Upper extremity vascular injury: a current in-theater wartime report from Operation Iraqi Freedom.

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.

The application of split-thickness skin graft as an autogenous arterial conduit in a goat (Capra hircus) model.

Adequate autogenous vein is often the limiting factor in achieving a successful infrainguinal bypass. Attempts have been made to find alternative conduits; however, these alternatives have demonstrated inferior patency rates. We attempt to show that a split-thickness skin graft conduit provides a feasible autogenous arterial conduit. Neoconduits were prepared with an autogenous split-thickness skin graft (STSG) tubularized for a length of 5-6 centimeters with an appropriate caliber match to native artery. The deep dermal side of the graft was randomized to form either the external surface or the luminal surface. The neoconduit was placed as an interposition graft in the left common carotid artery. Grafts were studied in vivo with duplex ultrasonography and ex vivo by histopathology and immunohistochemistry. Feasibility study involved 4 animals with grafts harvested for study at 24 hours (n = 2) and 7 days (n = 2). Two subsequent groups were studied to evaluate 3-month (n = 8) and 6-month (n = 5) patency. All grafts (n = 4) in the feasibility phase of the study were patent at the time of harvest without evidence of aneurysmal degeneration. In the subsequent 8 goats, grafts with the deep dermal side forming the extraluminal surface (n = 4) had a propensity to ulcerate and rupture or to become aneurysmal (75%). The patency rate of these grafts at 6 weeks was 25%. In contrast, grafts with the deep dermal side forming the intraluminal surface (n = 4) demonstrated 75% patency at 6 weeks. Because of these results the remaining goats underwent placement of neoconduits with the deep dermal side forming the luminal surface. These grafts maintained a patency rate of 80% at 6 months. Neoconduits implanted with a diameter greater than 1.5 times the native arterial diameter became aneurysmal. Histopathology demonstrated neointimal formation in all grafts patent for longer than 7 days. Immunohistochemical staining for Factor VIII/von Willebrand's factor (vWF) was reactive in the endoluminal cells of these grafts. Immunohistochemical staining for a-smooth muscle actin demonstrated reactivity in conduits patent for greater than 1 month. Split-thickness skin may provide a feasible source for autogenous conduit in arterial reconstructions and warrants further study. Technical factors affecting patency include orientation of the deep dermal surface of the STSG and the diameter of the neoconduit at the time of implantation.