title: Long-term follow-up and amputation-free survival in 497 casualties with combat-related vascular injuries and damage-control resuscitation.
abstract: BACKGROUND
  The effectiveness of damage-control resuscitation (DCR) has been demonstrated in recent US conflicts. Wartime casualties treated for hemorrhagic shock from vascular wounds were studied to report the 24-hour transfusion requirements, graft patency, and amputation-free survival for major vascular injuries.
  
  
  METHODS
  Joint Theater Trauma Registry data from August 2006 to April 2011 (56 months) were retrospectively reviewed. Included were casualties with a vascular injury who presented to US combat support hospitals in Iraq or Afghanistan. Amputation-free survival and graft patency were determined from record and imaging review.
  
  
  RESULTS
  The study group consisted of 497 severely wounded local national and military casualties (mean [SD] Injury Severity Score [ISS], 17 [8.5]) presenting with acidosis (pH 7.29 [0.15]), tachycardia (heart rate, 110 [29.31]), and coagulopathy (international normalized ratio, 1.6 [2.33]). Given DCR and early management of vascular injury, blood pressure, heart rate, temperature, hemoglobin, and base deficit improved promptly (p < 0.05) by intensive care unit admission. Transfusion requirements included packed red blood cells (15 [13] U; range, 1-70 U), fresh frozen plasma (14 [13] U; range, 1-72 U), cryoprecipitate (13 [15] U; range, 1-49 U), and platelets (8 [6] U; range, 1-36 U). Mean operative time was 232 minutes (range, 16-763 minutes). US casualties (n = 111) had limb salvage attempted for 113 extremity vascular injuries (3 [2%] iliac, 33 [30%] femoral, 23 [20%] popliteal, 13 [12%] tibial, 33 [30%] brachial, 4 [3%] ulnar, and 4 [(3%] radial). In this subgroup, 28 (25%) were revascularized by a primary repair or end anastomosis, 80 (71%) were revascularized by saphenovenous grafts, and 15 (3%) [corrected] were revascularized by prosthetic grafts. The follow-up ranged from 29 days to 1,079 days, (mean, 347 days), during which 96 grafts (84.9%) remained patent, 16 casualties (14.2%) required a delayed amputation, and 110 (99.1%) survived. Popliteal injuries had the highest amputation rate (7 of 23, 30.4%). The amputation-free survival was 84%.
  
  
  CONCLUSIONS
  In severely wounded casualties, wartime surgical strategies to save both life and limb evidently permit definitive procedures at initial surgery with excellent limb salvage results. This outcome analysis in a large cohort can help to refine surgical judgment and support contemporary DCR practices for major vascular injury.
  
  
  METHODS
  Epidemiologic study, level III; therapeutic study, level V.
authors.affiliation: Division of Vascular Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
authors.forename: Anahita
authors.initials: A
authors.lastname: Dua
authors.forename: Bhavin
authors.initials: B
authors.lastname: Patel
authors.forename: John F
authors.initials: JF
authors.lastname: Kragh
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Fox
mesh_terms: D000293:Adolescent; D000328:Adult; D055826:Afghan Campaign 2001-; D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion / Q000401:mortality / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D019934:International Normalized Ratio; D054542:Iraq War, 2003-2011; D008297:Male; D008875:Middle Aged; D008887:Military Medicine / Q000379:methods / Q000706:statistics & numerical data; D012151:Resuscitation / Q000401:mortality* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012771:Shock, Hemorrhagic / Q000401:mortality / Q000628:therapy; D014481:United States; D057772:Vascular System Injuries / Q000401:mortality* / Q000601:surgery / Q000628:therapy; D055815:Young Adult