title: Retrospective analysis of case series of patients with vascular war injury treated in a district hospital.
abstract: BACKGROUND
  As the Syrian civil war continues, medical care of the injured remains a priority for health facilities receiving casualties. Ziv Medical Centre, the closest hospital in Israel to the Syrian border, has received 500 casualties since February 2013. Seventeen of these patients had vascular injuries. This research reports the care of these seventeen patients and explores the challenges of treatment in patients with little antecedent clinical history and improvised initial care that may be complicated by delay to definitive care, sepsis and limb ischaemia.
  
  
  METHODS
  Electronic and paper patient records were examined. Descriptive case series data are presented.
  
  
  RESULTS
  Fifteen of the 17 patients were male. The mean age was 20 years (range 8-30 years). Causes of injury included gunshot wounds (4 patients), shrapnel (multi-fragment) injury (12 patients), and 1 patient was run over and dragged behind a car. The time from injury to transfer to definitive care ranged from 5h to 7 days (mean 43 h). All but one patient had associated non-vascular multiple-trauma. Thirteen patients presented with limb ischaemia. Four patients had arterio-venous fistula (AVF) or pseudoaneurysm. There were 5 upper and 10 lower limb major vascular injuries. Three patients had neck vessel injuries. All patients were investigated with CT angiography and underwent surgical or endovascular intervention. In 12 patients, 4 vessels were debrided and re-anastomosed and 13 vessels bypassed. Endovascular repair was performed in 4 patients. After initial revascularisation, 4 patients went on to amputation. There were no deaths.
  
  
  CONCLUSIONS
  The injuries treated are heterogeneous, and reflect the range of high energy vascular trauma expected in conflict. The broad range of vascular solutions required to optimise outcomes, in particular, limb salvage, in turn, reflect the challenges of dealing with such injuries, especially within the context of sepsis, ischaemia and delay. As war continues, there is a pressing need to address the needs of patients with high energy injuries in austere environments where there is a dearth of health resources and where definitive care may be days away.
authors.affiliation: Vascular Surgery Unit, Ziv Medical Centre, Safed, Israel(1); Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.
authors.forename: Tal
authors.initials: T
authors.lastname: Salamon
authors.affiliation: Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel; Department of Orthopedic Surgery, Ziv Medical Center, Safed, Israel.
authors.forename: Alexander
authors.initials: A
authors.lastname: Lerner
authors.affiliation: Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel; Department of Orthopedic Surgery, Ziv Medical Center, Safed, Israel.
authors.forename: David
authors.initials: D
authors.lastname: Rothem
authors.affiliation: Interventional Radiology Unit, Ziv Medical Center, Safed, Israel.
authors.forename: Alexander
authors.initials: A
authors.lastname: Altshuler
authors.affiliation: Department of Vascular Surgery, Carmel Medical Center, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel.
authors.forename: Ron
authors.initials: R
authors.lastname: Karmeli
authors.affiliation: Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel; Department of General and Hepatobiliary Surgery, Ziv Medical Center, Safed, Israel.
authors.forename: Evgeny
authors.initials: E
authors.lastname: Solomonov
authors.affiliation: Department of Surgery, Ziv Medical Center, Safed, Israel. Electronic address: seemabiswas@msn.com.
authors.forename: Seema
authors.initials: S
authors.lastname: Biswas
mesh_terms: D000293:Adolescent; D000328:Adult; D000465:Algorithms; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D000068337:Armed Conflicts; D002648:Child; D019091:Critical Pathways; D005260:Female; D006767:Hospitals, District; D006801:Humans; D015601:Injury Severity Score; D007557:Israel; D023821:Limb Salvage / Q000379:methods*; D008297:Male; D008887:Military Medicine; D009104:Multiple Trauma / Q000503:physiopathology / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D013593:Syria; D013997:Time Factors; D014656:Vascular Surgical Procedures / Q000379:methods*; D057772:Vascular System Injuries / Q000503:physiopathology / Q000601:surgery*
keywords: Amputation; Bypass; Graft; Injury; Trauma; Vascular; War