U.S. Department of Defense


Date of this Version



Published in Journal of Vascular Surgery, Volume 45, Issue 6, June 2007, Pages 1197-1205.


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 non-coalition 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.