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The Complete Management of Traumatic Vascular Injury in a Local Population During Operation Iraqi Freedom

Michael A. Peck, MD,  Norman M. Rich William D. Clouse, MD, Mitch W. Cox, MD, Donald H. Jenkins, MD, David L. Smith, MD, Todd E. Rasmussen, MD
The 332nd Air Force Theater Hospital (AFTH), Balad Iraq, Wilford Hall USAF Medical Center, Lackland AFB, TX and Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD and Wilford Hall USAF Medical Center, Lackland AFB, TX

Objective(s): While the management of vascular injury in coalition forces has been described in studies from US centers, there have been no reports of the in-theater treatment of wartime vascular injury in the Iraqi population during Operation Iraqi Freedom. The objective of this study is to report the complete management of traumatic vascular injury in the local population and illustrate the unique aspects of this strategy.

Methods: From 1 September 2004 through 31 January 2006 all vascular injuries treated at the central level III facility in Iraq were registered and retrospectively reviewed.

Results: During this period 170 major vascular injuries were treated in the local population (N=140 patients): extremity 77% (N=130), neck and great vessel 17% (N=29) and thoracoabdominal 6% (N=11). Age range was 4-68 years and included 12 pediatric vascular injuries. Primary or delayed primary wound closure following repetitive washout, derbridement and the vacuum assisted closure adjunct occurred in 71% (N=99) of patients while 29% (N=41) had wounds that remained open to granulate or required split thickness skin grafting. All peripheral vascular reconstructions were performed with autologous vein. By necessity, due to difficulties with patient follow-up and home wound management, all patients remained at the theater hospital through definitive wound healing (range 3-28 days). Surgical infection occurred in only 6% (N=8) of cases including 3 anastamotic blowouts. The early amputation and mortality rates were 5% (N=7) and 2% (N=3) respectively.
Conclusions:
This study is the first in-theater report of vascular injury management in the Iraqi population. These injuries present unique challenges related to patient age and wounds that require complete management in-theater. Despite working in an austere environment, vascular reconstruction using autologous vein and a unique wound management strategy results in a high rate of wound closure and remarkably low infection, amputation and mortality rates.