater U.S. medical evacuation occurred via Balad Air Base and the 332nd EMDG. Thus, all injured force movement flowed either directly into the 332nd EMDG or via forward positions to the 332nd. Specifically, within theater, there is a graduated capability and response to vascular injury as a casualty proceeds toward departure from theater.¹⁷ Level I care is delivered at scene and consists of combat medic care and triage with no dedicated surgical capability. Level II sites are staffed by forward/field surgical teams (FSTs) consisting of limited personnel and resources capable of performing immediately life-saving maneuvers and stabilization with a main goal of evacuation. The level II fixed sites consist of 25 or less staff with general and orthopedic surgeons. Level III care consists of the highest available care within theater. Modular expansion has created full-spectrum trauma care at the 332nd EMDG, including complete peripheral vascular provision. There are three operating rooms with two-bed capability (Fig. 2). Recently, mobile endovascular resources (OEC 9800, GE Healthcare, Wauwatosa, WI, USA) and floating fluoroscopy table with inventory have become available.

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• Fig. 1. 

  A Balad Air Base, Iraq (yellow cross), is 40 miles north of Baghdad on the eastern edge of the volatile Sunni Triangle and is home to the 332nd EMDG Air Force Theater Hospital. Currently, other level III theater facilities are present in Baghdad and Mosul (red crosses). B The 332nd EMDG U.S. Air Force Theater Hospital.

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• Fig. 2. 

  Three operating rooms are present at the 332nd EMDG Air Force Theater Hospital, each with two-bed capability.

Extremity vascular injuries where limb salvage was attempted were entered prospectively into a registry (the Balad Vascular Registry) and retrospectively reviewed. Vascular injuries associated with traumatic amputation or severely mangled extremities amputated in the field or immediately upon arrival at our facility were not included in this report. Specifically, this in-theater communication describes the therapeutic interventions, early limb viability, and noted complications following UE vascular injury. UE vascular injury was defined as injury to the subclavian vessels and distal in the shoulder girdle, arm, and forearm.

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RESULTS 

Incidence and Distribution of UE Vascular Injury 

During the year-long study period 2,473 battle-related injuries were evaluated at the 332nd EMDG. There were 163 major vascular injures identified, for a rate of 6.6%. The anatomic distribution of major vascular injury is illustrated in Figure 3A, with 126 of the injuries occurring in extremities where limb salvage was attempted. Of these, 43 (34% of extremity vascular injuries, 1.7% of all battle-related injuries) were in the upper extremity (Fig. 3B). Over half (n = 26, 60%) of UE injuries had been assessed at level II facilities in-theater prior to arrival at the Air Force Theater Hospital. All transport from forward was via rotary wing aircraft. Time from wounding, specifically vascular injury, was not obtained. However, recent theater data indicate casualties are arriving at level II to level III care within 2 hr of injury.¹⁸, ¹⁹

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• Fig. 3. 

  A Distribution of vascular injuries treated in-theater at the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq, from 1 September 2004 through 31 August 2005. B Distribution of UE and LE vascular injuries treated in-theater at the 332nd. C Breakdown by anatomic location of UE vascular injuries treated in-theater at the 332nd.

Improvised explosive devices accounted for the mechanism of injury in 28 (65%) UE vascular injuries with 12 gunshot wounds. Other mechanisms included humeral fracture secondary to fall, one motor vehicle crash, and one penetrating injury to the forearm. Of UE injuries, 11 (26%) had been operated on at forward locations and six (14%) had temporary axillobrachial artery shunts in place upon arrival at our facility (Fig. 4). Five of the six (83%) were patent at our examination.

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• Fig. 4. 

  Representative axillobrachial temporizing shunt in place prior to definitive in-theater repair with greater saphenous vein.

The determination of the location for definitive repair was selective, as was shunt placement. In general, reconstruction occurred at the first level of care with the surgical capability, expertise, and resources. However, this was fluidly modified based upon forward triage factors such as time, concomitant injuries, casualty numbers, life-saving requisites, sites, instrumentation, and transport to a more secure level. These factors also played a significant role in the decision to place a temporary shunt. Our experience with temporary shunting has recently been described.²⁰ Only two (4.6%) of 43 UE injuries underwent diagnostic arteriography prior to exploration as physical and Doppler examination as well as extensive wounding mandated immediate exploration in the vast majority of injuries.

Levels of injury included 10 (23%) subclavian-axillary, 25 (58%) brachial, and 10 (23%) distal to the brachial bifurcation. Two patients had multilevel injury (Fig. 3C). All five axillosubclavian vein injuries were associated with arterial injury. Concomitant nerve injuries were noted at exploration in 38 (88%) of the 43 patients. Ten (23%) patients had associated bony fractures in addition to vascular injury.

Therapeutic Interventions and Early Complications 

Figure 5 represents the locations and types of repairs performed. Twenty-eight bypass grafts were placed for arterial injury. Of these grafts, three were in the subclavian-axillary position, 20 were brachial interpositions, and five were bypass grafts from the brachial artery to forearm vessels. Two prosthetic grafts were used. These were subclavian-axillary grafts and were placed for expeditious repair and size matching with no early complications appreciated. All other grafts were reversed greater saphenous vein. Ten arterial injuries were repaired primarily: seven proximal to the elbow and three distal. Arterial ligation was used in seven patients (one subclavian artery, two subclavian veins, five forearm arteries). Although no venous injuries were grafted, three subclavian vein primary repairs were done. Venous injury beyond the thoracic inlet was commonplace with some component of brachial or forearm vein ligation in all injuries. UE fasciotomy through the carpal tunnel was accomplished in all but two UE injuries. No UE fasciotomies required extensor compartment release.

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• Fig. 5. 

  Types of repair performed in UE vascular injuries by anatomic location. SC/A, subclavian/axillary; Distal, forearm vessels; BPG, bypass graft; Rep, primary repair; Lig, ligation.

Early complications were significant and occurred most commonly after brachial artery interposition grafting (Table I). Four (9.3%) early brachial graft thromboses occurred. Graft resection, thrombectomy, and regrafting were necessary in two patients. Thrombectomy alone with fasciotomy was performed in one patient. Soft tissue graft coverage was difficult in this patient, and he required forearm muscle flap coverage 2 days after thrombectomy. Ultimately, the graft became infected and anastomotic hemorrhage developed, necessitating graft removal. One early thrombosis led to amputation. Two (7.1% of grafts, 4.7% of patients) brachial interposition grafts developed early infection requiring removal with oversewing of the native brachial artery, one semielectively and one emergently due to anastomotic hemorrhage as noted above. Both were beyond the pro-funda brachii artery and maintained viable, functional limbs with systemic antibiotics and negative-pressure wound care. Early amputation occurred in four (9.3%) patients. This outcome was due to brachial graft thrombosis (n = 1), axillary artery and vein ligation for damage control (n = 1), and ultimate soft tissue nonviability after brachial artery grafting (n = 2). No early morbidity was evident from venous injury or ligation at or distal to the brachial level, nor was there clear evidence of acute venous hypertension appreciated.

Table I. Early complications after repair of UE vascular injury

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DISCUSSION 

OIF represents the first sizeable U.S. military conflict since Vietnam and, as such, provides an opportunity to revisit vascular injury management during time of war. This report uses the Balad Vascular Registry to depict the in-theater experience with UE vascular injury at the 332nd EMDG/Air Force Theater Hospital at Balad Air Base, Iraq, from September 2004 through August 2005. The development of FSTs and graded echelons of care in conjunction with ever-maturing damage control maneuvers and critical care concepts constitutes the most rapid and complex care that fighting forces have been provided to date. Thus, this yearlong experience affords insight into contemporary wartime UE vascular injury occurrence and the early effectiveness of current surgical techniques within this combat setting.

It appears that UE vascular injury comprises varying proportions of vascular trauma based upon the environment. In civilian settings, vascular injury to the shoulder girdle, arms, and forearms is reported to constitute 30–60% of extremity vascular trauma.⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶ In the Vietnam Vascular Registry, Rich and colleagues⁴ detailed 38% of extremity injuries occurring in the UE. Remarkably, our experience in Iraq, with 34% of extremity injuries occurring in this region, suggests UE injury pervasiveness during war has not significantly changed. Similar to previous armed conflicts, our communication portrays wartime UE vascular injury occurring slightly more than half as often as LE vascular injury. Why UE vascular injury may be more prevalent in the civilian setting is unclear. However, this might be related to the more frequent use of ground-born weapons during times of armed conflict, leading to a more substantial proportion of LE injuries.

A unique feature of this interim report is the 9.3% early limb loss rate we encountered with UE vascular injury. In their sentinel depiction of arterial injury during World War II, DeBakey and Simeone¹ reported a 24% arm loss rate. At that time, even though successful repair and vein grafting were understood, routine ligation was used in-theater due to the anathema of infection and hemorrhage with the associated morbidity and mortality on the battlefield. The dictum of successful battlefield repair was instituted during the Korean Conflict. Hughes², ³ demonstrated in-theater vascular repair was superior to ligation, with arm amputation rates precipitously decreasing from over 30% to roughly 3%. In Vietnam, Rich et al.⁴ documented the possibility of losing an arm to vascular injury at just over 5%.

Several civilian centers have documented minimal risk of limb loss with UE vascular injury.⁶, ⁷, ⁸, ⁹ This continues to be the case worldwide in large trauma centers. Manford et al.¹⁰ recorded only one UE amputation after repair of 46 vascular injuries in New Orleans. In India, Shanmugam and colleagues¹¹ performed no early and only one late arm amputation in 27 patients with UE vascular injury. Similarly, no amputations were required in 123 patients with UE vascular injury in a communication from Houston.¹² Finally, Zellweger and associates,¹³ from Cape Town, South Africa, analyzed 124 brachial artery injuries, of which only one patient underwent early amputation due to delay in transport.

Why does the experience with UE loss appear so significant in Iraq? There are several plausible contributing factors. In general, the science and understanding of injury and its therapy are continually improving. The precedent of prior conflict and the remarkable strides our national trauma initiatives have made may make today's military surgeons more conscious of and adept at recognizing vascular injury, thus acting upon it promptly. This may lead to limb salvage endeavors never considered rational before. Next, current modifications in the concepts of battlefield care likely move injured to medical personnel more expeditiously with life- and limb-saving maneuvers applied quicker. For instance, FSTs of today's level II echelons may apply tourniquets, place damage control temporary shunts, and perform fasciotomy minutes from injury, thus allowing for limb salvage attempts in extreme cases. Current body armoring techniques are also saving troops who otherwise would die of wounds immediately. These factors may contribute to the repair of UE vascular injuries never before surviving to operation. It is noteworthy that, while perhaps somewhat high for current elective civilian practice, both the infection and thrombosis rates herein are comparable, if not improved, from those in Vietnam.⁴, ⁵ This is indeed acceptable for in-theater repair. The impact of these specific complications on early limb loss was minimal as only one arm was lost due to thrombosis.

Lastly, the mechanism of injury may contribute to augmented UE loss. The institution by the enemy of the improvised explosive device, which accounts for two-thirds of UE vascular injuries, is clearly more damaging than civilian penetrating and blunt trauma. The combination of close range blast with both blunt and burn components as well as multiple penetrating missiles make these quite challenging wounds to assess and treat. This is relayed by the fact that nearly all of our early complications and limb loss occurred in those undergoing brachial interposition grafting, an event which is exceptionally rare outside of military conflict.¹³ It is fascinating that, similar to the current experience, the Vietnam Vascular Registry details fragments accounting for 60% of vascular injuries.⁴, ⁵ To what degree blast and burn also contributed to these wounds during this period is unclear, but our suspicion is not as much as today's conflict. Therefore, it is possible that UE vascular injury is being diagnosed and repair performed more rapidly in patients who would not have survived previously and in those with more significant multimechanistic wounds, consequently precipitating a higher UE loss rate.

Perhaps a more important end point for patients with these injuries is long-term functional outcome. Small, civilian experiences have associated nerve and bony injuries, blunt mechanism, as well as UE fasciotomy with worse functional outcome.⁸, ¹⁴, ¹⁵, ¹⁶ It appears, however, that functional recovery may occur to some degree in many patients.⁸, ¹², ¹⁴, ¹⁵, ¹⁶ Therefore, there is no clear clinical indicator at this time to deter aggressive limb salvage. While this communication cannot comment on late functional ability, it is clear that most of those with UE vascular injury treated in Iraq have these features. Without doubt, one of the most challenging components of care in the rehabilitation setting during this conflict continues to be UE amputation and vascular injury.²¹

Another limitation with this interim report is the relatively short collection period and, with the increasing number of in-theater treatment sites, the difficulty of collecting accurate data. Despite this limitation, the central location of the Air Force Theater Hospital as the main theater evacuation facility allows for the establishment of a practically inclusive vascular registry from which the data for this report were collected. Although this series of 43 patients is comparable to published series of UE vascular injury, the numbers are too small to derive absolute conclusions.

In summary, it appears UE vascular injury remains less common than LE injury during times of war. During OIF, the early arm amputation rate after UE vascular injury repair appears more significant than recently reported. This is likely related to the current warfare mechanisms of injury as well as contemporary asset management and education enhancing recognition, leading to earlier treatment in those who would not have been repaired previously.

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