War injuries of the femoral artery and vein: a report on 67 cases.

During the war in Croatia (from May 1991 to December 1995), 67 patients with war injuries of the femoral vein and/or artery were treated at the Surgical Clinic of Split Clinical Hospital. All the wounded were admitted directly from the battlefield or from front-line hospitals. There were five women and 62 men with a median age of 29 (range 15-54) years. There were 70 arterial (28 isolated) and 49 venous injuries (six isolated). Forty-six arterial injuries were repaired by reverse vein graft. Four proximal profound femoral arteries were reconstructed. Major venous injuries were repaired, 11 by compilation autogenous vein graft. No synthetic grafts were used. Repair of veins with large defects using compilation saphenous vein grafts gave good results. Six profound femoral veins and two superficial femoral veins were ligated. Vein ligation should be avoided unless another life-threatening injury demands priority. Twenty-one patients required open prophylactic fasciotomy. Two patients died (3%) and three ultimately underwent amputation (5%). Intermittent hyperbaric oxygen therapy was given to 18 heavily wounded patients with beneficial effect. The results support an immediate and coordinated approach to femoral vascular trauma with repair of arterial and venous injuries.

[Vascular injuries in war]. / Gefässverletzungen im Krieg.

OBJECTIVE: This paper reviews military vascular injuries in Southern Croatia. BACKGROUND: Report of surgical procedures in war-related arterial and venous injuries in association with soft tissue destruction and bone involvement, with its post-operative medical and physical therapy. For vascular surgeons cases are presented, which are seldomly seen in civilian circumstances. For this reason this paper is published. PATIENTS AND METHODS: A retrospective review was done for 189 wounded (13 females, 175 males) with vascular injuries in the time period from June 1991 through December 1993. Ninety-one (48.1%) of the patients sustained injuries due to explosive weapons (different types of mines, grenades and its fragments). Extensive soft-tissue and bone destruction was associated in 55 (36.2%) wounded. The age ranged from 14 to 63 (mean 27.3) years. The operative techniques involved the debridement of devitalised and infected tissue, prophylactic fasciotomy, the reconstruction of major venous injuries, application of microsurgical techniques in selected cases and the extensive use of autogenous interposition grafts. The wounds were treated by secondary closure and routinely antibiotics were given. In selected cases an arteriography was performed preoperatively. Vascular injury with a prolonged time of ischemia were the most common indication for hyperbaric oxygenation (HBO). RESULTS: Six (3.2%) patients died from associated severe injuries. In sixteen (15.1%) cases a subsequent amputation had to be performed. CONCLUSIONS: The results of this study support the reconstruction of major vessel damage in order to save a limb. Careful and regular follow-up examinations also by other medical specialties proved to enhance a positive outcome for this severely injured patients. We also suggest the extensive use of HBO in war casualties.

War injuries of the crural arteries.

Twenty-eight patients with military crural vascular injuries are presented. In the group undergoing immediate repair (21 patients), the time interval between trauma and surgery was 20 min to 30 h (mean 8 h 30 min). In those receiving delayed repair (seven patients), the interval between trauma and surgery was 3-47 (mean 14) days. Hyperbaric oxygenation therapy was used in conjunction with surgery and antibiotic therapy in 13 of the 28 patients. Explosive injuries were found in 14 patients and high-velocity missile injuries in nine; associated fractures were present in 20. Twenty of the 28 patients with crural vascular injuries had combined arterial and venous injuries, while eight had isolated arterial injuries. Twenty-five patients with distal ischaemia required arterial repair; five late amputations resulted. Military crural vascular injuries should be treated with soft tissue debridement, removal of foreign material, and microvascular arterial and concomitant vein reconstruction. This should be followed by external skeletal stabilization for bony and/or soft tissue instability, with fasciotomy for any associated compartment syndrome. The wound should be left open, with delayed closure or split skin grafting. It was felt that hyperbaric oxygen therapy reduced the amputation rate following combat-related crural vessel injuries.

Hyperbaric oxygen for the treatment of nonarteritic anterior ischemic optic neuropathy.

This clinical study tackled the problem of hyperbaric oxygen in patients with nonarteritic anterior ischemic optic neuropathy. Twenty-one patients were included in the study. The patients were divided into two groups: experimental and control. Experimental group consisted of 10 patients, who had been previously treated with corticosteroids, without significant success. In four patients with a clinical picture of PNO atrophy, medical steroid treatment failed to any significant improvement in visual acuity. In 6 patients, however, this treatment resulted in a significant improvement of both visual acuity and field of vision. These patients showed further improvement on control testing performed six month later. All patients from the control group were treated with corticosteroids per os and by local application, but without any significant improvement as revealed by visual acuity and visual field testing. Authors' results pointed the possibility of conservative treatment of patients with anterior ischemic optic neuropathy, especially those in whom steroid therapy had proved inefficient.

The effects of hyperbaric oxygen on visual functions in ischaemic optic neuropathy.

The effects of hyperbaric oxygen therapy were studied in nine patients with non-arteritic anterior ischaemic optic neuropathy, who had been unsatisfactorily treated with corticosteroids. In four patients with signs of optic disc atrophy there was no improvement of visual functions after hyperbaric oxygen treatment, whereas in the other five patients, who had no signs of optic disc atrophy, visual acuity and visual field improved. The achieved improvements were maintained at a control examination six months later. Results suggest that hyperbaric oxygen might be a new remedy for the selected cases of non-arteritic ischaemic optic neuropathy and call for a controlled clinical study aiming to accurately assess its efficacy.

Hyperbaric oxygen dose of choice in the treatment of glaucoma.

The subjects in the study were 111 patients with open angle glaucoma who were submitted to treatment by hyperbaric oxygenation. Two groups were formed at random, an experimental one of 91 patients and a control group of 20 patients. The experimental group consisted of four subgroups classified according to the course of treatment they received: 30 sessions (31 patients), 20 sessions (20 patients), 15 sessions (20 patients) and 10 sessions (20 patients). For the treatment a large walk-in recompression chamber was utilized, once a day, at a pressure of 2.0 bars, for 90 minutes. Visual acuity and mean intraocular pressure values taken before and after hyperbaric oxygen treatment did not show a statistically significant difference either between the treated and control subjects, or at control examinations after three and six months. During the follow-up period, changes in the visual field area in control subjects were discrete and statistically not significant. At the same time the visual field values increased after the therapy in all the subgroups. In the 10-session course subgroup the increase was not statistically significant. In all other subgroups, statistical significance was at the level of P < 0.01. Control after three months demonstrated the same level of statistical significance; control at the end of six months failed to show a statistically significant difference. The 20-session course is recommended for initial treatment. When visual field values return to 50 percent of the improved values achieved during initial treatment, it is suggested that hyperbaric oxygen treatment be repeated.

The effect of hyperbaric oxygen breathing on the visual field in glaucoma.

Following the hypothesis that chronic ischemia is the main cause of functional deficiency in glaucoma, a double blind clinical experiment was carried out to study the effect of hyperbaric oxygenation in 51 glaucoma subjects, of which 31 were in the experimental group and 20 in the control group. In the experimental group there was a significant improvement of visual fields (p < 0.05), whereas there was no change in the subjects in the control group. Hyperbaric oxygen did not have any influence on intraocular pressure. The achieved visual field improvements remained stable for 3 months (p < 0.05), except for I3 and I4 isopters of the left eye and I4 isopter of the right eye, while they were considerably reduced after 6 months (p > 0.05).

Effect of hyperbaric oxygenation on maximal aerobic performance in a normobaric environment.

Eighteen female physical education students, randomly divided into three groups, inhaled 100% O2 for 60 minutes in a hyperbaric chamber. Pressure in the chamber amounted to 2.8 ATA. Three days before the hyperbaric oxygenation (HBO) all the students were subjected to a treadmill test. The first group was retested after 30 minutes, the second after 3 hours and the third 6 hours after the HBO. The first and the second groups of subjects achieved statistically significant maximal oxygen consumption after the HBO (14.4 and 10% respectively) and were capable of sustaining considerably higher exertion on treadmill (12.8%, namely 18.1%, both values were significant on the level of p less than 0.05). The ventilation efficiency parameters (VEO2 and R) did not differ with any of the three groups of subject during the exertion before and after the HBO, although after the HBO the exertion was considerably higher.