Anatomic distribution and mortality of arterial injury in the wars in Afghanistan and Iraq with comparison to a civilian benchmark.
OBJECTIVE
The purpose of this study was to examine the anatomic distribution and associated mortality of combat-related vascular injuries comparing them to a contemporary civilian standard.


METHODS
The Joint Trauma Theater Registry (JTTR) was queried to identify patients with major compressible arterial injury (CAI) and noncompressible arterial injury (NCAI) sites, and their outcomes, among casualties in Iraq and Afghanistan from 2003 to 2006. The National Trauma Data Bank (NTDB) was then queried over the same time frame to identify civilian trauma patients with similar arterial injuries. Propensity score-based matching was used to create matched patient cohorts from both populations for analysis.


RESULTS
Registry queries identified 380 patients from the JTTR and 7020 patients from the NTDB who met inclusion criteria. Propensity score matching for age, elevated Injury Severity Score (ISS; >15), and hypotension on arrival (systolic blood pressure [SBP] <90) resulted in 167 matched patients from each registry. The predominating mechanism of injury among matched JTTR patients was explosive events (73.1%), whereas penetrating injury was more common in the NTDB group (61.7%). In the matched cohorts, the incidence of NCAI did not differ (22.2% JTTR vs 26.6% NTDB; P = .372), but the NTDB patients had a higher incidence of CAI (73.7% vs 59.3%; P = .005). The JTTR cohort was also found to have a higher incidence of associated venous injury (57.5% vs 23.4%; P < .001). Overall, the matched JTTR cohort had a lower mortality than NTDB counterparts (4.2% vs 12.6%; P = .006), a finding that was also noted among patients with NCAI (10.8% vs 36.4%; P = .008). There was no difference in mortality between matched JTTR and NTDB patients with CAI overall (2.0% vs 4.1%; P = .465), or among those presenting with Glasgow Coma Scale (GCS) <8 (28.6% vs 40.0%; P = 1.00) or shock (SBP <90; 10.5% vs 7.7%; P = 1.00). The JTTR mortality rate among patients with CAI was, however, lower among patients with ISS >15 compared with civilian matched counterparts (10.7% vs 42.4%; P = .006).


CONCLUSIONS
Mortality of injured service personnel who reach a medical treatment facility after major arterial injury compares favorably to a matched civilian standard. Acceptable mortality rates within the military cohort are related to key aspects of an organized Joint Trauma System, including prehospital tactical combat casualty care, rapid medical evacuation to forward surgical capability, and implementation of clinical practice guidelines. Aspects of this comprehensive combat casualty care strategy may translate and be of value to management of arterial injury in the civilian sector.
United States Army Institute for Surgical Research, Fort Sam Houston San Antonio, San Antonio, Tex 78234, USA.
Nickolay P
NP
Markov
Joseph J
JJ
DuBose
Daniel
D
Scott
Brandon W
BW
Propper
W Darrin
WD
Clouse
Billy
B
Thompson
Lorne H
LH
Blackbourne
Todd E
TE
Rasmussen
D000328:Adult; D055826:Afghan Campaign 2001-; D001158:Arteries / Q000293:injuries*; D019985:Benchmarking; D001753:Blast Injuries / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D002423:Cause of Death; D016009:Chi-Square Distribution; D019033:Delivery of Health Care, Integrated; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D054542:Iraq War, 2003-2011; D008297:Male; D008887:Military Medicine / Q000592:standards / Q000706:statistics & numerical data*; D016017:Odds Ratio; D011379:Prognosis; D057216:Propensity Score; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014481:United States; D057772:Vascular System Injuries / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D014950:Wounds, Penetrating / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D055815:Young Adult