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.

LIGATION  OF  VESSELS

Pearls

THROMBECTOMY

Pearls

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”).

TEMPORARY  VASCULAR  SHUNTS

Pearls