The basic principles in managing vascular trauma include wide exposure for proximal and distal control followed by missile tract exploration . The goal is restoration of perfusion and flow preferably using autogenous repair . The presence of associated venous injury is also repaired if the hemodynamic situation allows (Fig. 15.6). In the presence of massive soft tissue injury, extra-anatomical repairs should be considered. The whole aim is still to save the life before the limb and not to end up losing a patient while the limb is being salvaged [88]. However, the recent data from the gulf war seems to indicate that this concept should not be used to shy away from attempted repair and limb salvage [8, 19, 24]. Patients with wartime vascular injuries, especially popliteal injuries, were found to be able to well tolerate the stresses associated with the need for revascularization [89].

The established operative principles include debridement of the injured vessel and removal of any distal thrombi that may by present in the distal vessel, especially in the presence of transection. In these situations, the distal vessel very often may have a clot that has tamponaded the retrograde bleeding. It is important to make sure that there is evidence of good back-bleeding before resumption of flow. This may require the gentle passage of a Fogarty catheter to insure that there is no distal thrombi (Figs. 15.7 and 15.8). Revascularization should be obtained with no tension nor stenosis. Once revascularization is completed, it is important to check the adequacy of the reconstruction to make sure that there are no technical issues that may predispose for graft or reconstruction failure (Figs. 15.9 and 15.10). The injured tissues should be thoroughly debrided and the wound should be heavily irrigated. Power irrigation is not recommended although copious irrigation can be valuable [90]. Soft tissue coverage is an essential component of the management as the vascular reconstruction has to be covered by viable soft tissue [19, 91, 92]. This may occur with the use of local muscle flap or any other flaps that can be planned even from the start of the procedure [27, 91, 92]. Joint and bone stability are crucial to protect the repair [27, 93, 94]. Bone debris are removed and bone realignment is often achieved using external fixators [27, 93, 95].

The issue of whether the joint and bone stability should be addressed before or after the vascular injury remains a debatable matter [96]. Most vascular surgeons prefer to reestablish flow first and this is often dictated by the duration of the ischemia and the complexity of the requirements for reconstruction and revascularization [97, 98]. The argument for the need of bony stabilization to better assess the expected length for a bypass or a vascular reconstruction is logical but does not necessarily apply [99]. Most vascular surgeons can predict the needed amount of distance for the reconstruction. The use of a temporary shunt has also allowed some flexibility in addressing this issue, or addressing issues of concomitant significant intra-abdominal injury [20, 100–104]. The liberal use of shunt allows for the reestablishment of flow and allows for some delay in addressing the injury [100–105]. The shunt can easily be used when dealing with a large size vessel. This is especially true when dealing with vessels such as the superficial femoral artery or the external iliac artery. However, in the below-knee and tibial vessels, the use of such shunts is not as simple as it may appear.

The revascularization options are always tailored to perform the simplest reconstruction that could restore the circulation. The options include primary repair if possible. The edges of injured vessel are trimmed. If there is a defect that cannot be repaired primarily, a vein patch angioplasty may be used. Alternatively, that segment can be resected with an end-to-end anastomosis if the segment is short or the use of a vein bypass if there is a larger defect. It is important to harvest the vein from the contralateral limb to avoid any associated venous injury or further compromise of the venous return by harvesting the ipsilateral vein. In the presence of a combined arterial and venous injury , an attempt to also repair the venous injury is carried out as this could improve the patency of the revascularization and decrease the postoperative edema, especially if the venous return is compromised. At the completion of the reconstruction, it is important to monitor for the presence of any compartmental hypertension related to the prolonged ischemia. This can be checked by pressure measurement. In some situations, a four-quadrant fasciotomy is performed immediately and routinely (Figs. 15.11 and 15.12) . Nerves are tagged for later repair or if easily approximated may be considered to be repaired in the same setting (Fig. 15.13). The most challenging part is often soft tissue coverage of the vascular reconstruction and the bone fractures. The neighboring muscles are the best option to provide coverage of the vessels and bones and the skin is often left open (Fig. 15.14) [27, 91, 92, 106]. The skin wound is allowed to granulate for later skin graft or reconstruction as needed (Figs. 15.15 and 15.16). In some situations, soft tissue coverage may be formed by local flaps (Fig. 15.17). In other situations, a free flap may be required to allow for coverage of the reconstruction and the aligned fractures (Fig. 15.18) [27, 91, 92, 107].

Some of the innovative concepts in the management of vascular trauma include the nonoperative management of occult injury and the use of less invasive treatment options. The nonoperative management originated when surgeons identified some vascular injuries that remained asymptomatic despite not being intervened upon. Mild intimal flaps that are not causing significant flow disturbances may be observed without requiring any intervention. This was clearly demonstrated by Dennis et al. and shown to be an effective and durable approach [81]. The nonoperative management of clinically occult arterial injuries resulted in delayed surgery in only 9% of the cases. Mild occult injuries however are very rarely seen in war-related injuries but one should be aware of the possibility of nonoperative management, especially in mild occult injuries related to blunt trauma.

Less invasive treatment options have been identified for pseudoaneurysms , especially if it is of the iatrogenic type. Compression of the pseudoaneurysm by duplex ultrasonography is one option [108–110], followed by thrombin injection as an option [110–113]. In conflict management these are rarely available options and the pseudoaneurysms here will typically require a major surgical reconstruction. Occasionally some pseudoaneurysms may be amenable to endovascular treatment [114–118].

The endovascular treatment can be used in the form of embolization or placement of stent graft across the pseudoaneurysm [119–121]. Embolization is ideal for pseudoaneurysms of branch vessels, such as the branches of the profunda femoris or occasional tibial vessels. In general, there is very limited use for endovascular treatment in infra-inguinal vascular trauma, especially in war-related injuries. It can be used for thoracic and thoracic inlet penetrating trauma without massive tissue destruction. In this situation, a stent graft may be an ideal option to control a bleeding subclavian artery in critically ill patients [122–124]. The ideal candidate for endovascular treatment is a patient with low-velocity wound who has a challenging surgical exposure [125, 126]. On the other hand, a patient with a high-velocity wound and severe contamination such as seen in most war-related vascular trauma or an injury that needs distal embolectomy and debridement will clearly be a poor candidate for such endovascular treatment [125, 126]. One established role for endovascular treatment in vascular injury has been in the blunt chest trauma causing thoracic aortic disruption. The management of thoracic tears distal to the left subclavian artery following blunt decelerating chest trauma has been revolutionized by the use of stent graft which seems to be an ideal solution for managing such complex patients [127–130].

An additional important aspect in the management of vascular trauma has been the use of prosthetic grafts in complex military vascular trauma. Although using autogenous graft is ideal in a battlefield situation, polytetrafluoroethylene (PTFE) grafts have been used to expeditiously revascularize a limb even in the presence of tissue destruction and contamination [24, 37, 131]. Studies from the military suggest that emergent revascularization with PTFE may allow patient stabilization for transport and later elective care, and is a reasonable option with an acceptable short-term patency rate approaching 79%. Clearly some grafts will have to be replaced later electively, but in the acute setting the placement of PTFE grafts to revascularize and prevent amputation seems to be well tolerated.

Another important aspect that we notice in the patients with vascular trauma from a conflict management relates to the mangled extremity [88, 132, 133]. Many patients may present with a mangled extremity , and the question of preserving the limb versus amputation is always of a critical decision [88, 132–135]. Very often the emotions are very inflamed and every attempt may be made to try to prevent an amputation. Several scores have been developed to evaluate mangled extremities and assess their predictive value in deciding on the need for amputation [2, 133–137]. Most studies seem to indicate that low scores that are indicative of limb salvage can be fairly predictive [2, 133–137]. However, scores at or above the amputation threshold should be cautiously interpreted because they are not very accurate at predicting outcomes [2, 133–137]. We have all witnessed patients with scores suggestive of amputation who ultimately managed to have limb preservation . The main issue with all these patients relates to the soft tissue damage that may occur and the ability to protect the limb from the soft tissue infection and osteomyelitis. In addition, the presence of neurologic deficits suggestive of tibial nerve injury has been used often as a major determining factor for considering amputation [138]. Even tibial nerve injury has been found recently not to be fully predictive for the need for amputation. The concern with prolonged attempts at limb salvage is that despite numerous operations and numerous procedures, the patient may end up with an insensate leg or a nonfunctional leg and may ultimately require amputation after multiple operations and treatment attempts [139]. This can be very damaging psychologically to the patient, limiting their ability to rehabilitate and reintegrate into society [140–143]. Nevertheless, patients psychologically may be more accepting for the reconstruction attempts than the thought of having missed an opportunity to limb preservation [133]. With the advancement of prosthetics and prosthetic management and rehabilitation , patients with amputations have been able to be fitted with valuable prosthetic requirements [144–146]. Patients with massive destruction and non-salvageable limbs may recover faster with an amputation than heroic attempts at limb salvage that ultimately fail [141, 147–149]. Early fitting with a prosthesis may allow for earlier recovery and reintegration into society [150].