War injuries of the femoral artery and vein: a report on 67 cases.

During the war in Croatia (from May 1991 to December 1995), 67 patients with war injuries of the femoral vein and/or artery were treated at the Surgical Clinic of Split Clinical Hospital. All the wounded were admitted directly from the battlefield or from front-line hospitals. There were five women and 62 men with a median age of 29 (range 15-54) years. There were 70 arterial (28 isolated) and 49 venous injuries (six isolated). Forty-six arterial injuries were repaired by reverse vein graft. Four proximal profound femoral arteries were reconstructed. Major venous injuries were repaired, 11 by compilation autogenous vein graft. No synthetic grafts were used. Repair of veins with large defects using compilation saphenous vein grafts gave good results. Six profound femoral veins and two superficial femoral veins were ligated. Vein ligation should be avoided unless another life-threatening injury demands priority. Twenty-one patients required open prophylactic fasciotomy. Two patients died (3%) and three ultimately underwent amputation (5%). Intermittent hyperbaric oxygen therapy was given to 18 heavily wounded patients with beneficial effect. The results support an immediate and coordinated approach to femoral vascular trauma with repair of arterial and venous injuries.

[Vascular injuries in war]. / Gefässverletzungen im Krieg.

OBJECTIVE: This paper reviews military vascular injuries in Southern Croatia. BACKGROUND: Report of surgical procedures in war-related arterial and venous injuries in association with soft tissue destruction and bone involvement, with its post-operative medical and physical therapy. For vascular surgeons cases are presented, which are seldomly seen in civilian circumstances. For this reason this paper is published. PATIENTS AND METHODS: A retrospective review was done for 189 wounded (13 females, 175 males) with vascular injuries in the time period from June 1991 through December 1993. Ninety-one (48.1%) of the patients sustained injuries due to explosive weapons (different types of mines, grenades and its fragments). Extensive soft-tissue and bone destruction was associated in 55 (36.2%) wounded. The age ranged from 14 to 63 (mean 27.3) years. The operative techniques involved the debridement of devitalised and infected tissue, prophylactic fasciotomy, the reconstruction of major venous injuries, application of microsurgical techniques in selected cases and the extensive use of autogenous interposition grafts. The wounds were treated by secondary closure and routinely antibiotics were given. In selected cases an arteriography was performed preoperatively. Vascular injury with a prolonged time of ischemia were the most common indication for hyperbaric oxygenation (HBO). RESULTS: Six (3.2%) patients died from associated severe injuries. In sixteen (15.1%) cases a subsequent amputation had to be performed. CONCLUSIONS: The results of this study support the reconstruction of major vessel damage in order to save a limb. Careful and regular follow-up examinations also by other medical specialties proved to enhance a positive outcome for this severely injured patients. We also suggest the extensive use of HBO in war casualties.

War injuries of the crural arteries.

Twenty-eight patients with military crural vascular injuries are presented. In the group undergoing immediate repair (21 patients), the time interval between trauma and surgery was 20 min to 30 h (mean 8 h 30 min). In those receiving delayed repair (seven patients), the interval between trauma and surgery was 3-47 (mean 14) days. Hyperbaric oxygenation therapy was used in conjunction with surgery and antibiotic therapy in 13 of the 28 patients. Explosive injuries were found in 14 patients and high-velocity missile injuries in nine; associated fractures were present in 20. Twenty of the 28 patients with crural vascular injuries had combined arterial and venous injuries, while eight had isolated arterial injuries. Twenty-five patients with distal ischaemia required arterial repair; five late amputations resulted. Military crural vascular injuries should be treated with soft tissue debridement, removal of foreign material, and microvascular arterial and concomitant vein reconstruction. This should be followed by external skeletal stabilization for bony and/or soft tissue instability, with fasciotomy for any associated compartment syndrome. The wound should be left open, with delayed closure or split skin grafting. It was felt that hyperbaric oxygen therapy reduced the amputation rate following combat-related crural vessel injuries.

Military injuries to the popliteal vessels in Croatia.

OBJECTIVE: The paper reviews military popliteal vascular injuries in Croatia. SUMMARY BACKGROUND DATA: Popliteal vascular injuries still pose difficult problems for vascular surgeons despite improvements in resuscitation, surgical techniques and wound coverage. Popliteal vascular injuries, both arterial and venous, with a high incidence of associated musculoskeletal injuries are presented in patients with military injuries in South Croatia. METHODS: 26 wounded with popliteal vascular injuries are presented. Explosive injuries are found in 21 and associated fractures in 9 cases. In immediate repair group the time interval between trauma and surgery was 2 to 30 hours (average 9.8 hours). In the delayed repair group the interval between trauma and surgery was 11 days to 24 days. RESULTS: 21 out of 26 patients with popliteal vascular injuries had combined arterial and venous injuries; 4 patients had isolated popliteal arterial injuries, while 8 patients had other vascular injuries along with the popliteal ones; 8 amputations resulted (30.8%). CONCLUSION: Popliteal vascular injuries caused by typical military mechanism during the war in Croatia present large and extensive defects of tissues and bones, are often associated with other injuries and require more extensive surgical therapy. Evacuation of the wounded under very difficult conditions as well as considerable organization and transportation problems are characteristic for this war and greatly affect the success of vascular reconstruction. Hyperbaric oxygen therapy offers a safe noninvasive method of improving wound healing and decreasing edema formation in popliteal vascular injuries.