War injuries of major extremity arteries

During the period 1991-1994, 99 patients (all males, median age 35 years) with combat-related injuries of major limb arteries were managed. Mechanism: mine fragments (40%), high-velocity projectiles (35%), and shotgun pellets (25%). Patients were admitted 1 hour to 16 hours (median 8 hours) after injury; 39% were in severe hemorrhagic shock. Arterial injury was diagnosed by clinical findings. Preoperative angiography was usually not necessary. Of 99 injured patients, 50 (51%) showed signs of distal ischemia and required arterial reconstruction. No primary amputation was performed. Reconstruction was always necessary in cases of injury of axillary or popliteal arteries, but not of superficial femoral or brachial arteries. Ligation of injured single forearm or crural arteries was well tolerated. End-to-end anastomosis by reconstruction was possible only in 38% of cases. In 56% of patients, autologous venous bypass was performed. Uncontrolled wound infection developed in 22% of cases, leading to a secondary hemorrhage compelling arterial ligature (8%), and thrombosis (6%). The secondary amputation rate after arterial reconstruction was 10%. Injury of major vessels was associated with limb bone fractures, nerve damage, or major vein injuries in 68% of cases, frequently on the forearm, the popliteal region, and the crural region. When limb ischemia was present, vascular reconstruction had priority over orthopedic immobilization. Arterial injury was almost always associated with the venous damage in the forearm, the popliteal region, and the crural region. Injured veins of the upper limb were ligated; venous repair was more often indicated in lower limb injury (52%). The method of choice was lateral suture/patch. Gunshot damage to peripheral nerves was rarely treated with primary repair.