Arteriography in the delayed evaluation of wartime extremity injuries

Recent combat casualties have stimulated a reassessment of the principles of management of high-risk extremity injuries with a normal vascular examination. Rapid evacuations have presented numerous U.S. soldiers to our service for evaluation in the early postinjury period. The objective of this single-institution report is to analyze the application of liberal arteriography in the delayed evaluation of modern wartime extremity injuries. Data from consecutive wartime evacuees evaluated for extremity injuries between March 2002 and November 2004 were prospectively entered into a database and retrospectively reviewed. Analysis was focused on arteriography and its role in our current diagnostic and therapeutic approach. Information including injury sites and mechanisms, associated trauma, battlefield repairs performed, arteriography technique, complications, findings, and need for further intervention were reviewed. Indications for imaging in this high-risk group included proximity to vascular structures, abnormal or equivocal physical examination, adjunctive operative planning, and evaluation of battlefield repair. Ninety-nine of 179 patients (55%) with extremity injuries underwent arteriography, with 142 total limbs studied. The majority of them were wounded by explosive devices (82%) or high-velocity rifle munitions (14%). Abnormalities were found in 75 of 142 (52.8%) imaged limbs in 46 of the 99 (46.5%) patients. Twenty-four of these patients (52.2%) required additional operative intervention. Occult vascular injury findings were associated with bony fracture in 68% and nerve injury in 16%. Median delay between injury and stateside evaluation was 6 days. Two thirds of these soldiers presented with a normal physical examination result. There were no access site complications or incidents of contrast-induced acute renal failure. The liberal application of arteriography is a low-risk method to provide high-yield data in the delayed vascular evaluation of extremities injured from modern military munitions. Physical examination findings remain the most useful indicator, but a normal examination can be misleading and should not guide the decision for invasive imaging. Lesions are found and require further intervention at a higher rate than expected from the typical civilian trauma experience.     

Optimal limb salvage in penetrating civilian vascular trauma

To evaluate current treatment of peripheral vascular trauma, we reviewed our recent experience with noniatrogenic penetrating vascular injuries of the extremities. Between 1979 and 1984, 139 patients sustained 204 vascular injuries inflicted by single gunshots (64%), stabbings (24%), and shotguns (12%). Eighty-four percent of patients underwent preoperative arteriography, which revealed occult arterial injury in 13 patients (9%). Compartmental hypertension necessitated fasciotomy in 19% of patients and was required more often after combined arterial and venous injuries (29%) than after isolated arterial injury (14%). Arterial continuity was restored by interposition grafting with reversed saphenous vein (62%), end-to-end anastomosis (19%), vein patch angioplasty (8%), or primary repair (4%). After arterial repair, completion angiography detected the need for revision in 8% of patients. Arterial ligation was performed in 7% of injuries and was only used in the treatment of tibial and distal profunda femoris injuries. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. No deaths occurred, and a single patient required amputation. We conclude that a protocol of preoperative arteriography, liberal. use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates that approach 100% after penetrating vascular trauma to the extremities.     

Management of war-related vascular wounds in French role 3 hospital during the Afghan campaign

ObjectivesTo describe the management of war-related vascular injuries in the Kabul French military hospital.MethodsFrom January 2009 to April 2013, in the Kabul French military hospital, we prospectively included all patients presenting with war-related vascular injuries. We collected the following data: site, type, and mechanism of vascular injury, associated trauma, type of vascular repair, amputation rate and complications.ResultsOut of the 922 soldiers admitted for emergency surgical care, we recorded 45 (5%) patients presenting with vascular injuries: 30 (67%) gunshot-related, 11 (24%) explosive device-related, and 4 (9%) due to road traffic accident. The majority of injuries (93%) involved limbs. Vascular injuries were associated with fractures in 71% of cases. Twelve (26.7%) had an early amputation performed before evacuation. Twenty (44.4%) patients underwent fasciotomy and three (6.6%) sustained a compartment syndrome.ConclusionsThis was the first French reported series of war-related vascular injuries during the last decade’s major conflicts. The majority of injuries occurred in the limbs. Autologous vein graft remains the treatment of choice for arterial repair. Functional severity of these injuries justifies specific training for military surgeons.     

Revascularization of the limbs using vein grafts after vascular injuries

We report on 32 patients with vascular injury of a limb undergoing a total of 41 revascularization procedures with interposition vein grafts. A combined arterial and venous injury was present in nine cases, an isolated venous injury in four, and an isolated arterial injury in 19 cases. Eighteen per cent of patients with arterial injuries had normal distal pulses on initial examination. Preoperative arteriography was performed in 12 cases, and intraoperative arteriography in four. All venous injuries were diagnosed at operation. In most cases, the contralateral greater saphenous vein was used for grafting. Four patients had postoperative thrombosis after arterial reconstruction resulting in below knee amputation in two cases. Two patients suffered from postoperative swelling caused by venous insufficiency, one after ligation of an injured axillary vein, and the other one following venous thrombosis of a superficial femoral vein repair. It is concluded that revascularization of arterial and venous injuries of the extremities with interposition vein grafts is successful in most cases resulting in low amputation rates, and should be attempted in all major vascular injuries in viable limbs.     

The continuing challenge of popliteal vascular injuries

During a 6 year period, 35 patients with 56 popliteal vascular injuries were treated. Thirty-three arteries and 23 popliteal veins were affected. Fifty-four percent of the patients had both an arterial and a venous injury. Twenty injuries were due to penetrating trauma and 15 injuries to blunt force. An overall amputation rate of 16 percent followed attempts at vascular repair. Blunt injuries were associated with a 30 percent amputation rate, whereas penetrating injuries were associated with only a 5 percent amputation rate. When our results were reviewed and compared with those of others, several factors important for determining the rate of limb salvage in popliteal vascular injuries were noted: (1) early recognition and prompt treatment, (2) absence of blunt injury with attendant soft tissue damage; (3) resection of damaged arterial tissue with end-to-end anastomosis or saphenous vein grafting in conjunction with the liberal employment of local heparin and a Fogarty catheter thrombectomy, (4) repair of concomitant popliteal venous injuries; (5) use of completion arteriography to reveal technical errors amenable to correction at time of operation; and (6) fasciotomy, used liberally but selectively.     

Delayed evaluation of combat-related penetrating neck trauma

OBJECTIVE: The approach to penetrating trauma of the head and neck has undergone significant evolution and offers unique challenges during wartime. Military munitions produce complex injury patterns that challenge conventional diagnosis and management. Mass casualties may not allow for routine exploration of all stable cervical blast injuries. The objective of this study was to review the delayed evaluation of combat-related penetrating neck trauma in patients after evacuation to the United States. METHOD: From February 2003 through April 2005, a series of patients with military-associated penetrating cervical trauma were evacuated to a single institution, prospectively entered into a database, and retrospectively reviewed. RESULTS: Suspected vascular injury from penetrating neck trauma occurred in 63 patients. Injuries were to zone II in 33%, zone III in 33%, and zone I in 11%. The remaining injuries involved multiple zones, including the lower face or posterior neck. Explosive devices wounded 50 patients (79%), 13 (21%) had high-velocity gunshot wounds, and 19 (30%) had associated intracranial or cervical spine injury. Of the 39 patients (62%) who underwent emergent neck exploration in Iraq or Afghanistan, 21 had 24 injuries requiring ligation (18), vein interposition or primary repair (4), polytetrafluoroethylene (PTFE) graft interposition (1), or patch angioplasty (1). Injuries occurred to the carotid, vertebral, or innominate arteries, or the jugular vein. After evacuation to the United States, all patients underwent radiologic evaluation of the head and neck vasculature. Computed tomography angiography was performed in 45 patients (71%), including six zone II injuries without prior exploration. Forty (63%) underwent diagnostic arteriography that detected pseudoaneurysms (5) or occlusions (8) of the carotid and vertebral arteries. No occult venous injuries were noted. Delayed evaluation resulted in the detection of 12 additional occult injuries and one graft thrombosis in 11 patients. Management included observation (5), vein or PTFE graft repair (3), coil embolization (2), or ligation (1). CONCLUSIONS: Penetrating multiple fragment injury to the head and neck is common during wartime. Computed tomography angiography is useful in the delayed evaluation of stable patients, but retained fragments produce suboptimal imaging in the zone of injury. Arteriography remains the imaging study of choice to evaluate for cervical vascular trauma, and its use should be liberalized for combat injuries. Stable injuries may not require immediate neck exploration; however, the high prevalence of occult injuries discovered in this review underscores the need for a complete re-evaluation upon return to the United States.     

Verletzungsmuster und -ursachen in modernen Kriegen

Epidemiological analyses of injury patterns and mechanisms help to identify the expertise military surgeons need in a combat setting and accordingly help to adjust infrastructure and training requirements. Therefore, a MEDLINE search (1949–2009), World Wide Web search (keywords “combat, casualties, war, military, wounded and neurosurgery”) and an analysis of deaths among allied war casualties in Afghanistan and Iraq were performed. Up to 10th December 2009 there had been 4,688 allied military deaths in Iraq and 1,538 in Afghanistan. Of these 22% died in non-hostile action, 33% in direct combat situations and the majority of 45% in indirect combat actions. The leading causes of injury were explosive devices (70%) and gunshot wounds. Chest or abdominal injuries (40%) and traumatic brain injuries (35%) were the main causes of death for soldiers killed in action. The case fatality rate in Iraq is approximately half that of the Vietnam War, whereas the killed-in-action rate in Afghanistan (18.7%) is similar to the Vietnam War (20%); however, the amputation rate is twice as high in modern conflicts. Approximately 8–15% of the fatal injuries seem to be potentially survivable. Military surgeons must have an excellent expertise in a wide variety of surgical specialties. Life saving emergency care, especially in the fields of thoracic, visceral and vascular surgery as well as practical skills in the fields of neurosurgery and oral and maxillofacial surgery are required. Additionally, it is of vital importance to ensure the availability of sufficient tactical and strategic medical evacuation capabilities for the wounded.     

Kriegschirurgische Versorgung von Gef??verletzungen der Extremit?ten

Delivery of combat health support means a challenge for personnel and material. Past military conflicts have provided lessons for civilian surgical practice, whereas nowadays civilian experiences influence military surgical practice in the austere environment of today??s battlefield. Due to high explosives, ammunition and high-velocity missiles and also improved body armor, military surgeons have to deal with devasting extremity trauma, which has not been seen routinely in former conflicts because survival was not possible due to core injuries. Extremity injuries represent 50?C75% of all injuries sustained by soldiers and 15% of wounded soldiers die of exsanguination from extremity wounds. The bleeding from some of these injuries can be arrested by a tourniquet, direct pressure and/or hemostatic dressing application in the field allowing for casualty evacuation. Nevertheless, 4.4?C7% of all injuries need definitive vascular surgical treatment because of ongoing life and limb-threatening hemorrhaging and ischemia. From routine ligation of vascular injuries in World Wars I and II surgeons adapted to principles of in-theater repair of arterial and venous injuries in Korea and Vietnam. Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) provided the first opportunities since Vietnam for the development of a registry of vascular injuries, the re-evaluation of established vascular surgical principles under austere conditions and adaptation where necessary. The aim of the following article is to provide information on the current management of wartime vascular injuries on the basis of U.S. experiences in the on-going conflicts OIF/OEF.     

Popliteal artery injuries in an urban trauma center with a rural catchment area: do delays in definitive treatment affect amputation?

Extended length of time from injury to definitive vascular repair is considered to be a predictor of amputation in patients with popliteal artery injuries. In an urban trauma center with a rural catchment area, logistical issues frequently result in treatment delays, which may affect limb salvage after vascular trauma. We examined how known risk factors for amputation after popliteal trauma are affected in a more rural environment, where patients often experience delays in definitive surgical treatment. All adult patients admitted to the Level I trauma center, the University of Mississippi Medical Center, with a popliteal artery injury between January 2000 and December of 2007 were identified. Demographic information management and outcome data were collected. Body mass index, mangled extremity severity score (MESS), Guistilo open fracture score, injury severity score, and time from injury to vascular repair were examined. Fifty-one patients with popliteal artery injuries (53% blunt and 47% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. Patients requiring amputation had a higher MESS, 7.8 versus 5.3 (P < 0.01), and length of stay, 43 versus 15 days (P < 0.01), compared with those with successful limb salvage. Body mass index, injury severity score, Guistilo open fracture score, or time from injury to repair were not different between the two groups. Patients with a blunt mechanism of injury had a slightly higher amputation rate compared with those with penetrating trauma, 25.9 per cent versus 8.3 per cent (P = non significant). MESS, though not perfect, is the best predictor of amputation in patients with popliteal artery injuries. Morbid obesity is not a significant predictor for amputation in patients with popliteal artery injuries. Time from injury to repair of greater than 6 hours was not predictive of amputation. This study further demonstrates that a single scoring system should be used with caution when determining the need for lower extremity amputation.     

Vascular trauma to the lower extremity: the Lebanese war experience

The authors' experience with 386 patients who were operated on for vascular injuries to the lower extremities is reviewed. Of these, 118 had popliteal injuries, 252 had femoral injuries and 16 had tibial injuries. The overall mortality rate was 2.33% with no mortality in the popliteal and tibial injuries group whereas there were nine deaths in the femoral injuries group. The overall amputation rate was 5.95%, with 3.17% amputation rate for the femoral injuries group versus 11.86% for the popliteal injuries group and 6.25% for the tibial injuries group. Delay in repair (more than 6h from injury), associated femoral fractures and shocked condition on admission led to increased amputation rate. Prompt surgical repair, arterial as well as venous repair for popliteal and femoral injuries especially if femoral fracture is present, external skeletal fixation and/or traction, and fasciotomy when necessary led to improved limb salvage.     

Noninvasive diagnosis of vascular trauma by duplex ultrasonography

Duplex ultrasonography was used prospectively in the initial evaluation of 198 patients with 319 potential vascular injuries of the neck and extremities. Patients who were unstable or who had obvious arterial trauma were excluded. Injury was caused by gunshot in 104 (53%), blunt trauma in 42 (21%), stab wound in 34 (17%), and shotgun in 18 (9%). Duplex ultrasonography correctly characterized and localized vascular injuries in 23 patients: arterial disruptions (13), intimal flaps (4), acute pseudoaneurysms (3), arteriovenous fistulas (2), and shotgun pellet arteriopuncture (1). Nineteen other patients had vasospasm (13) or external compression (6) without evidence of intrinsic vessel injury, these 42 studies had true-positive results. Twenty patients underwent arterial repair (13 on the basis of duplex ultrasonography alone), one had primary amputation, three required fasciotomy, and 18 were observed. Two patients with false-negative results had minor shotgun pellet arteriopunctures that were missed by duplex ultrasonography, but neither needed repair. One hundred fifty-three patients had true-negative results on duplex ultrasonography: all clinically had only proximity injuries and easily palpable distal pulses. The result of one duplex ultrasonography study was found to be false-positive on arteriography. The sensitivity of duplex ultrasonography was 95%, the specificity was 99%, and the overall accuracy was 98%. These results closely approximate those reported with the use of exclusion arteriography in the evaluation of similar vascular trauma patients. Furthermore, duplex ultrasonography has no interventional risks and is more cost-effective for screening such injuries than arteriography or exploration. Duplex ultrasonography is a reliable method of diagnosis in patients with potential peripheral vascular injuries.     

Management of small artery vascular trauma.

This 11-year retrospective study reviewed 99 arterial injuries distal to the brachial bifurcation or popliteal trifurcation in 89 extremities in 88 patients. Associated injuries occurred in 78 of 88 (89%) patients, including 10 fractures or dislocations, 66 nerve injuries, and 59 single or multiple tendon injuries. Fasciotomy was performed in 9 upper extremities and 11 lower extremities (23% of patients). The selection of operative treatment by arterial repair or ligation was by surgeon choice (52% repair and 48% ligation). Postoperative patency was found in 45 of 47 (96%) repaired arteries. In cases of isolated single arterial injuries (10), there were excellent results, and there was no difference in the results between repair and ligation. In cases of nonisolated single arterial injuries (69), there were 46% and 36% nonvascular complications in the repaired and ligated groups, respectively. In 10 patients with nonisolated multiple arterial injuries in the same extremity, the results of repair of one artery with ligation of the other artery versus repair of both arteries were identical, and there were no vascular complications. Operative exploration was the key to complete evaluation of vascular and neuro/musculoskeletal injuries. The data suggest that one functional artery distal to the elbow or knee is sufficient for limb viability and vascular function (follow-up range: 0 to 110 months; mean: 12 months). Nerve injury was the single most important factor of extremity injury in terms of the degree of functional loss.     

The complete management of extremity vascular injury in a local population: a wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base, Iraq

BACKGROUND: Although the management of vascular injury in coalition forces during Operation Iraqi Freedom has been described, there are no reports on the in-theater treatment of wartime vascular injury in the local population. This study reports the complete management of extremity vascular injury in a local wartime population and illustrates the unique aspects of this cohort and management strategy. METHODS: From September 1, 2004, to August 31, 2006, all vascular injuries treated at the Air Force Theater Hospital (AFTH) in Balad, Iraq, were registered. Those in noncoalition troops were identified and retrospectively reviewed. RESULTS: During the study period, 192 major vascular injuries were treated in the local population in the following distribution: extremity 70% (n=134), neck and great vessel 17% (n=33), and thoracoabdominal 13% (n=25). For the extremity cohort, the age range was 4 to 68 years and included 12 pediatric injuries. Autologous vein was the conduit of choice for these vascular reconstructions. A strict wound management strategy providing repeat operative washout and application of the closed negative pressure adjunct was used. Delayed primary closure or secondary coverage with a split-thickness skin graft was required in 57% of extremity wounds. All patients in this cohort remained at the theater hospital through definitive wound healing, with an average length of stay of 15 days (median 11 days). Patients required an average of 3.3 operations (median 3) from the initial injury to definitive wound closure. Major complications in extremity vascular patients, including mortality, were present in 15.7% (n=21). Surgical wound infection occurred in 3.7% (n=5), and acute anastomotic disruption in 3% (n=4). Graft thrombosis occurred in 4.5% (n=6), and early amputation and mortality rates during the study period were 3.0% (n=4) and 1.5% (n=2), respectively. CONCLUSIONS: To our knowledge, this study represents the first large report of wartime extremity vascular injury management in a local population. These injuries present unique challenges related to complex wounds that require their complete management to occur in-theater. Vascular reconstruction using vein, combined with a strict wound management strategy, results in successful limb salvage with remarkably low infection, amputation and mortality rates.     

Management of military vascular injuries.

BACKGROUND: Vascular injuries caused by high-velocity military missiles during war present large and extensive defects of tissues and bones, are often associated with other injuries. In this study we will discuss the surgical strategy and results of military vascular injuries. METHODS: A retrospective review of records of 63 patients treated between January 1995 and December 1999 was undertaken. RESULTS: The mean age of the wounded was 22.3 years (range, 20 to 37 years). The mean time for evacuation from the place of injury to the hospital was 2.3 hours (range, 15 min to 10 hrs). There were 58 (76.3%) arterial and 18 (23.7) venous injuries. Vascular injuries concomitant with 28 (36.9%) bone fractures, six (7.9%) nerve injuries, nine (11.8%) hemopneumothorax and one (1.3%) abdominal injuries. The treatment of the injured arteries were 39 (51.3%) saphenous vein interposition grafting, 13 (17.1%) end to end anastomosis, 12 (15.7%) primary suture, seven (9.2%) synthetic graft replacement. Three patients (3.9%) died because of hypovolemic shock. Five patients underwent amputation (6.6%) and fasciotomy was performed after vascular repair in 11 cases (14.5%). CONCLUSIONS: At the military vascular injuries, the right timing, and also prompt treatment save the life of the patients and give better qualified living to the patient.     

Vascular injuries--management in a non-university central hospital]

In a retrospective study the surgically treated vascular injuries (n = 35) of the last 10 years were evaluated. One third of the patients had multiple trauma and in 57% of the cases vascular injury was accompanied by a fracture. All patients (n = 28) except those who underwent delayed amputation (amputation rate 14%) have been followed personally for an average of 5.1 years. 90% of these patients showed an excellent or acceptable longtime result in regard to vascularity, nobody complained of claudication. Diagnosis of a vascular injury was mostly confirmed by direct surgical exploration, only one third of the lesions were diagnosed by arteriogram. A positive signal in Doppler examination does not exclude vascular injury and therefore cannot replace arteriography or exact clinical evaluation.     

Arterial injuries

The authors review arterial injuries in 68 patients treated at Maisonneuve-Rosemont Hospital in Montreal between 1975 and 1982. Penetrating trauma caused 54.4% of these injuries, which consisted of either laceration or intimal tear with thrombosis. Arterial injuries of the extremities were predominant (58.8%). Associated injuries were frequent. Surgical repair was effected in 60 patients. End-to-end anastomosis, angioplasty and venous or prosthetic bypass grafting were the techniques used. Postoperative complications occurred in 37% of the patients. Overall mortality was 19% and was related mainly to aortic injury. The amputation rate for arterial injuries of the extremities was 15%. Prompt recognition and treatment of arterial injuries are important in order to achieve the best results.     

Isolated iliac vascular injuries and outcome of repair versus ligation of isolated iliac vein injury

Objective

The incidence of morbidity and mortality for iliac vascular injuries in the literature are likely overestimated owing to associated injuries. Data for isolated iliac vascular injuries are very limited. No large studies have reported the incidence of morbidity for repair versus ligation of isolated iliac vein injuries.

Upper Extremity Vascular Injury: A Current In-Theater Wartime Report from Operation Iraqi Freedom

Past wartime experience and recent civilian reports indicate upper extremity (UE) vascular injury occurs less often and with less limb loss than lower extremity (LE) injury. Given advances in critical care, damage control techniques, and military armor technology, the objective of this evaluation was to define contemporary patterns of UE injury and effectiveness of vascular surgical management in UE vascular injury during Operation Iraqi Freedom (OIF). From 1 September 2004 through 31 August 2005, 2,473 combat-related injuries were treated at the central echelon III surgical facility in Iraq. Patients with UE vascular injuries upon arrival were reviewed. Vessels injured were delineated. Therapeutic interventions, early limb viability, and complication rates following vascular repair were recorded. Of casualties treated during the study period, 43 (1.7%) UE and 83 (3.3%) LE vascular injuries were identified. Of the UE injuries, 11 (26%) had been operated on at forward locations and six (14%) had temporary shunts in place upon arrival at our facility. Injury levels included 10 (23%) subclavian-axillary, 25 (58%) brachial, and 10 (23%) distal to the brachial bifurcation. Two patients had multilevel injury. Twenty-eight grafts were placed, and 10 vessel repairs and eight ligations were performed. Two (4.7%) brachial interposition grafts required removal due to infection. Four (9.3%) subacute brachial graft thromboses occurred. Four (9.3%) patients underwent early UE amputation. In this most recent U.S. military evaluation of wartime UE vascular injury, UE injury appears rare, with LE injury twice as frequent. Yet, UE limb loss appears more substantial than noted previously. These findings are likely related to significant tissue destruction occurring with the combined mechanisms of injury sustained in OIF.Presented at the Sixteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Park City, UT, January 27-29, 2006.The views expressed in this report are those of the authors and do not reflect the official policy of the Department of Defense or other departments of the U.S. government.     

Emergency center arteriography.

From 1983 through 1989, 1,882 emergency center arteriograms were performed on 1,802 patients suspected of having peripheral vascular injuries. The most common indication for emergency center arteriography (ECA) was the proximity of an injury to a major vascular structure. This was the only indication in 1,712 injured extremities (91%). There were 1,510 true negative arteriograms, 294 true positives, 7 false negatives, and 14 false positives. Accordingly, the sensitivity was 95.5% and the specificity was 97.7%. The remaining 57 arteriograms were either equivocal or technically inadequate. Further evaluation of these patients uncovered an additional 11 vascular injuries. Operative intervention was required for 196 (64.3%) injuries detected by emergency arteriography. The remaining 109 injuries were considered minor and were not repaired. No complications developed in 91 patients (88%) with minor vascular injuries who were available for a mean follow-up duration of 12 months. One thousand forty-eight patients (69.4%) with negative arteriograms were followed for a mean of 18 months, and no vascular complications were noted. Emergency center arteriography is a rapid, accurate, and cost-effective technique. It is of particular value in detecting the presence of occult arterial injuries when proximity of a major vascular structure is the sole indication for arteriography. When formal arteriographic support is either unavailable or time consuming, ECA is recommended.     

Civilian arterial injuries.

During 1968-1973, 122 patients with 126 arterial injuries were treated. In 94 instances (90 patients), these injuries involved extremities. Systolic blood pressure was below 90 mm Hg upon admission in 55.6% of all patients and 37.7% of those with injuries to arteries of the extremities. The decision for operative exploration and repair of arteries of extremities was based largely on clinical grounds (shock, loss of pulse). Preoperative arteriography was needed infrequently, while operative angiography was nearly routine. Although several cases of late revascularization or traumatic thrombosis of renal artery have been reported, hypertension complicates the postoperative period, and early, aggressive approach is essential. Mortality was 10.6%, from aortic injuries. There were no deaths among patients with arterial injuries distal to inguinal ligament or thoracic outlet. The amputation rate from reconstruction failure was 1.1%, none occurring in the last 3 years of the series. The high patency rate and lack of evidence of pulmonary embolization suggest that associated venous injuries be repaired routinely. Arterial injuries represent ideal lesions (normal arterial wall with excellent run-in and run-off). Prompt treatment of shock and early, proper management of patients' mechanical disruptions will salvage many lives and most limbs.