title: Limb salvage after vascular reconstruction followed by tissue transfer during the Global War on Terror.
abstract: BACKGROUND
  Combat extremity wounds are complex and frequently require an immediate vascular reconstruction in the operational environment followed by delayed tissue coverage at a stateside medical treatment facility. The purpose of this study was to evaluate limb salvage outcomes after combat-related vascular reconstruction that subsequently required delayed soft tissue coverage during the Global War on Terror.
  
  
  METHODS
  Patients who incurred a war-related extremity injury necessitating an immediate vascular intervention followed by definitive limb reconstruction requiring flap coverage from combat injuries were reviewed. Patient demographics, types of vascular and extremity injuries, and surgical interventions were examined. Outcomes included limb salvage, primary and secondary graft patency, flap outcomes, and complications. Differences between upper extremities (UEs) and lower extremities (LEs) were compared.
  
  
  RESULTS
  From 2003 to 2012, 27 patients were treated for combat-related extremity injuries with an immediate vascular reconstruction followed by delayed tissue coverage. Fifteen LEs and 12 UEs were treated. The mean age was 24 years. An explosion was the cause in 77% of patients, with a mean Injury Severity Score (ISS) of 19. An autogenous vein bypass was the most common reconstruction performed in 20 patients (74%). Other vascular repairs included a primary repair, a patch angioplasty with bovine pericardium, and a bypass with use of a prosthetic graft. Eight patients (30%) had a concomitant venous injury, and 23 (85%) had a bone fracture. Thirty flaps were performed at a mean of 33 days from the original injury. Pedicle flaps were used in 24 limbs and free tissue flaps in six limbs. Muscle, fasciocutaneous, bone, and composite flaps were used for tissue coverage. At a mean follow-up of 16 months, primary patency rates of all arterial reconstructions were 66% in the UE and 53% in the LE (P = .69). Secondary patency rates were 100% in the UE and 86% in the LE (P = .48). The overall limb salvage rate was 81%. Limb salvage rates were 66% in the LE and 100% in the UE (P = .04). Three amputated lower limbs (60%) had inline flow to the foot. The flap success rate was 96%. Reasons for amputation included arterial thrombosis, flap failure, persistent soft tissue infection, osteomyelitis, and debilitating peripheral nerve injuries with associated chronic pain.
  
  
  CONCLUSIONS
  Immediate vascular repair followed by delayed tissue coverage can be performed with a high (>80%) limb salvage rate after combat trauma. Limb salvage rates were higher in the UE despite equivocally high arterial patency rates. Wounded warriors can expect limb salvage by use of this international algorithm.
authors.affiliation: Division of Vascular Surgery, Department of General Surgery, Naval Medical Center San Diego, San Diego, Calif; Department of Surgery, Kandahar Air Field NATO Role III, Multinational Medical Unit, Kandahar, Afghanistan. Electronic address: kevin.casey@med.navy.mil.
authors.forename: Kevin
authors.initials: K
authors.lastname: Casey
authors.affiliation: Department of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center, Bethesda, Md.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Sabino
authors.affiliation: Division of Vascular Surgery, Department of General Surgery, Naval Medical Center San Diego, San Diego, Calif; Department of Surgery, Kandahar Air Field NATO Role III, Multinational Medical Unit, Kandahar, Afghanistan.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Weiss
authors.affiliation: Department of Plastic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Anand
authors.initials: A
authors.lastname: Kumar
authors.affiliation: Department of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center, Bethesda, Md; Department of Surgery, Kandahar Air Field NATO Role III, Multinational Medical Unit, Kandahar, Afghanistan; Department of Plastic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Ian
authors.initials: I
authors.lastname: Valerio
mesh_terms: D000293:Adolescent; D000328:Adult; D000465:Algorithms; D000671:Amputation, Surgical; D019091:Critical Pathways; D006801:Humans; D015601:Injury Severity Score; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008887:Military Medicine; D011183:Postoperative Complications / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000009:adverse effects; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013524:Surgical Flaps / Q000009:adverse effects; D023481:Terrorism; D013997:Time Factors; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects; D057772:Vascular System Injuries / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D055815:Young Adult