title: The epidemiology of vascular injury in the wars in Iraq and Afghanistan.
abstract: BACKGROUND
  Blood vessel trauma leading to hemorrhage or ischemia presents a significant cause of morbidity and mortality after battlefield injury. The objective of this study is to characterize the epidemiology of vascular injury in the wars of Iraq and Afghanistan, including categorization of anatomic patterns, mechanism, and management of casualties.
  
  
  METHODS
  The Joint Theater Trauma Registry was interrogated (2002-2009) for vascular injury in US troops to identify specific injury (group 1) and operative intervention (group 2) groups. Battle-related injuries (nonreturn to duty) were used as the denominator to establish injury rates. Mechanism of injury was compared between theaters of war and the management strategies of ligation versus revascularization (repair and interposition grafting) reported.
  
  
  RESULTS
  Group 1 included 1570 Troops injured in Iraq (OIF) (n = 1390) and Afghanistan (OEF) (n = 180). Mechanism included explosive (73%), gunshot (27%), and other (<1%) with explosive more common in OIF than OEF (P < 0.05). During this period, 13,076 battle-related injuries occurred resulting in a specific rate of 12% (1570 of 13,076), which was higher in OIF than OEF (12.5% vs 9% respectively; P < 0.05). Of group 1, 60% (n = 940) sustained injury to major or proximal vessels and 40% (n = 630) to minor or distal vessels (unknown vessel, n = 27). Group 2 (operative) comprised 1212 troops defining an operative rate of 9% (1212 of 13,076) and included ligation (n = 660; 54%) or repair (n = 552; 46%). Peak rates in OIF and OEF occurred in November 2004 (15%) and August 2009 (11%), respectively and correlated with combat operational tempo.
  
  
  CONCLUSIONS
  The rate of vascular injury in modern combat is 5 times that reported in previous wars and varies according to theater of war, mechanism of injury and operational tempo. Methods of reconstruction are now applied to nearly half of the vascular injuries and should be a focus of training for combat surgery. Selective ligation of vascular injury remains an important management strategy, especially for minor or distal vessel injuries.
authors.affiliation: United States Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: White
authors.forename: Adam
authors.initials: A
authors.lastname: Stannard
authors.forename: Gabriel E
authors.initials: GE
authors.lastname: Burkhardt
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Eastridge
authors.forename: Lorne H
authors.initials: LH
authors.lastname: Blackbourne
authors.forename: Todd E
authors.initials: TE
authors.lastname: Rasmussen
mesh_terms: D055826:Afghan Campaign 2001-; D000346:Afghanistan; D019917:Blood Vessel Prosthesis Implantation; D001808:Blood Vessels / Q000293:injuries; D006801:Humans; D007493:Iraq; D054542:Iraq War, 2003-2011; D008026:Ligation; D008887:Military Medicine; D012042:Registries; D057772:Vascular System Injuries / Q000453:epidemiology* / Q000601:surgery*; D014857:Warfare