Epidemiology of Vascular Injury Within the U.S. Department of Defense Trauma Registry From 2007-2023

Background: Since WWII, the incidence of vascular trauma in U.S. military casualties has steadily risen, with the highest rates having been reported from the recent conflicts in Iraq and Afghanistan. Within civilian populations, the incidence of vascular trauma is lower, but with disproportionately higher rates of mortality, morbidity, and resource use for these injuries. Analyses of trauma databases have informed technological advances that best help our U.S. Military Health System (MHS) manage vascular injuries. We sought to perform a retrospective cohort analysis in military casualties with and without vascular injuries alongside an updated descriptive assessment of vascular injuries by anatomic location seen within deployed Military Treatment Facilities (MTF). Study Design and Methods: This is a secondary analysis of a dataset from the Department of Defense Trauma Registry from 2007 to 2023. Vascular injuries were identified using clinical diagnostic codes, looking for vascular injury to a named blood vessel. Serious injuries were defined by us as an abbreviated injury scale by body region of ≥3. Results: From 2007 to 2023, our dataset included 48,301 casualties, of which 2,765 (6%) had at least one major vascular injury. Of these 2,765 casualties with a vascular injury, 34% were U.S. servicemembers and 33% were humanitarian casualties. There were 184 pediatric casualties: 17 (1%) were <4 years, 51 (2%) were 5-9 years, 80 (3%) were 10-14 years, and 36 (1%) were 15-17 years. Most vascular casualties were caused by an explosive mechanism (53%), followed by firearms (41%), motor vehicles (3%), and falls at (1%). Casualties involving a vascular injury had a higher composite injury severity score (median of 17 versus 5) with a higher percentage of serious injuries in each AIS region when compared to casualties without vascular injuries. The most common types of major vascular injury on a per-1000 basis were those involving the superficial femoral artery (8.6), radial artery (7.7), jugular vein (7.4), femoral vein (7.3), or popliteal artery (6.2). Among those with any major vascular injury, the median 24-hour blood product volume was 9 units (interquartile range 1-29). Both 24-hour survival and survival to discharge were lower for casualties with a vascular injury. Conclusions: Among military casualties who survived long enough to reach a military treatment facility with surgical capabilities, the incidence of vascular injuries was high, and these injuries were severe. Our findings support the need for adequate pre-deployment vascular training for deploying surgeons. Moreover, with future conflicts having the potential for delayed evacuation, preparing for the prolonged management of pre-hospital vascular injury in a pre-hospital setting is paramount.