Penetrating femoropopliteal injury during modern warfare: experience of the Balad Vascular Registry.
OBJECTIVE
Wounding patterns, methods of repair, and outcomes from femoropopliteal injury have been documented in recent civilian literature. In Operation Iraqi Freedom, as in past conflicts, these injuries continue to be a therapeutic challenge. Therefore, the objective of the current study is to document the pattern of femoropopliteal injuries, methods of repair, and early outcomes during the current military campaign in Iraq.


METHODS
From September 1, 2004, to April 30, 2007, all vascular injuries arriving at the Air Force Theater Hospital (the central echelon III medical facility in Iraq; equivalent to a civilian level I trauma center), Balad Air Base, Iraq were prospectively entered into a registry. From this, injuries involving the lower extremities were reviewed.


RESULTS
During the 32-month study period, 9289 battle-related casualties were assessed. Of these, 488 (5.3%) were diagnosed with 513 vascular injuries, and 142 casualties sustained 145 injuries in the femoropopliteal domain. Femoral level injury was present in 100, and popliteal level injury occurred in 45. Injuries consisted of 59 isolated arterial, 11 isolated venous, and 75 combined. Fifty-eight casualties were evacuated from forward locations. Temporary arterial shunts were placed in 43, of which 40 (93%) were patent on arrival at our facility. Our group used shunts for early reperfusion before orthopedic fixation, during mass casualty care, or autogenous vein harvest in 11 cases. Arterial repair was accomplished with autogenous vein in 118 (88%), primary means in nine (7%), or ligation in seven (5%). Venous injury was repaired in 62 (72%). Associated fracture was present in 55 (38%), and nerve injury was noted in 19 (13%). Early limb loss due to femoropopliteal penetrating injury occurred in 10 (6.9%). Early mortality was 3.5% (n = 5).


CONCLUSIONS
Femoropopliteal vascular injury remains a significant reality in modern warfare. Femoral injuries appear more prevalent than those in the popliteal region. Early results of in-theater repair are comparable with contemporary civilian reports and are improved from the Vietnam era. Rapid evacuation and damage control maneuvers such as temporary shunting and early fasciotomy assist timely definitive repair and appear effective.
Woodward
E Baylor
EB
332nd EMDG/AFTH, Balad Air Base, Iraq. edward.woodward-02@travis.af.mil
Clouse
W Darrin
WD
Eliason
Jonathan L
JL
Peck
Michael A
MA
Bowser
Andrew N
AN
Cox
Mitchell W
MW
Jones
W Tracey
WT
Rasmussen
Todd E
TE
D000671:Amputation, Surgical; D001808:Blood Vessels / Q000293:injuries*; D005263:Femoral Artery / Q000293:injuries / Q000601:surgery; D005268:Femoral Vein / Q000293:injuries / Q000601:surgery; D006772:Hospitals, Military / Q000706:statistics & numerical data; D006801:Humans; D007493:Iraq; D054542:Iraq War, 2003-2011; D008026:Ligation; D023821:Limb Salvage / Q000706:statistics & numerical data; D008889:Military Personnel / Q000706:statistics & numerical data; D011150:Popliteal Artery / Q000293:injuries / Q000601:surgery; D011152:Popliteal Vein / Q000293:injuries / Q000601:surgery; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000706:statistics & numerical data; D014680:Veins / Q000637:transplantation; D014950:Wounds, Penetrating / Q000401:mortality / Q000601:surgery*