Epidemiology of Upper Extremity Vascular Injury in Contemporary Combat.

The incidence of wartime upper-extremity vascular injury (UEVI) has been stable for the past century. The objective of this study is to provide a contemporary review of wartime UEVI, including epidemiologic characterization and description of early limb loss. The Department of Defense Trauma Registry (DoDTR) was queried to identify US service members who sustained a battle-related UEVI in Afghanistan between January 2009 and December 2015. Anatomic distribution of injury, mechanism of injury (MOI), associated injuries, early management, and early limb loss were analyzed. Analysis identified 247 casualties who sustained 308 UEVIs. The most common injury was to the vessels distal to the brachial bifurcation (63.3%, n = 195), followed by the brachial vessels (27.3%, n = 84) and the axillary vessels (9.4%, n = 29). The predominant MOIs were penetrating explosive fragments (74.1%, n = 183) and gunshot wounds (25.9%, n = 64). Associated fractures were identified in 151 (61.1%) casualties and nerve injuries in 133 (53.8%). Angiography was performed in 91 (36.8%) casualties, and endovascular treatment was performed 10 (4%) times. Temporary vascular shunts were placed in 39 (15.8%) casualties. Data on surgical management were available for 171 injuries and included repair (48%, n = 82) and ligation (52%, n = 89). The early limb loss rate was 12.1% (n = 30). For all casualties sustaining early limb loss, the MOI was penetrating fragments from an explosion; the average injury severity score (ISS) was 32.3, and the mortality was 6.7% (n = 2). In those without amputation, the ISS and mortality were low at 20 and 4.6% (n = 10), respectively. Overall mortality was 4.9% (n = 12). The early limb loss rate was increased compared with initial descriptions from Operation Iraqi Freedom. Amputations are associated with a higher ISS. Improved data capture and fidelity, or differing MOIs, may account for this trend. Proficiency with open and endovascular therapy remains a critical focus for combat casualty care.

Vuoncino M ，Soo Hoo AJ ，Patel JA ，White PW ，Rasmussen TE ，White JM ... -  《-》

A contemporary, 7-year analysis of vascular injury from the war in Afghanistan.

Vascular injury is a leading cause of death and disability in military and civilian trauma. Although a previous interim study defined the distribution of vascular injury during the wars in Iraq and Afghanistan, a contemporary epidemiologic assessment has not been performed. The objective of this study was to provide a current analysis of vascular injury during the final 7 years of the war in Afghanistan, including characterization of anatomic injury patterns, mechanisms of injury, and methods of acute management. The Department of Defense Trauma Registry was analyzed to identify U.S. military service members who sustained a battle-related vascular injury and survived to be treated at a surgical facility in Afghanistan between January 1, 2009, and December 31, 2015. All battle-related injuries (nonreturn to duty) were used as a denominator to establish the injury rate. Mechanism and anatomic distribution of injury as well as the acute management strategies of revascularization, ligation, and use of endovascular techniques were defined. Of 3900 service members who sustained a battle-related injury, 685 patients (17.6%) had 1105 vascular injuries (1.6 vascular injuries per patient). Extremity trauma accounted for 72% (n = 796) of vascular injuries, followed by the torso (17%; n = 188) and cervical (11%; n = 118) regions. Lower extremity vascular injury was the most prevalent anatomic location (45%; 501/1105). Explosion with fragment penetration accounted for 70% (477/685) of injuries, whereas gunshot wounds accounted for 30% (205/685). Open repair was performed in 559 cases (57%; 554/981), whereas ligation was the initial management strategy in 40% (395/981) of cases. In addition, 374 diagnostic endovascular procedures were completed, 27 therapeutic endovascular interventions to include stent placement and angioplasty were performed and 55 inferior vena cava filters were placed. Mortality of the vascular injury cohort was 5%. The rate of vascular injury in modern combat is higher than that reported in previous wars. Open reconstruction is performed in half of cases, although ligation is an important damage control option, especially for minor or distal vessel injuries. Angiographic techniques are increasingly being used and documented within wartime registries more than ever. Proficiency with open and endovascular methods of vascular injury management remains a critical need for the U.S. military and will require partnership with civilian institutions to attain and maintain.

Patel JA ，White JM ，White PW ，Rich NM ，Rasmussen TE ... -  《-》

Management and outcome of 597 wartime penetrating lower extremity arterial injuries from an international military cohort.

Vascular injury is a leading cause of death and disability in military and civilian settings. Most wartime and an increasing amount of civilian vascular trauma arises from penetrating mechanisms of injury due to gunshot or explosion. The objective of this study was to provide a comprehensive examination of penetrating lower extremity arterial injury and to characterize long-term limb salvage and differences related to mechanisms of injury. The military trauma registries of the United States and the United Kingdom were analyzed to identify service members who sustained penetrating lower limb arterial injury (2001-2014). Treatment and limb salvage data were studied and comparisons made of patients whose penetrating vascular trauma arose from explosion (group 1) vs gunshot (group 2). Standardized statistical testing was used, with Bonferroni corrections for multiple comparisons. The cohort consisted of 568 combat casualties (mean age, 25.2 years) with 597 injuries (explosion, n = 416; gunshot, n = 181). Group 1 had higher Injury Severity Score (P < .05) and Mangled Extremity Severity Score (P < .0001), required more blood transfusion (P < .05), and had more tibial (P < .01) and popliteal (P < .05) arterial injuries; group 2 had more profunda femoris injuries (P < .05). Initial surgical management for the whole cohort included vein interposition graft (33%), ligation (31%), primary repair with or without patch angioplasty (16%), temporary vascular shunting (15%), and primary amputation (6%). No difference in patency of arterial reconstruction was found between group 1 and group 2, although group 1 had a higher incidence of primary (13% vs 2%; P < .05) and secondary (19% vs 9%; P < .05) amputation. Similarly, longer term freedom from amputation was lower for group 1 than for group 2 (68% vs 89% at 5.5 years; Cox hazard ratio, 0.30; P < .0001), as was physical functioning (36-Item Short Form Health Survey data; mean, 39.80 vs 43.20; P < .05). The majority of wartime lower extremity arterial injuries result from an explosive mechanism that preferentially affects the tibial vasculature and results in poorer long-term limb salvage compared with those injured with firearms. The mortality associated with immediate limb salvage attempts is low, and delayed amputations occur weeks later, affording the patient involvement in the decision-making and rehabilitation planning. We recommend assertive attempts at vascular repair and limb salvage for service members injured by explosive and gunshot mechanisms.

Sharrock AE ，Tai N ，Perkins Z ，White JM ，Remick KN ，Rickard RF ，Rasmussen TE ... -  《-》

Wartime vascular injuries in the pediatric population of Iraq and Afghanistan: 2002-2011.

Contemporary war-related studies focus primarily on adults with few reporting the injuries sustained in local pediatric populations. The objective of this study is to characterize pediatric vascular trauma at US military hospitals in wartime Iraq and Afghanistan. Review of the Department of Defense Trauma Registry (DoDTR) (2002-2011) identified patients (1-17 years old) treated at US military hospitals in Iraq and Afghanistan using ICD-9 and procedure codes for vascular injury. US military hospitals treated 4402 pediatric patients between 2002 and 2011. One hundred fifty-five patients (3.5%) had a vascular injury. Mean age, gender, and injury severity score (ISS) were 11.1 ± 4.1 years, 79% male, and 34 ± 13.5, respectively. Vascular injuries were primarily from penetrating mechanisms (95.6%; 58.0% blast injury) to the extremity (65.9%), torso (25.4%), and neck (8.6%). Injuries were ligated (31%), reconstructed (63%), or observed (2%). Limb salvage rate was 95%. Mortality rate was 9%. This study is the first to report vascular trauma in a pediatric population at wartime. Vascular injuries involve a high percentage of extremity and torso wounding. Torso vascular injury in children is four times lethal relative to other injury patterns, and therefore should be considered in operational planning both in the military and civilian setting regarding pediatric vascular injuries.

Villamaria CY ，Morrison JJ ，Fitzpatrick CM ，Cannon JW ，Rasmussen TE ... -  《-》

Pelvic, spinal and extremity wounds among combat-specific personnel serving in Iraq and Afghanistan (2003-2011): A new paradigm in military musculoskeletal medicine.

Previous studies regarding musculoskeletal injuries sustained during war have been limited by a lack of specificity regarding wounds incurred by combat-specific personnel. This investigation endeavoured to develop a comprehensive catalogue of the extent of musculoskeletal trauma, as well as the frequency of distinct injuries, among soldiers possessing a single combat-specific specialty. The Department of Defense Trauma Registry (DoDTR) and the Armed Forces Medical Examiner System (AFMES) were queried for all individuals with the combat-specific designation of cavalry scout who sustained injuries during deployment between the years 2003 and 2011. This data was refined to include only those soldiers found to have injuries involving the spine, pelvis, or extremities. Soldier age, rank, injury location (Afghanistan or Iraq), injury scenario (combat vs. non-combat) and mechanism of wounding were recorded, as were injury-specific data. Statistical comparisons for categorical variables were made using the chi-square statistic. Sixty-seven percent (n=472) of 701 cavalry scouts injured during deployment sustained one or more injuries to the musculoskeletal system. Mean age for the group was 25.9 (range 18-54) years and 3.3 musculoskeletal injuries were incurred on average per casualty. The majority of casualties occurred during combat and in the Iraq theatre. Sixty-nine percent (n=328) of musculoskeletal casualties were incurred following explosion, and 20% (n=94) occurred due to gunshot. No significant difference (p>0.05) was encountered for the risk of musculoskeletal injury by wound mechanism. Forty-six percent of all injuries involved the lower extremities, while 32% occurred in the upper extremities. Tibial fractures were the most common injury encountered (8%), while amputations comprised 11% of all wounds. Spinal cord injury occurred in 12% of all casualties and represented 4% of all musculoskeletal wounds. This effort is among the first to combine complimentary data from the DoDTR and AFMES over a multi-year period in order to comprehensively catalogue musculoskeletal wounds sustained by combat-specific soldiers. This investigation highlights a 49% incidence of injuries involving the spine, pelvis, and/or extremities within a cohort of combat-specific soldiers. Elevated rates of amputations, spinal injuries, and pelvic trauma were also appreciated as compared to earlier reports.

Schoenfeld AJ ，Dunn JC ，Belmont PJ 《-》