Long-term follow-up and amputation-free survival in 497 casualties with combat-related vascular injuries and damage-control resuscitation

• Published in: The journal of trauma and acute care surgery Vol. 73; no. 6; pp. 1517 - 1524
• Main Authors: Dua, Anahita, Patel, Bhavin, Kragh, Jr, John F, Holcomb, John B, Fox, Charles J
• Format: Journal Article
• Language: English
• Published: United States 01-12-2012
• Subjects: Adolescent; Adult; Afghan Campaign 2001; Aged; Aged, 80 and over; Blood Transfusion - mortality; Blood Transfusion - statistics & numerical data; Child; Child, Preschool; Female; Follow-Up Studies; Glasgow Coma Scale; Humans; Injury Severity Score; International Normalized Ratio; Iraq War, 2003-2011; Male; Middle Aged; Military Medicine - methods; Military Medicine - statistics & numerical data; Resuscitation - mortality; Resuscitation - statistics & numerical data; Retrospective Studies; Shock, Hemorrhagic - mortality; Shock, Hemorrhagic - therapy; United States; Vascular System Injuries - mortality; Vascular System Injuries - surgery; Vascular System Injuries - therapy; Young Adult; United States
• ISSN: 2163-0755; 2163-0763
• DOI: 10.1097/TA.0b013e31827826b7

The effectiveness of damage-control resuscitation (DCR) has been demonstrated in recent US conflicts. Wartime casualties treated for hemorrhagic shock from vascular wounds were studied to report the 24-hour transfusion requirements, graft patency, and amputation-free survival for major vascular injuries.
Joint Theater Trauma Registry data from August 2006 to April 2011 (56 months) were retrospectively reviewed. Included were casualties with a vascular injury who presented to US combat support hospitals in Iraq or Afghanistan. Amputation-free survival and graft patency were determined from record and imaging review.
The study group consisted of 497 severely wounded local national and military casualties (mean [SD] Injury Severity Score [ISS], 17 [8.5]) presenting with acidosis (pH 7.29 [0.15]), tachycardia (heart rate, 110 [29.31]), and coagulopathy (international normalized ratio, 1.6 [2.33]). Given DCR and early management of vascular injury, blood pressure, heart rate, temperature, hemoglobin, and base deficit improved promptly (p < 0.05) by intensive care unit admission. Transfusion requirements included packed red blood cells (15 [13] U; range, 1-70 U), fresh frozen plasma (14 [13] U; range, 1-72 U), cryoprecipitate (13 [15] U; range, 1-49 U), and platelets (8 [6] U; range, 1-36 U). Mean operative time was 232 minutes (range, 16-763 minutes). US casualties (n = 111) had limb salvage attempted for 113 extremity vascular injuries (3 [2%] iliac, 33 [30%] femoral, 23 [20%] popliteal, 13 [12%] tibial, 33 [30%] brachial, 4 [3%] ulnar, and 4 [(3%] radial). In this subgroup, 28 (25%) were revascularized by a primary repair or end anastomosis, 80 (71%) were revascularized by saphenovenous grafts, and 15 (3%) [corrected] were revascularized by prosthetic grafts. The follow-up ranged from 29 days to 1,079 days, (mean, 347 days), during which 96 grafts (84.9%) remained patent, 16 casualties (14.2%) required a delayed amputation, and 110 (99.1%) survived. Popliteal injuries had the highest amputation rate (7 of 23, 30.4%). The amputation-free survival was 84%.
In severely wounded casualties, wartime surgical strategies to save both life and limb evidently permit definitive procedures at initial surgery with excellent limb salvage results. This outcome analysis in a large cohort can help to refine surgical judgment and support contemporary DCR practices for major vascular injury.
Epidemiologic study, level III; therapeutic study, level V.