Management of complex vascular trauma.

In Israel, many terrorist acts, like combat incidents, involve explosive devices and result in vascular trauma. Complex vascular trauma of the extremities (CVTE) is a reflection of the amount of energy (a) released by the injuring agent and (b) absorbed by the vital tissues. Such trauma includes extensive arterial and venous lacerations with loss of substance, cornminuted fractures, neural injury and extensive soft tissue loss. The rate of limb loss with such trauma approaches 40%. 1 Current treatment of CVTE in the civilian is in many ways similar to that in the military population. Still, these two populations differ significantly with respect to diagnostic methods, injuring agents and management. Management of vascular trauma was a major issue during World Wars I and II, when ligation was the accepted approach. Vascular repair had a high complication rate, usually from thrombosis and haemorrhage. The classic World War II report by DeBakey and Simeone in 1946 analysed 2471 arterial injuries in American casualties in Europe. Almost all were treated by ligation with a subsequent overall amputation rate approaching 50%. For popliteal artery injuries there was an amputation rate of 73%. 2 During the Korean conflict, which paralleled the evolution of contemporary vascular surgery, the first sucessful vascular reconstructions were accomplished. With the Vietnamese war came the establishment of the principles of modern vascular reconstructive surgery. The results were monitored through the Vietnam Vascular Registry. 3 The objective of contemporary trauma surgery is to maintain correct priorities. Initial treatment of vascular trauma is similar to the treatment of any major trauma. Special attention is placed on control of external haemorrhage, fracture and spinal stabilisation, and rapid transport. Vascular trauma of the torso is usually an immediate threat to life, whereas injury to an extremity vessel is more often a threat to the affected limb. The diagnosis of vascular injury in the extremities is clear when the patient arrives with external bleeding from a wound, such as in the thigh, which is controlled by application of external pressure. The classical presentation of limb ischaemia is encountered rarely in the context of vascular trauma. The soft signs of suspected vascular trauma in an otherwise stable patient can be evaluated with objective tests such as continuous Doppler-signal analysis, colour-flow duplex scan and angiography. Angiography is still considered the "gold standard" for diagnosis of vascular injury. The importance of a careful history combined with thorough physical examination in establishing the correct diagnosis is often underscored in authoritative reviews. ~ Unfortunately, in victims of mass casualty from explosive trauma and even in an individual patient with haemorrhagic shock, these didactic approaches are not always applicable. Haemodynamically unstable patients with exsanguinating vascular injuries need to be expeditiously transferred to the operating room while the airway is being secured. The haemorrhage is usually controlled by direct pressure over the site of bleeding using digital pressure or an instrument such as sponge forceps. Blind clamping in the bleeding wound is ineffective and may cause damage to adjacent structures and exsanguination. Manual compression of the external bleeding site must be maintained until proximal and distal control are formally obtained. Through a limited aseptic field, proximal vascular control is obtained while the patient is being resuscitated with fluids and blood products. Following successful resuscitation and comprehensive examination for additional injuries, attention is then turned to the injured site.