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Extremity vascular injuries managed during war
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Surgeons in Operation Iraqi Freedom save lives and limbs while in-theater

The first large report of wartime extremity vascular injuries and complex wounds that require their complete treatment to occur in-theater, was published in the June 2007 issue of the Journal for Vascular Surgery. Surgeons found that vascular reconstruction using autogenous veins combined with a strict wound management strategy results in successful limb salvage with remarkably low infection, amputation and mortality rates.

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From September 1, 2004 to August 31, 2006 in Operation Iraqi Freedom there were 192 major vascular injuries in 4,323 local Iraqi non-coalition troops treated at the Air Force Theater Hospital (Level III) in Balad, Iraq. One hundred thirty-four of the vascular injuries were to the extremities and are the focus of this report. The age range was 4 to 68 years, including 12 pediatric injuries.

A penetrating mechanism was responsible for 88 percent of wounds, mostly due to explosive devices,†said Maj. Michael A. Peck, MD, a vascular surgeon at Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, Texas. The majority of the extremity vascular injuries were complex and most included loss of soft tissue and muscle, fractures, nerve damage and venous injuries.

Dr. Peck said that despite this degree of devastation, more than 90 percent of extremities were salvaged at the time of hospital discharge and remained viable at the initial post-hospital visit. Two people died and there were only 19 complications.

A strict wound management strategy was used, which included repeat operative washout and debridement. Frequently scheduled trips were made to the operating room for ongoing wound debridement and the placement of a negative pressure wound dressing. Delayed primary closure or secondary coverage with split thickness skin graft was required in 57 percent of these complex extremity wounds.  

All of these local patients remained at the in-theater hospital through definitive wound healing with an average length of stay of 15 days (median 11 days). Patients required an average of 3.3 operations from initial injury to definitive wound closure. Five patients had a surgical wound infection while four had acute anastamotic disruption. thrombosis occurred in six cases and there was early amputation in four individuals.

This experience represents one small part of the overall wartime management of vascular injuries,said Dr. Peck. "In our unique patient population we combined sound vascular surgical practices learned from our surgical predecessors wartime experiences and modern technology, namely the negative pressure wound dressing, to achieve excellent limb salvage rates. The surgical principles that were steadfastly adhered to included adequate resection of injured blood vessels, balloon catheter thrombectomy to remove blood clots, use of heparin anticoagulation to prevent further clot formation and performing repairs with patients own veins rather than using prosthetic materials.

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