Penetrating femoropopliteal injury during modern warfare: Experience of the Balad Vascular Registry
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From the Western Vascular Society
Penetrating femoropopliteal injury during modern
warfare: Experience of the Balad Vascular Registry
Major E. Baylor Woodward, MD,a,c,d Lt Colonel W. Darrin Clouse, MD,a,b,d
Major Jonathan L. Eliason, MD,a,b,d Major Michael A. Peck, MD,a,b,d
Lt Colonel Andrew N. Bowser, MD,a,b,d Major Mitchell W. Cox, MD,a,d
Lt Colonel W. Tracey Jones, MD,a,b,d and Lt Colonel Todd E. Rasmussen, MD,a,b,d Balad, Iraq;
San Antonio, Texas; Travis Air Force Base, Calif; and Bethesda, Md
Objective: Wounding patterns, methods of repair, and outcomes from femoropopliteal injury have been documented in
recent civilian literature. In Operation Iraqi Freedom, as in past conflicts, these injuries continue to be a therapeutic
challenge. Therefore, the objective of the current study is to document the pattern of femoropopliteal injuries, methods
of repair, and early outcomes during the current military campaign in Iraq.
Methods: From September 1, 2004, to April 30, 2007, all vascular injuries arriving at the Air Force Theater Hospital (the
central echelon III medical facility in Iraq; equivalent to a civilian level I trauma center), Balad Air Base, Iraq were
prospectively entered into a registry. From this, injuries involving the lower extremities were reviewed.
Results: During the 32-month study period, 9289 battle-related casualties were assessed. Of these, 488 (5.3%) were
diagnosed with 513 vascular injuries, and 142 casualties sustained 145 injuries in the femoropopliteal domain. Femoral
level injury was present in 100, and popliteal level injury occurred in 45. Injuries consisted of 59 isolated arterial, 11
isolated venous, and 75 combined. Fifty-eight casualties were evacuated from forward locations. Temporary arterial
shunts were placed in 43, of which 40 (93%) were patent on arrival at our facility. Our group used shunts for early
reperfusion before orthopedic fixation, during mass casualty care, or autogenous vein harvest in 11 cases. Arterial repair
was accomplished with autogenous vein in 118 (88%), primary means in nine (7%), or ligation in seven (5%). Venous
injury was repaired in 62 (72%). Associated fracture was present in 55 (38%), and nerve injury was noted in 19 (13%).
Early limb loss due to femoropopliteal penetrating injury occurred in 10 (6.9%). Early mortality was 3.5% (n ⴝ 5).
Conclusions: Femoropopliteal vascular injury remains a significant reality in modern warfare. Femoral injuries appear
more prevalent than those in the popliteal region. Early results of in-theater repair are comparable with contemporary
civilian reports and are improved from the Vietnam era. Rapid evacuation and damage control maneuvers such as
temporary shunting and early fasciotomy assist timely definitive repair and appear effective. ( J Vasc Surg 2008;47:
1259-65.)
For many reasons, including use of body armor, for- The current report documents the value, in terms of
ward positioning of surgical capability, widespread use of early limb salvage, compared with that achieved in Viet-
temporary shunting and fasciotomies, rapid evacuation nam, of lessons learned in the interim, such as the applied
strategies, and increased survival after wounding, the prev- strategies of temporary arterial shunting and aggressive
alence of extremity vascular injury in Iraq appears greater venous repair on femoral and popliteal injuries. It also
than in previous wars. These specific factors have also likely explores the potential for a comprehensive vascular registry
contributed to improved in-theater limb salvage. This is concentrated on improving future functional-limb out-
apparent in previously published experience with vascular comes.
injury in Operation Iraqi Freedom (OIF).1-4 PATIENTS AND METHODS
During 32 consecutive months, from September 1,
From the 332nd EMDG/AFTH, Balad Air Base, Iraqa; San Antonio 2004 through April 30, 2007, all casualties who sustained
Military Vascular Surgery Service, Wilford Hall USAF Medical Center, vascular injury who were evaluated and treated at the
San Antoniob; Division of Vascular Surgery, David Grant USAF Medical
Center, Travis AFBc; and The Norman M. Rich Department of Surgery,
332nd Expeditionary Medical Group (EMDG)/Air Force
Uniformed Services University of the Health Sciences, Bethesda.d Theater Hospital (AFTH), Balad Air Base, Iraq, were pro-
Competition of interest: none. spectively entered into a database (the Balad Vascular Reg-
The views expressed in this report are those of the authors and do not reflect the istry).1 The AFTH is unique: In addition to being a level III
official policy of the Department of Defense or other departments of the
facility (equivalent to a level I trauma center in a civilian
United States government.
Presented at The Twenty-second Annual Meeting of the Western Vascular setting), it also serves as the central aeromedical evacuation
Society, Kona, Hawaii, Sep 8-11, 2007. facility for all United States (US) casualties leaving Iraq. A
Correspondence: E. Baylor Woodward, MD, FACS, Division of Vascular detailed description of the graduated response to vascular
Surgery, 101 Bodin Circle, Travis AFB, CA 94535-1800 (e-mail: edward. injury in Iraq is available.2 Thus, all US troops sustaining
woodward-02@travis.af.mil).
0741-5214/$34.00
vascular injuries, even if definitively treated at forward
Copyright © 2008 by The Society for Vascular Surgery. facilities, are practically included by this registry. A fellowship-
doi:10.1016/j.jvs.2008.01.052 trained vascular surgeon is consistently present at the
1259
JOURNAL OF VASCULAR SURGERY
1260 Woodward et al June 2008
AFTH and assessed all patients with vascular injury whose position grafting, or panel graft repair due to significant size
data are in the registry. Vascular repairs were performed by mismatching. In no instances was femoral vein used for
trained vascular or general surgeons. venous repairs.
Institutional Review Board approval was obtained for Fasciotomies were deemed necessary by surgeon dis-
this report and use of the database. Data recorded included cretion; however, experience in OIF with fasciotomy omis-
age and nationality, wounding mechanism, the vessel(s) sion in limb injury has been unfavorable. Indeed, significant
injured, method of repair, use of temporary shunt and morbidity has been noted in US troops with limb injuries
patency thereof, presence of concomitant venous injury, requiring air evacuation in whom a fasciotomy was incom-
associated fracture or major nerve injury, and early follow-up plete or had been omitted. Thus, nearly all patients with
information. From this, patients identified as having sus- femoral and popliteal arterial injuries in this series under-
tained injury in the femoropopliteal domain were identified went four-compartment fasciotomy. In three Iraqis, omis-
and retrospectively reviewed. Only vascular injuries in sion was attempted and delayed fasciotomy was required.
which limb salvage was attempted were included in the In one Iraqi, who was shot near the AFTH, superficial
registry and this report. Femoropopliteal injuries treated femoral artery (SFA) autogenous interposition grafting was
with primary amputation for a mangled extremity or other performed for isolated injury and omission of fasciotomies
indications, such as damage control or mass casualty situa- was successful. All US casualties underwent four-compartment
tions, were excluded. fasciotomies before evacuation. This experience has pro-
Lower extremity vascular injuries initially evaluated at duced clinical practice guidelines calling for routine use of
our facility were diagnosed in most instances by the pres- two-incision, four-compartment fasciotomies in all lower
ence of hard signs, such as pulsatile bleeding, expanding extremity vascular injuries.
hematoma, or overt ischemia. These patients were taken Early limb salvage in US forces was determined as
directly to the operating room (OR) for exploration and reaching the continental US (CONUS) with a viable
definitive repair. Although angiographic capabilities were treated limb. A viable limb is defined as one that is pink and
available, this was rarely required to diagnose injury. Intra-
warm, with either a palpable pedal pulse or audible contin-
operative evaluation of the repair was accomplished either
uous wave pedal Doppler signal. In Iraqi casualties, salvage
by return of a palpable pulse or by return of an adequate,
was defined as the treated limb being viable at discharge
audible continuous wave pedal Doppler signal. For patients
from the AFTH, or death not related to the limb. Early
brought in direct from the field, use of tourniquets was
mortality was defined as death during these respective
standard practice when it appeared there was significant
periods. Subsequent information on US casualties evacu-
hemorrhage and they were able to be placed above the level
ated was obtained through weekly telemedicine confer-
of injury.5,6
ences conducted with receiving medical centers both in
The wounds of casualties transferred to our facility
Germany and CONUS.
from a forward operating base with surgical capabilities had
Incidence and distribution of lower extremity vas-
often been explored there. Vascular injuries were identified
and temporary vascular shunts frequently placed before cular injury. During the 32-month study period, 9289
transport to the AFTH. Intravascular shunts were interro- battle-related casualties were evaluated at the 332nd
gated for patency on return to the OR with continuous EMDG/AFTH. Of these, 488 (5.3%) were diagnosed with
wave Doppler. Shunts were used in our facility as a tempo- 513 vascular injuries, and 142 casualties sustained 145
rizing adjunct during mass casualty situations, completion injuries in the femoropopliteal domain for an overall prev-
of bony fixation, and during concomitant venous repair or alence of 1.56% (Tables I and II).
saphenous vein harvesting. Penetrating injuries to femoral vessels occurred in 97
Vascular repair was accomplished with various tech- patients. Three of these patients had bilateral femoral vessel
niques, depending on the extent of injury to the vessel. injury, thus accounting for the 100 femoral injuries. There
Balloon thrombectomy was performed if there was inade- were 43 isolated arterial injuries, 10 isolated venous inju-
quate bleeding/backbleeding. Regional heparinization was ries, and 47 patients with combined arterial and venous
performed in the inflow and outflow segments. Primary injury. The most commonly injured artery in the femoral
means were considered if there was minimal circumferential level was the SFA (75 patients). There were 37 cases of
loss to healthy vessel wall. Also considered was the kinetic combined SFA and femoral vein injury. Of the 97 patients
energy of the wounding mechanism and the anticipated with femoral injuries, 52 (54%) were Iraqi (army, police,
area of blast damage. In short, arteries were débrided back and civilians) and 45 (46%) were US military.
to healthy appearing vessel wall before repair. There were 45 cases of popliteal level injury: 16 in-
An effort was made to repair and maintain patency of volved the popliteal artery alone, 1 patient had isolated
major venous structures, unless the physiologic state of the popliteal vein injury, and 28 had combined popliteal artery
patient prevented such attempts, such as in damage control and vein injury. Thirty (66.7%) of these were in Iraqi
situations where there were severe multisystem injuries. casualties (army, police or civilians) and 15 (33.3%) were in
The order and extent of arterial and venous repairs were US military personnel. The mean age of Iraqi patients was
individualized by the surgeon. Techniques used for venous 42 years (range 12-72 years). The mean age of US casual-
repair included lateral suture repair, saphenous vein inter- ties was 24 years (range, 18-45 years).JOURNAL OF VASCULAR SURGERY
Volume 47, Number 6 Woodward et al 1261
Table I. Anatomic distribution of femoral level injuries
Anatomic location Injuries, No. Percentage
Total injuries 100
Artery only 43
SFA 37 37
CFA 1 1
PFA 3 3
CFA/SFA/PFA 1 1
CFA/SFA 1 1
Vein only 10
FV 9 9
CFV 1 1
Artery and vein 47
PFA/CFV 2 2 Fig 1. Superficial femoral artery and femoral vein injuries. A
SFA/FV 37 37 temporary arterial shunt is in place while a panel graft repair of the
PFA/FV 3 3 femoral vein is undertaken.
SFA/CFA/CFV 1 1
PFA/CFA/CFV 2 2
CFA/CFV 2 2
CFA, Common femoral artery; CFV, common femoral vein; FV, femoral
vein; PFA, profunda femoral artery; SFA, superficial femoral artery.
Table II. Anatomic distribution of popliteal level injuries
Anatomic location Injuries, No. Percentage
Total injuries 45
Popliteal artery only 16 35.6
Popliteal vein only 1 2.2
Popliteal artery and vein 28 62.2
Table III. Methods of arterial repair
Level of arterial injury Method of repair No. (%)
Fig 2. Completed interposition vein graft repair of superficial
femoral artery and panel graft repair of the femoral vein.
Femoral (n ⫽ 90) Autogenous 76 (84.4)
Primary 7 (7.8)
Ligation 7 (7.8)a
Popliteal (n ⫽ 44) Autogenous 42 (95.5) apy (V.A.C., KCI Inc, San Antonio, Tex), and multiple
Primary 2 (4.5) trips to the OR before closure of all wounds, as we have
Ligation 0 (0) previously described.4 Because of these wounding mecha-
a
All ligations involved the profunda femoral artery. nisms, many patients in the current study had numerous
and severe associated injuries. Concomitant fractures oc-
curred in 55 (38%) patients. Documented nerve injury was
Mechanism of injury and associated limb injury. present in 19 (13%).
Femoral territory injuries were caused by fragmentation Methods of arterial repair. Details of arterial repair
wounds from improvised explosive devices (IEDs) in 52 are summarized in Table III. Autogenous vein was used in
cases, high-velocity gunshot wounds in 47, and a rocket- 118 (88%) arterial repairs. Of 90 repairs at the femoral
propelled grenade in one. Popliteal injuries were caused by artery level, 76 (84.4%) were repaired by autogenous
IEDs in 27 cases and high-velocity gunshot wounds in 18. means, including 74 interposition bypass grafts and two
Overall, the mechanism of femoropopliteal penetrating vein patch angioplasties (Fig 1 and 2). Seven (7.8%) were
injury was IED in 79 (54.5%) and high-velocity gunshot repaired primarily, and seven injuries (7.8%) at the femoral
wound in 65 (45%). This distribution was similar compar- level were treated with ligation. All ligations involved the
ing Iraqis with US forces. It is difficult to neatly characterize profunda femoral artery (PFA). Of 44 popliteal artery inju-
wounds caused by IEDs. They may cause either high- or ries, 42 were repaired by autogenous methods (95.5%),
low-velocity type penetration in conjunction with blast and including 40 interposition grafts and two vein patch angio-
burn. This clearly depends on the type of explosive and plasties, and two (4.5%) were repaired primarily. There
missiles used, not to mention distance from the device. were no instances of popliteal artery ligation. In no cases
Most cases involved extensive soft tissue destruction requir- was a prosthetic device used for arterial reconstruction. In
ing significant sharp débridement, negative pressure ther- four cases, a patient arrived from forward with prostheticJOURNAL OF VASCULAR SURGERY
1262 Woodward et al June 2008
conduit. These were returned to the OR and replaced with tation in survivors by anatomy of arterial injury was as
autogenous conduit (Table III). follows: one of seven (14%) resulted from CFA injury, three
Venous injuries. Overall, 86 femoropopliteal venous of 72 (4.2%) from SFA injury, and six of 42 (14.3%) from
injuries were identified, 10 of which were isolated femoral popliteal artery injury. The reasons for limb loss included
vein injury. Nine of these involved the femoral vein and one early repair failure in nine cases (7% of arterial repairs
the common femoral vein. In 47 cases, the femoral venous excluding PFA ligations) and progression of extensive soft
injury was combined with arterial injury. Again, the most tissue injury in one case (0.7% of injured limbs).
commonly injured vein in these cases was the femoral vein
(n ⫽ 40; 85%). Methods of femoral venous repair included DISCUSSION
autogenous means in 27 (47.4%), primary repair in 18 Austere environments, the lack of usual supplies, and
(31.6%), and ligation in 12 (21%). One patient had isolated exposure to horrific injuries all affirm Debakey’s comment
popliteal vein injury, and 28 had popliteal venous injuries that “war is never a cheerful business.”9 The military cam-
combined with arterial injury. These injuries were repaired paign in Iraq has now lasted for ⬎57 months, resulting in
by autogenous means in eight (27.6%), primary means in ⬎32,000 wounded, with an estimated ⬎25,000 extremity
nine (31%), and ligation in 12 (41.4%). Thus, venous repair injuries. Now, as we approach this fifth year of the war in
was undertaken in 62 of 86 (72%) femoropopliteal venous Iraq, we continue to evaluate and report the management
injuries. When autogenous interposition grafting was re- of wartime extremity vascular injury in an effort to enhance
quired, a simple great saphenous interposition graft was care of such injuries for both military and civilian settings.
used. Four saphenous vein panel grafts were performed, This report comments on current patterns of injury in the
and all were in femoral vein injuries. femoral and popliteal distribution, techniques of manage-
Temporary shunts. Our initial experience,7 as well as ment and repair, and the observed early limb salvage and
that of others,8 with the use of temporary vascular shunts in mortality rates.
Iraq has been previously detailed. For the time of this study, The prevalence of vascular injury in Iraq is twice that in
58 patients with femoral or popliteal injury were received at Vietnam. Yet, femoral and popliteal artery injury account
our institution from forward locations. Temporary arterial for 17.5% and 8.6% of vascular injuries, respectively. This is
shunts had been placed in 43 (74.1%), and 40 (93%) were somewhat reduced compared with the past. Femoral artery
patent on arrival to our facility. Our group used 11 arterial injury represented 20.9% of vascular injuries in World War
shunts as a temporary measure before definitive repair. II but was 32% to 35% in Korea and Vietnam.9-13 Popliteal
Thus, excluding isolated profunda femoris arterial injuries, arterial injuries constituted 21.7% of vascular injuries in
54 of 126 (43%) femoropopliteal arterial injuries were Vietnam and 26.6% in Korea. In contrast to 90% in prior
shunted, 20 popliteal artery injuries (45%) were temporarily wars, during OIF, extremity vascular injuries represent 75%
shunted, 31 SFA injuries (41%) were shunted, and 3 CFA of the overall distribution of vascular injury.1 There appears
injuries (38%) were shunted. Shunts used included Argyle to be a higher prevalence of neck and truncal vascular
(Tyco Healthcare/Kendall, Mansfield, Mass) and Sundt injuries in the current campaign (25%),1 partly because of
(Integra, Plainsboro, NJ) carotid shunts. All shunts were the inclusion of local nationals receiving care in US facili-
secured proximally and distally with either silk suture or ties.1,4 So, although extremity injury is occurring more
rubber vessel loops. Two of 43 shunts (4.7%) were dis- frequently, other injuries are also. This may dilute the
lodged during transport. overall contribution of femoropopliteal injury in this par-
ticular theater.
RESULTS Early amputation for penetrating femoropopliteal in-
Early limb loss and survival. Five (3.4%) early deaths jury occurred in 6.9% (10 of 145) of our cohort. When
occurred. Causes of death included multisystem organ accounting for early mortality and axial arterial injuries
failure and sepsis. No death occurred as an independent alone (8.3%), this still compares favorably with past con-
result of vascular injury or repair failure. All patients who flicts. World War II amputation rates were 53.2% for fem-
died early sustained an arterial injury in the axial femoral oral injuries and 72.5% for popliteal artery injuries.9 Many
(non-PFA) or popliteal domain. These included one CFA were treated with ligation and early amputation. Limb loss
injury, two popliteal injuries, and two SFA injuries. No from femoral injury in Korea improved to 8% owing to
patients required amputation before they died. Four deaths more consistent attempts at in-theater autogenous re-
were after IED injury (5% of IED injury) and one after pair.10-12,14-17 With this, popliteal injuries resulted in a 30%
gunshot wound (1.5% of gunshot wounds). to 40% amputation rate.12,14 In Vietnam, this approach was
In all casualties, early limb loss with femoral or popliteal further matured, and the global amputation rate stabilized
level vascular injury occurred in 10 cases (6.9%). Because all at 19% but that for popliteal arterial injury remained at
occurred in those with arterial injury, limb loss due to nearly 30%.13,18,19 Early mortality in this report is 3.5% (5
femoral or popliteal arterial injury was 10 of 134 (7.5%). Of of 142). In Korea, 13% died early,10-12,14-17 and there was
legs lost, all sustained concomitant venous injury. Early a 1.7% mortality13,18,19 for all vascular injuries in Vietnam.
limb loss in survivors with arterial injury occurred in 10 of What are the factors effecting this reduced early ampu-
129 limbs (7.8%), and excluding limbs with a PFA injury as tation rate? Although this is difficult to determine objec-
their solitary arterial injury, 10 of 121 (8.3%). Early ampu- tively, theater attributes may be relevant. The contempo-JOURNAL OF VASCULAR SURGERY
Volume 47, Number 6 Woodward et al 1263
rary medical evacuation system has provided a time to care This report has some other significant limitations. The
which is now roughly 90 minutes.20,21 This contrasts to 10 Balad Vascular Registry, owing to its descriptive, retrospec-
to 15 hours reported in World War II and Korea.9,10 tive nature, is subject to constantly rotating surgeons who
Progress was made in Vietnam, with some 80% of casualties may have different styles of data collection and patient
in that conflict arriving at surgical care within 5 hours.22 management. Follow-up is limited to the early postinjury
These results also suggest the improved theater manage- period. In Iraqi patients, longer evaluation is not possible.
ment structure in place in OIF is effective. Most are transported to our facility from remote locations.
The use of temporary shunting is not new, but its use in When discharged, they return back to their points of origin,
civilian centers remains controversial.23-26 Earlier wartime with follow-up unreasonable. American casualties are evac-
experiences are scant.27 In Iraq, proximity to surgical care, uated from Iraq early, making direct follow-up impossible.
limited resources, and casualty flow have lent themselves to Data are gathered using weekly teleconferences with cen-
temporary shunting. Indeed, 40% of femoral and popliteal ters in Germany and CONUS.
arterial injuries in this report were shunted. This has expe- These specific issues have driven the military vascular
dited re-establishment of perfusion before definitive repair. surgery community to collectively focus on pursuing later
Animal studies using carotid shunts have indicated systemic evaluation of those with vascular injury by way of the newly
anticoagulation is unnecessary, with adequate shunt patency established Global War on Terrorism Vascular Injury Ini-
for ⬎24 hours.28 We have noted shunts in the femoropopli- tiative. Longer-term study of those in the Balad Vascular
teal distribution do quite well in patients as they are evacuated Registry is needed. Also, studies are ongoing to evaluate the
to higher levels of care.7 This is further confirmed in this significance of various aspects of shunting, including ve-
report. Although it is difficult to parse the definitive, indepen- nous shunting, shunt size, flow and timing effects, and
dent influence of shunting owing to the heterogeneity of these pharmacologic therapeutic shunting. We hope these efforts
patients, the common use of shunting and the early salvage will provide insight into the understanding of vascular
results reported here are compelling. injury management and functional limb salvage.
We have been aggressive at repair of associated femoral
CONCLUSION
and popliteal venous injury, as seen in our overall 72%
repair rate. The independent influence of wartime venous Penetrating femoropopliteal injuries continue to be
injury on limb loss and morbidity was established by Rich common in present day warfare. Acceptable limb salvage
et al.29-32 Venous repair in extremity injury has been re- and mortality rates after femoropopliteal injury are being
futed in some literature, however, and the superiority of achieved in OIF and are similar to current civilian experi-
this liberal application of venous repair remains statistically ences. This experience shows progress compared with re-
unproven. Nevertheless, with the extensive soft tissue in- sults from Vietnam. This may be due to an aggressive use of
jury and varying degrees of penetrating injury seen in Iraq, shunting, fasciotomy, and venous repair in these injuries. A
this attitude appears to have served well. In addition, it comprehensive registry is necessary to help answer ques-
should be noted that all limbs lost in this experience had tions surrounding long-term outcomes.
associated venous injury. The generous use of fasciotomies We would like to acknowledge and thank all of the
also has proven itself, as noted. surgeons, nurses, and medical personnel who worked self-
Comparisons with current civilian experiences appear lessly to care for these patients.
noteworthy. A 10.8% amputation rate for femoropopliteal
injuries was reported in a South African description.33 AUTHOR CONTRIBUTIONS
Other relatively recent communications have produced Conception and design: EW, WC
similar results.34-37 Asensio et al36 detailed 298 femoral Analysis and interpretation: EW, WC, TR
vessel injuries in Los Angeles, 86% of which were penetrating. Data collection: EW, WC, JE, MP, AB, MC, WJ, TR
Early limb loss occurred in 3%, early mortality was 9%, and Writing the article: EW, WC, TR
23% experienced significant complications. Independent pre- Critical revision of the article: EW, WC, JE, MP, AB, MC,
dictors of mortality were Injury Severity Score (ISS) ⬎25, two WJ, TR
or more hard signs of vascular injury, coagulopathy, age ⬎45 Final approval of the article: EW, WC, JE, MP, AB, MC,
years, and a Glasgow Coma Scale of ⬍8. WJ, TR
Outcomes analysis from popliteal vascular injuries in Statistical analysis: EW, WC
the National Trauma Data Bank reported amputation was Obtained funding: Not applicable
required in 9% of those with penetrating injury.37 Associ- Overall responsibility: EW
ated fractures, nerve injury, and complex soft tissue wounds
were independently associated with limb loss. The environ-
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DISCUSSION
Dr Vincent L. Rowe (Los Angeles, Calif). Thank you, how many surgeons were fellowship-trained in vascular surgery?
society, for inviting me to be a discussant. The manuscript With regard to the patient follow-up, my question is what was the
entitled “Penetrating Femoropopliteal Injury During Modern average follow-up of patients treated? Short follow-up is men-
Warfare: Experience of the Balad Vascular Registry” provides tioned in the manuscript but the actual length of follow-up is not
detail into the current patterns of injury in the femoropopliteal defined.
arterial region, techniques of repair, the early limb salvage, and In 2001 Norman Rich et al documented the distribution of
mortality rates during the current mission of Operation Iraqi vascular injury, amputation rates and lessons learned from each
Freedom. The authors utilized a vascular registry to comprise time of major conflict. Dr Rich documented that in World War II,
the information on each patient. The authors also acknowledge the preferred method was ligation for vascular injuries and ampu-
that due to the rotation of staff surgeons with different methods tation rates were quite high. Later in the Korean conflict, due to
of data collection, the completeness of the database and long- progress in vascular surgical techniques and implementation of
term patient follow-up were shortcomings of the paper. Because helicopter transport, the amputation rates decreased to 13%. In the
of the surgeon rotation that was in place, what was the average Vietnam conflict, where primary repair for venous injuries was
level of training in vascular surgery for each of the surgeons preferred, similar amputation rates to the Korean conflict were
involved in the care of these patients? Also, more specifically, observed.JOURNAL OF VASCULAR SURGERY
Volume 47, Number 6 Woodward et al 1265
In this manuscript the authors do make comparisons between In regards to noticing differences in amputation rates between
this current mission and past times of conflict. The authors state those shunted and those who were not shunted, this was not
that regional heparinization, fasciotomies, as well as temporal specifically reviewed by this report, but it would be very interesting
arterial shunting played important roles in their management of to look at this. My feeling is that it does contribute to limb salvage
vascular injuries and decreasing amputation rates to 6.9%. I have as it limits ischemic time as these patients are being flown back and
the following questions: Did the authors see a difference in ampu- forth throughout theater.
tation rate with these patients that had arterial shunts in place on In regards to the question of why we did not include patients
arrival to their unit as compared to those that did not? Also, the who underwent primary amputation and if that is consistent with
authors did not include patients treated with primary amputations past reports, I would answer that by saying that we did not include
in their analysis. Please explain why, and is the consistent with the those patients because we wanted this report to be an assessment of
amputation rates that are quoted in prior times of conflict? our ability to repair these wounds, so that if we did not intervene or
Were there any predictors for failure or success in terms of try to repair the injury it was not included. The accounts from
concomitant injuries, bony injuries that can be reported from this World War II included primary amputations because at that time
registry? ligation and amputation was the standard treatment. The reports
And lastly, do the authors see their form of management for from Korea and Viet Nam used in this report did not include
vascular injuries being applicable to civilian traumatic arterial inju- primary amputation, as autogenous methods of repair were start-
ing to be utilized and developed.
ries?
As far as any predictors of success or failure or lessons learned,
I’d like to thank the authors for providing the manuscript to
the need for routine fasciotomy is one lesson. Oftentimes you
me in a timely manner and for their role in the ongoing success of
cannot tell at the time of initial injury whether the patient requires
Operation Iraqi Freedom.
fasciotomy or not. One thing that has to be learned by surgeons
Dr Edward Woodward. Dr Rowe, thank you for your com- arriving in theater is that these injuries that are being seen are
ments and questions. To address them sequentially, concerning completely different than anything that has been seen stateside.
the average level of training for surgeons stationed at Balad, there They are often wounded by mechanisms involving very high
is always one dedicated slot for a certified vascular surgeon, so there velocities and extensive destruction of soft tissue. Also the need for
is always one certified vascular surgeon at Balad. In addition, serial tissue débridement is something that is stressed over there.
depending on the rotation, there may be general surgeons or These wounds are often very contaminated and the initial destruc-
cardiac surgeons who are in place who may be comfortable with tion of soft tissue may not become apparent until after many serial
performing vascular repairs. débridements. Also the use of the wound V.A.C. between débride-
Concerning the question of average length of follow-up of ments is helpful to resuscitate tissue and allow these dirty wounds
patients treated, it was not specifically calculated; however, it to be closed usually within 3 to 4 days of V.A.C. treatment and
tended to be approximately 1 week for Iraqi casualties, and then repeated débridements.
they were discharged from the hospital. One difficulty with Iraqi In addressing the question of applicability of our treatment
patients is that many of them are air-evacuated to our hospital from modalities in Iraq to civilian management; yes, I think some of the
remote locations, and at the time of discharge, they are flown back principles can be applied, such as shunting during bony fixation to
to those locations so follow-up is very difficult—if not impossible—for limit ischemic time of the injury, but again, these are very different
that population. For US casualties, approximately 5 to 7 days for wounds than are seen at civilian trauma centers, so not all manage-
US forces. That is the time that it takes for them to reach stateside. ment strategies may be applicable to a civilian setting.You can also read
