Identification of risk factors for arterial repair failures and lessons learned: Experiences from managing 129 combat vascular extremity wounds in the Sri Lankan War.

BACKGROUND: In extremity vascular trauma, early complications occur at a rate of 13% to 44%. The most common of which are infection, dehiscence, thrombosis, and stenosis. Failure of the arterial repair, also called arterial blowout, has the potential for exsanguinating hemorrhage and poses a considerable challenge for the surgeon to save limb and life. METHOD: All adults with extremity vascular injuries admitted in 8-month period were prospectively recorded and retrospectively analyzed. Extremity vascular injuries in this group include those in which limb salvage attempted. 5 arterial blowouts in a recorded 87 arterial repairs were analyzed for demographics, presentation, management and outcome in the context of identifying most probable causative factors. RESULT: 5 arterial blowouts occurred out of 87 arterial repairs for a rate of 5.75%. These occurred at a mean of 14 days post-operatively. All patients were male with the majority of the injuries, 80%, resulting from gunshot wounds. All injuries were associated with severe soft tissue injury and clinical evidence of bacterial infection. Technical error, inadequate debridement, prolonged exposed vessel and unstable skeletal injury were noted as causative factors in addition to the commonly reported causes of repair failure. At a mean follow-up of 17 days, the arterial blowout cohort had 80% limb survival rate. CONCLUSION: Ischemic, damaged and contaminated military wounds lead to infections of varied degree. Delay in closure due to tight distal muscle compartments or severe persistent soft tissue infections, necessitating serial irrigation and debridement (I&D) of wounds, is the common chain noted leading to arterial blowout. To break this chain of events the authors suggest early identification of at risk limbs and aggressive soft tissue cover of the newly constructed repair. LEVEL OF EVIDENCE: Case series, level IV.

Challenges encountered and lessons learnt from venous injuries at Sri Lankan combat theatres.

PURPOSE: The objective of this study was to characterise the spectrum of peripheral venous injury in the Sri Lankan war theatres, including categorisation of anatomic patterns, mechanism and management of casualties, including short-term results of surgical repair of traumatic venous injuries versus ligation. In addition, the effects and outcome of combined arterial and venous injuries versus arterial injury alone are compared. METHODS: All adults with extremity vascular injuries admitted to a military base hospital during an 8-month period were prospectively recorded and those with a venous injury were analysed. RESULT: A total of 123 vascular injuries were recorded in the study period, of which 70 had a venous injury, combined with an arterial injury in 58 (83%) and in isolation in 12 (17%). There were 43 transections, 26 lateral tears and a single through and through penetrating injury. Twenty-five (36%) vein injures were repaired and 45 ligated. Only six popliteal veins were repaired in 21 lower limbs that underwent arterial revascularisation. In the combined arterial/venous injuries group 13 primary amputations were performed and five delayed amputations were necessary. There were no amputations in the isolated venous injury group. There were three deaths (4.3%), 18 infections with four cultures positive for pseudomonas species, five arterial graft thromboses were recorded. There were significantly more blood transfusions and concomitant skeletal injuries, resulting in more amputations, in combined arterial and venous injuries in comparison with arterial injury alone (all p values<0.05). CONCLUSIONS: In an ideal setting, venous injuries should be repaired when possible and tolerated by the patient in order to ameliorate the risk of thrombotic and infectious complications. An aggressive use of shunting, fasciotomies and venous repair in wartime limb injuries at echelon structured care may prevent preventable limb loss in these challenging case scenarios.