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Introduction | Military Vascular Trauma
Introduction | Military Vascular Trauma
History and Background of Military Practice | Military Vascular Trauma
History and Background of Military Practice | Military Vascular Trauma
GWOT | Military Vascular Trauma
GWOT | Military Vascular Trauma
General Principles of Vascular Trauma | Military Vascular Trauma
General Principles of Vascular Trauma | Military Vascular Trauma
Arterial Injury | Military Vascular Trauma
Arterial Injury | Military Vascular Trauma
Extremity Vascular Injury | Military Vascular Trauma
Extremity Vascular Injury | Military Vascular Trauma
Endovascular Management of Vascular Trauma | Military Vascular Trauma
Endovascular Management of Vascular Trauma | Military Vascular Trauma
Blunt Thoracic Aortic Trauma | Military Vascular Trauma
Blunt Thoracic Aortic Trauma | Military Vascular Trauma
Neck Trauma | Military Vascular Trauma
Neck Trauma | Military Vascular Trauma

Well good afternoon everyone thanks for sticking around to hear me talk. It's been a real pleasure and honor to be able to do this at the request of Dave and Mike and having all of you attended is really nice. I'm going to speak about a topic that's kinda near

and dear to my heart. Over the last 10 years I've been in the Army Reserve and have had the chance to deploy to both Iraq and Afghanistan several times. And during that time as a vascular surgeon we are called upon to go as really

general trauma vascular and everything under the sun. But because of my specialization in vascular surgery I've really been able to learn a lot from these various conflicts and a lot of the trauma that that we've encountered. As

this is the AVIR meeting I'd like to include points that are more relevant to endovascular management of vascular trauma as well and how those are starting to come on the battlefield more and more and kind of depending on where

you are. Vascular trauma can be anything from a paper cut on your finger to blast injury from an improvised explosive device thats found and not uncommonly in the battlefield. We have civilian urban centres trauma

with stab wounds to the abdomen and the picture on the right showing aortic laceration. And we have vascular trauma which occurs in the cath lab with a femoral artery pseudoaneurysm as you can see on this picture. So trauma includes

you know various aspects of vascular disruption leading to potential complications of their vessel thrombosis and lack of blood flow or an aneurysm formation which can subsequently lead to either embolisation

or rupture.

Lessons learned during various past US military operations have really advanced our knowledge of vascular trauma surgery and these techniques can be translated to surgical practices and trauma centers

around the country and the world. Historically speaking military wartime experience gave us specific lessons and techniques that were translated into civilian surgery and critical care. Starting from the Vietnam era Korean

Conflict down to now. But as our war front is escalated on two fronts both in Iraq and Afghanistan and now some other places within the Middle East our military wartime experience has kind of had to borrow some things from civilian

in order to provide a less invasive and somewhat rapid control of hemorrhage where it relates to vascular trauma. The paradigm as far as endovascular treatment of vascular injuries in the battlefield and military trauma has kind

of changed. There have been at BAMC in San Antonio as well as at Fort Detrick in Maryland several areas of research that has been ongoing as far as surgical vascular trauma are concerned .And working in close concert with civilian

sector and industry there have been vast efforts that have been made to try to improve our vascular care especially where it relates to trauma in the battlefield. You can see that from conflicts dating back to World War II vascular

trauma has been commonplace. Back in those days there was no protective armor as we have now and thoracic trauma as well as abdominal vascular trauma were pretty much life-threatening and morbidity and mortality were extremely

high. Korean War very similar. Surgical trauma started making its way into the research sector and based on lessons learned here there was a big push within the army to develop a specific group of researchers

to look into these patterns of trauma. Vietnam war of course with improved medevac casevac capabilities with helicopters and getting patients injured at the scene to an area for treatment really improved their capability to save

lives and limbs both. And of course in the global war on terrorism both in OYF and OEF...or Operation Iraqi Freedom and Enduring Freedom... this is just escalated to a point where ability to get an injured soldier from

the battlefield to a treatment area is very rapid and moving up the escalon of treatment centers and treatment facilities within the battlefield to conus or continental United States is pretty rapid well-organized and develop

now. In my experience this is our base where we were...just to kind of give you an illustrative example kind of how spartan and remote we're located. We were what's called a level-two facility. A level two facility is basically what's called a

forward surgical team where we work in concert with special operations and also infantry units in the actual area of operations to be able to receive combat casualties by helicopter. Right behind this T wall is here was where the

helicopter would land and bring them straight into this tent which were basically set up as modular units with a basic operating room set up with two tables you can see it's pretty rudimentary in this picture. Those were

basically the front lines. Where we going to treat the soldiers to get their hemorrhage under control do damage control laparotomies and do things that were going to enable us to stabilize the patient enough to transport them to the

next level of care which would be called a level-three facility. Level three facilities have CAT scanners they have a higher level of care that can be offered to those patients. Most US soldiers are really treated expeditiously with

the goal of transporting them onwards to Germany and then the United States for definitive treatment. That didn't mean we didn't offer with immediate with life-threatening injuries some more definitive care but we try to move them

along as much as possible. But during the counterinsurgency mission back in 2011 when I had gone to Afghanistan they actually had made a push that we were treating local Nationals as well within our facilities and that got rapidly

exhausted because we had so many resources and we really were treating a lot of those folks definitively within the theater of operations. This is in Balad around 2009. Balad was

the largest air force base in Iraq which was a level-three facility. And in that facility you know we would have trauma...this is you know my crew out in the middle of the night...we would have multiple patients coming in. They

would treat them in this level three facility rapidly as much as possible with damage control airway breathing circulation and warming. And then we would move them onto the next level of care which was going to be either OR or

transport out to Germany basically a level-4 facility as we call it. This is a local national so he was treated within our hospital system for his injuries. You can see a basic setup. This is also in Balad where we had

digital subtraction angiography capabilities. But we really didn't have much in terms of guidewires catheters sheaths. I was using in angio caps basically putting them in femoral arteries and doing spot films all the

way down the leg to see if there was any vascular injury that could be identified. If I needed to treat him I didn't have the stents or balloons or anything to do it we had to do it open. But it gave us at least some diagnostic capability. Most

of the time this was only for peripheral vascular. In the intra-abdominal our capabilities were very limited. However that did change and that changed rapidly as vascular surgeons like myself and other trauma

surgeons realize that endovascular skills and techniques would be valuable in the battlefield. What happened in the Global War On Terrorism...I put a picture of myself but you can see that the body armor that I am wearing in this really

protects the torso and the pelvic areas as well as the head. So the real areas that are exposed are the arms and the legs. And that's why peripheral vascular trauma escalated so much. We had improved armored vehicles you know but improvised

explosive devices or IEDs as they're known were commonplace. And you could be sitting in a Humvee or you could be sitting in an MRAP you know IED blows up and it's the legs and the arms that are injured. Under sniper fire same thing

you know arms and legs. Torso was spared but so that really made us have to escalate our our ability to treat those extremity vascular injuries. And one of those things was tourniquet use. You know tourniquets have received good and

bad rap in the past you know. But all soldiers carry tourniquets in their

Global War On Terrorism...I put a picture of myself but you can see that the body armor that I am wearing in this really

protects the torso and the pelvic areas as well as the head. So the real areas that are exposed are the arms and the legs. And that's why peripheral vascular trauma escalated so much. We had improved armored vehicles you know but improvised

explosive devices or IEDs as they're known were commonplace. And you could be sitting in a Humvee or you could be sitting in an MRAP you know IED blows up and it's the legs and the arms that are injured. Under sniper fire same thing

you know arms and legs. Torso was spared but so that really made us have to escalate our our ability to treat those extremity vascular injuries. And one of those things was tourniquet use. You know tourniquets have received good and

bad rap in the past you know. But all soldiers carry tourniquets in their pockets. Sometimes two and three because you never know when you're gonna get hit even sitting in a hospital zone we have

people who are getting hit by incoming mortars. And so the infantry guys get it the worst but all soldiers are at risk. So you have a guy with the trauma or a girl with a trauma to the extremity applying a tourniquet rapidly can be limb saving

and also life-saving. Things that have improved really have been used of temporary vascular shunts in order to restore perfusion to an affected extremity so we can transfer them on- words for definiteive care. Particularly

where there's large contaminated wounds. Performing fasciotomies routinely on everybody...which I'll show a picture of that. Negative pressure wound therapy with wound vac application. And in theater repairs which as I alluded to earlier we

tried not to do definitive repairs on a lot of things as much as we could. But because that we had sometimes no choice of thoracic aortic injury had to be treated in in theater we were able to convince you know army and

and higher levels in the department of defense to provide those capabilities and they've been very good about it. And of course endovascular technologies which are going to get into is too far as what's going on with with current

This is just a diagram of the levels of care you know starting from level one which is the most basic aid station to level 2 FST or forward surgical team capabilities. Level three...level 2 / level

three...which are basically combat surgical hospitals which you'll see in big cities. In Afghanistan you'll see that in basically Bagram which is outside of Kabul and Kandahar and there was one that's no longer there on the

east part of Afghanistan. And then of course Iraq Baghdad Green Zone and Balad were the two big ones. And then of course level three / level 4 are more Air Force run bigger hospitals that have pretty much the same care that you can provide

the United States for a level four but you know....for level 3 excuse me.... but then level four would be Germany and level 5 will be United States. General

principles of vascular trauma. Makes sense right. Stop the bleeding and

restore perfusion to the affected anatomic distribution. You need to be able to diagnose this rapidly provide stability repair or ligate the affected blood vessel. Sometimes that still requires open direct repair and that's

usually where there's large contaminated wounds. Bypass can be offered to that patient depending on the particular clinical situation. We had several patients in Iraq who were Iraqi National Army and Iraqi police

forces that we were working in conjunction with and they didn't have the capability of transporting those all of those soldiers to Germany or back to the United States. So we had to do definitive bypass procedures for femoral popliteal

typical vessel injuries that they encountered. And of course endovascular repair using stents and of course coils to arrest bleeding or covering injured vessel which have started to become you know more commonly used. Of

course you know coils more commonly than stents and that's primarily because you know you can stop bleeding with the coils the stent's not always capable of stopping things with multiple injuries. This says your battery is very low seven

percent. I don't know I just didn't want to die out on us. Moving on general principles of trauma always start with your ABC's airway breathing circulation. Establish your large-bore IV lines external compression and touriquet

application. We look for soft signs and hard signs we call them of arterial injuries. Those are clinical...basically clinical identifier is that can tell us are there potentially a vascular injury. Because

you know you have an injured soldier who is hypothermic acidotic has you know multiple bullet wounds or shrapnel injuries. You don't know could you have hit an artery maybe maybe not. But obviously it's

paramount for us based on certain things to go ahead and diagnose that. And we treat everyone like they have one until we rule it out. You get the appropriate imaging where capable in level 3 and level 4. Or level 3 and higher we have a

CAT scanner. We have some sort of digital subtraction angiography to be able to diagnose these types of injuries and that's where it becomes important. Questions. Is this blunt or penetrating

injury? That becomes very paramount

because it can tell the complexity of the repair that may be required. If it's a penetrating injury maybe a single vessel that may be affected. It maybe one area of that blood vessel that can be repaired. If it's multiple times it's

going to be blunt injury can be a crush injury and large vascular distributions can be affected. We ask if it's arterial or venous. We ask how stable the patient is. We have to ask can I take this patient to the

operating room. You know we have a famous saying in surgery. Error. We are to OR before resuscitation in the middle is an error. So that's why we have to ask those important questions. For arterial injuries

you're going to see obvious signs of external bleeding end-organ or extremity ischaemia a pulsatile hematoma or internal bleeding with shock...the hard signs Soft signs are diminished pulse location or proximity to an injury or an artery or

some degree of neurologic dysfunction that might potentially be due. These are kind of our clinical signs that we use in immediate examination of a patient. Venus injury generally low pressure dark blood external bleeding non

expanding hematomas and shock is rare and less associated with an arterial injury. But major venous injuries either pelvic or abdominal can present with the with some really profound symptoms. We look at blood

vessel areas partial lacerations transections contusions pseudoaneurysm or external compression. Usually those patients are the ones that have femur fractures or dislocated knees joints that can basically once

they're reduced or fixed these orthopedic injuries you'll get improvement in circulation almost rapidly. Asking should I take the patient to the operating room or do further investigations? Any patients with

the following signs should not wait. Any external bleeding obviously expanding hematoma with shock or limb ischaemia. Hospital-based iatrogenic trauma you see it with venous central venous access hematomas local or central guidewire

puncture of innominate vein SVC or right atrium. Arterioles obviously we do that all the time in the cath lab with our diagnostic and therapeutic angiograms with catheterization. You can get pseudo- aneurysm arterial dissection and

thrombosis distal embolization leading to basically limb ischaemia and of course AV fistula formation. Pseudoaneurysms - walled-off extra luminal circulation of the blood as a result of arterial wall destruction can occur also

due to shrapnel injuries in the battlefield but very commonly we all see these in the cath lab. Moving a little bit fast through this. We use conservative management for smaller sizes. Ultrasound-guided compression and

then of course duplex directed thrombin inejction and surgery. Want to show you an interesting case we have here as well. Pseudoaneurysm indications for surgical intervention ongoing bleeding limb ischaemia nerve compression anything to

need aggressive anitcoagulation or threatened skin viability and a pseudoaneurysm surrounded by large hematoma. Here's an example of a large pseudoaneurysm that's caused skin

compromise. Community-based trauma. Not dissimilar in certain sense. More knife penetrating and gunshot wound injuries and impaled objects blunt trauma or associated with a lot of orthopedic and neurologic injuries. You have an open

book pelvic fractures you have thoracic- aortic transections from MVAs from rollovers and they can be obviously more often multi-system. But once again we see this a lot in the battlefield as well particularly where it relates to soldiers driving

an uneven terrain the mountains of Afghanistan the deserts of Iraq. These vehicles are unstable with very heavy bases and a lot of these civilian type trauma vascular injuries and nonvascular injuries

we've seen in the battle is well. And that's why we've worked closely in concert with our civilian counterparts to improve these trauma outcomes. Extremity vascular injuries 10%

follow penetrating external injury 1%

falling blunt extremely injury. 25% to 75% of popliteal artery injuries are due to blunt trauma. This is a picture of a gentleman who came in from the battlefield with multiple shrapnel wounds. As you can see

there's a tourniquet applied in his upper thigh and here we're evaluating them in the emergency resuscitative area and...I think this was in Afghanistan... but yet nonetheless you know they're doing Doppler examinations of him to

determine what needs to be done as we loosen the tourniquet checking for pulses and obviously hard signs of bleeding. These are examples of a patient with the popliteal artery dislocate a... excuse me...a posterior knee dislocation with

a popliteal artery compromise. This is a distal femur fracture as you can see right here and complete cessation of blood flow. And with restoration a reduction of that fracture you can see that the angiogram

subsequently shows improve circulation through this vessel. As surgeons when we take them to the operating room we are looking to see if we have inflow. To have uninterrupted blood flow. Do I have enough blood coming into the feeding

vessel. Answer is yes...perfect move on to looking at the rest of it. Do I have something that I can use to bypass or repair this blood vessel. Autologous tissue is obviously preferred. We don't in battlefield use prosthetic

conduits unless until we have to do it temporarily and in that case we would use a shunt. And there enough outflow to sustain the new construction. We must clear that of thrombus and sometimes we will do a venous repair or

AV fistula creation in order to maintain the viability of that bypass. Be prepared to do it an on table angiography which we always recommend if there's time and obviously capabilities. Watch the clock.

Keep in mind the time from injury shunting with damage control because sometimes required even in civilian trauma with prepare for definitive... excuse me with return for definitive repair. What should you do in the OR. Chuck Fox

who is now Colonel in Maryland and he's had a lot of experience and one of my mentors in the military always called it get good exposure. Go ugly early. We had a suicide bomber female who drove at a gate in Mosul Iraq actually back in 2009

at a high rate of speed and she was shot by the sentries on incoming because of explosive devices. But she was brought still alive to our emergency room. And there were multiple injuries abdomen pelvis lower

extremity. And you know we started operating with some small incisions nobody could find anything so one of the guys that I was with Chuck Rosen was there he basically said to me let's just follow what Colonel Fox

said. And we basically opened from stem all the way....the sternum....all the way down the leg. And we basically had the whole iliac femoral vessels down to the basically popliteal artery exposed. And we were able to repair a lot of those

injuries. And I don't know if the lady ended up surviving afterwards because we transferred her off but we went ugly early as we call it. We stablished proximal and distal arterial control which are the basic tenants of vascular surgery.

And some of those who are going to be seeing endovascular techniques can be employed to get those distal and proximal control of vascular injury. Do thrombectomy. Once again endovascular techniques have a role here. Use

shunts and use local heparin and try to make your arterial repair tension-free. This is a picture of a shunt connecting two blood vessels that are transected. And this is just placed within this...this is an SFA injury...that was used to continue to

perfuse that limb while other injuries were addressed and patient was transported to next level of care. Make your threshold low for fasciotomy which I mentioned. Fasciotomy is basically opening up skin and fascia to allow the

muscle to expand and allow continued perfusion of that limb. Once we have an ischemic limb for a period of time we always will do a fasciotomy after we restore perfusion. Because that will also... there's a lot of oxygen free radicals

that are released tissue edema and a whole host of physiological problems that can occur and this can be limb saving. And we always say in vascular and especially in the military even if you think about doing a fasciotomy just do

it. There may be some associated morbidity but it's ok you can always get them closed but you're going to save their leg. Here's another picture of a shunt as you

can see it kind of goes in a curlicue still connecting two ends of a lacerated vessel. You can get vascular injuries from elbow dislocation as well radial ulnar brachial arteries. You see applying an external fixator in this

given situation allowed basically a repair of the blood vessel with the vein graft. We can do vein patch angioplasty. That was an interposition graft. Vein patch angioplasty are basically looking at an arterial laceration and using a piece of

vein and making a patch if it's not a complete circumferential transection or injury. We can do tension-free primary repairs. I don't usually recommended it. In certain situations in a pinch if you need to fix the blood vessel like that

and it's a very minimal injury ok. And of course another picture of interposition autogenous vein graft. You can see between these two clearly transected ends you take a vein reverse it and you'll get the new

conduit. Nice operation if you can...don't have multiple injuries to do. Arteries that can be ligated with few consequences. Common carotid artery external carotid artery subclavian artery axillary artery your internal iliac

arteries your celiac axis. And these can be ligated obviously in a traditional open surgical sense. But with endovascular techniques you can coil

endovascular management of vascular trauma. Covered stent graft. You repair the vessel basically exclude the external injury and allow continuous

flow. Embolisation stop the bleeding. And of course balloon occlusion is control the bleeding stop the bleeding allow for definitive repairs and hemodynamic stability to be achieved. Here's an example of a profunda femoris

artery pseudoaneurysm which was repaired with a stent in the battlefield. These are not my pictures this another vascular surgeon who I borrowed from Dr. Rasmusin. And he was able to provide this in Kandahar actually where they had

better endovascular capabilities. They also had a TGIFridays we liked going there once in awhile. But...I'm just kidding...but not I'm not kidding they really did have one. But it was always nice because when you're in the desert and you

have to eat MREs for like three months or four months and you know having cheesy fries was a nice treat. Here we see a splenic trauma laceration from a MVA rollover. Once again not my pictures but this happened in Afghanistan on a

rough terrain. Soldier injured the spleen. They did an angiogram and basically found a huge exravasation of contrast and put in some Amplatzer plugs which occluded most of the blood flow to the spleen and allowed hemodynamic

stability on this patient. But you see that a lot of the extrav and external bleeding that was initially identified has slowed down and they may be able to provide that patient with the splenic preservation. But this patient

was transported to Germany and I unfortunately i don't know wh But this is an example of using coils to arrest bleeding in the field. Another example of a vascular injury to the

internal iliac artery in an open book pelvic fracture. At which time the patient was hemodynamically unstable. Pelvic binder was applied still continue to be unstable. Started having other difficulties with ventilation. Took him

to the angio suite there in... this was in Bagram...and they ended up using slurry gelfoam slurry to basically embolize various branches of the hypogastric artery to arrest the bleeding and allowed patient to become

stabilized hemodynamically. This is the ER-REBOA balloon. It's basically a soft tipped balloon occlusion catheter. As you can see very simple design. Can be placed without a wire through a 7Fr sheath in the femoral artery or

brachial artery. Although there are more complications associated with placement of these types of catheters and sheaths without good fluoroscopic capabilities in the brachial or radial arteries. But this has been

utilized in the battlefield. I did not have the opportunity to use this one when I was there but the people that I've spoken to who have used it said it is really worked well. Because you... they've even trained medics...and maybe

corpsmen to do this procedure as the patient is coming from a level 1 or level two. And they've really had great success in controlling some of the major life-threatening injuries that can occur from aortic intra-abdominal pelvic

injuries even lower extremities. It's basically an integrated A-line. You can use it for pressure monitoring soft atraumatic p-tip that's able to pass you know through a vessel. Obviously in the atherosclerosis iliofemoral disease

not going to be possible. But in the young trauma patient it'll just go slide right up. It's can deliver drugs and medications above the balloon. Guide wire-free. It's a compliant balloon. Has an

overpressure safety valve on it and like I said at seven Fr sheath compatible.

in civilian and military experience. Starting to gain more recognition with the army and other military medical

organizations. Can be lethal if not recognized. Usually distal to the left subclavian artery. This is just a schematic of what we call the zones of the aorta when we're looking at where their injuries are occurring and you see

seventy-nine percent of these will occur distal to the left subclavian artery. Takeoff you see a widened mediastinum which my clue you in an MVA or blunt trauma patient. And you can also see this type of thing occur with penetrating

injury which tends to be a little more leathal in terms of its ability to save these patients. One usually has a large pseudoaneurysm where the transection has occurred. As you can see in this is a picture right's another picture of where the injury is. And then taking them to endo suite. Getting wide access across the injury. Identifying where the injury is and then deploying a stent-graft to cover that

and exclude that. We've used intravascular ultrasound capabilities to also delineate the injury size the appropriate endograft and then place... that is a Gor Ctag graft which is a borrowed slide. But still you can see that

that effectively control that potentially life-threatening injury. Neck

trauma. This is available off the internet very widely but it's such a dramatic picture I had to put it in there. But it's very most common

penetrating associated vascular injuries in greater than thirty percent. Blunt injury as well. Non surgical therapy and neurologic and aerodigestive sequel are also going to be found. And it's an area where you know

multiple specialties are going to be required to treat this patient. I had a patient when I was a second-year fellow who came in with a knife through and through and we took him to the operating room. We're pulling the knife out

slowly slowly and you could see blood start coming. So we had the common carotid we clamped it. We saw that external... weirdly enough this thing went through. It didn't touch the ICAs. It transected both his posterior pharynx but both external

carotid arteries and we just ligated that off and that guy walked out of the hospital a week later. Believe it or not it's weird but it can be seen but very rare usually it's a little bit more complicated than that. We

look at neck injuries. Zone 1 zone 2 and zone 3. Why did I put this picture here primarily to show you that zone two right in here easy to access open surgical can take care of a problem that's relatively

easy to access with standard surgical incisions. When you get up into higher carotid and vertebral or lower just off the aortic arch type of carotid injuries supraclavicular stab injuries shrapnel

injuries...we saw this a lot in Iraq in Mosul where there were snipers that were taking out soldiers from higher points and they were getting those types of injuries...angiography is very key here. You can embolize things here you can use

covered stent grafts here you can use temporary balloons to control the bleeding from here while you get a posterior thoracotomy down to repair thoracic injury. So angiography being recognized by the military for neck

injuries has has been important as well as endovascular techniques.

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