Patel Jigarkumar A, White Joseph M, White Paul W, Rich Norman M, Rasmussen Todd E
Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Md.
Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Md.
J Vasc Surg. 2018 Dec;68(6):1872-1879. doi: 10.1016/j.jvs.2018.04.038. Epub 2018 Jun 23.
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.
血管损伤是军事和民用创伤中导致死亡和残疾的主要原因。尽管之前的一项中期研究确定了伊拉克和阿富汗战争期间血管损伤的分布情况，但尚未进行当代流行病学评估。本研究的目的是对阿富汗战争最后7年期间的血管损伤进行当前分析，包括解剖损伤模式、损伤机制和急性处理方法的特征描述。
对国防部创伤登记处进行分析，以确定在2009年1月1日至2015年12月31日期间遭受与战斗相关的血管损伤并存活至在阿富汗外科设施接受治疗的美国军人。所有与战斗相关的损伤（无法返回岗位）用作分母来确定损伤率。确定损伤的机制和解剖分布以及血管重建、结扎和血管内技术使用的急性处理策略。
在3900名遭受与战斗相关损伤的军人中，685例患者（17.6%）有1105处血管损伤（每位患者1.6处血管损伤）。四肢创伤占血管损伤的72%（n = 796），其次是躯干（17%；n = 188）和颈部（11%；n = 118）区域。下肢血管损伤是最常见的解剖部位（45%；50个1/1105）。碎片穿透爆炸占损伤的70%（477/685），而枪伤占30%（205/685）。559例（57%；554/981）进行了开放修复，而结扎是40%（395/981）病例的初始处理策略。此外，完成了374例诊断性血管内操作，进行了27例包括支架置入和血管成形术在内的治疗性血管内干预，并放置了55个下腔静脉滤器。血管损伤队列的死亡率为5%。
现代战争中血管损伤的发生率高于以往战争报道的发生率。尽管结扎是一种重要的损伤控制选择，特别是对于小血管或远端血管损伤，但一半的病例进行了开放重建。血管造影技术比以往任何时候都更多地用于战时登记并记录在案。熟练掌握血管损伤的开放和血管内处理方法仍然是美国军队的迫切需求，这将需要与民用机构合作以实现和维持。
