NOTE: See Appendix A, Appendix B and Appendix C for management based on anatomic location and Appendix F for basic equipment list
Most deploying non-vascular or non-cardiothoracic surgeons will have limited recent experience in vascular surgery. Prior to deployment, all military surgeons should take the ASSET+ course (DoD developed course currently part of the Emergency War Surgery Course). ASSET+ training was developed by military surgeons for military surgeons to given them iterative training on vascular exposures. Training for surgeons should emphasize the basic principles of vascular trauma management, including adequate exposure, proximal and distal control, vessel debridement to viable tissue, the creation of a tension-free anastomosis, repair or shunt, and adequate coverage with viable tissue. The most challenging aspect in the management of a wartime vascular injury is generally related to vascular exposure. As most of these injuries involve previously normal blood vessels, vessel suturing, and shunt placement are usually a relatively straightforward technical exercise. However, in the face of tissue destruction, hematoma, distorted anatomic landmarks, and the potential absence of a palpable pulse, the identification and adequate exposure of a wartime vascular injury can be a challenge for even an experienced surgeon. While the deploying surgeon will find additional detail regarding techniques and “pearls” in the appendices extremely valuable for pre-deployment review and as a reference during deployment, surgeons should also maximize opportunities to review anatomic exposures in cadaveric, simulation, and video settings prior to deployment. Furthermore, an atlas that covers vascular surgery and exposures should be at the immediate ready for every surgeon on a combat deployment.
Fogarty catheters are a key tool in the armamentarium of vascular injury management. Used primarily to remove thrombus, they can also be used to arrest bleeding from within the lumen of the vessel. The most common size used in extremity vascular injury is 2 and 3 Fr. At least one pass of a Fogarty should precede extremity vascular injury repair to assure removal of the traumatic thrombus burden before restoring inflow and outflow. The key tenet is not to cause native vessel damage. To lessen the risk of damage, avoid advancing the catheter too distal in the smaller vessels of the leg and arm and avoid over aggressive, static balloon inflation (i.e. angioplasty or “intimectomy”).
HARVESTING & USE OF AUTOLOGOUS VEIN
Pearls
USE OF PROSTHETIC GRAFT MATERIAL
Spatulate or Bevel the Conduit
Purpose: to prevent stenosis and mitigate size mismatch between conduit and in situ vessel
Bevel: to cut the edge of the conduit and in situ vessel (Figure 4)
Spatulate: to open the vessel to increase diameter (Figure 5)
ANASTOMOSIS TECHNIQUE: PARACHUTE VS TWO-POINT VS SINGLE-POINT FIXATION
Parachute
At the beginning of the anastomosis, no knot is started (Figure 6). Sutures are placed in a running fashion until the conduit is “parachuted down.” A knot is tied at the end of the anastomosis. This technique is helpful when sewing down to something with difficult exposure (pelvis), although some surgeons prefer this technique in every case.
Two-Point Fixation
The anastomosis is started on the bottom, in which a knot is tied. A second suture is placed on the opposite side of the first knot (Figure 7). This can either be tied down or tagged to assist with offloading tension. Sutures may be placed in a running fashion from either knot and met in the middle (Figures 7 and 8). This technique is helpful when sewing vessels that are under some tension, but some surgeons always prefer this method.
Single-Point Fixation
Similar to the two-point fixation, but a single knot is placed on the bottom of the vessels (Figure 9). The anastomosis is then carried around each side until the end, in which another knot is tied down to complete the anastomosis.
SOFT TISSUE COVERAGE & ANASTAMOTIC DISRUPTION