Vuoncino Matthew, Soo Hoo Andrew J, Patel Jigarkumar A, White Paul W, Rasmussen Todd E, White Joseph M
Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD.
Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD.
Ann Vasc Surg. 2020 Jan;62:98-103. doi: 10.1016/j.avsg.2019.04.014. Epub 2019 Jul 22.
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.
在过去一个世纪中，战时上肢血管损伤（UEVI）的发生率一直保持稳定。本研究的目的是对战时UEVI进行当代综述，包括流行病学特征及早期肢体缺失情况的描述。
查询国防部创伤登记处（DoDTR），以确定在2009年1月至2015年12月期间于阿富汗遭受与战斗相关UEVI的美国军人。分析损伤的解剖分布、损伤机制（MOI）、相关损伤、早期处理及早期肢体缺失情况。
分析确定了247名伤员，他们共发生308例UEVI。最常见的损伤部位是肱动脉分叉远端的血管（63.3%，n = 195），其次是肱血管（27.3%，n = 84）和腋血管（9.4%，n = 29）。主要的损伤机制是穿透性爆炸碎片（74.1%，n = 183）和枪伤（25.9%，n = 64）。151名（61.1%）伤员伴有骨折，133名（53.8%）伴有神经损伤。91名（36.8%）伤员进行了血管造影，其中10次（4%）进行了血管内治疗。39名（15.8%）伤员放置了临时血管分流管。有171例损伤的手术处理数据，包括修复（48%，n = 82）和结扎（52%，n = 89）。早期肢体缺失率为12.1%（n = 30）。对于所有发生早期肢体缺失的伤员，损伤机制均为爆炸产生的穿透性碎片；平均损伤严重度评分（ISS）为32.3，死亡率为6.7%（n = 2）。在未截肢的伤员中，ISS和死亡率较低，分别为20和4.6%（n = 10）。总体死亡率为4.9%（n = 12）。
与伊拉克自由行动最初的描述相比，早期肢体缺失率有所增加。截肢与较高的ISS相关。数据采集的改善和准确性提高，或不同的损伤机制，可能是导致这一趋势的原因。开放和血管内治疗的熟练程度仍然是战伤救治的关键重点。
