Gender-based discrimination is prevalent in the integrated vascular trainee experience and serves as a predictor of burnout

OBJECTIVE

Trainee burnout is on the rise and negative training environments may contribute. In addition, as the proportion of women entering vascular surgery increases, identifying factors that challenge recruitment and retention is vital as we grow our workforce to meet demand. This study sought to characterize the learning environment of vascular residents and to determine how gender-based discrimination and bias (GBDB) affect the clinical experience.

METHODS

A survey was developed to evaluate the trainee experience; demographics and a two-item burnout index were also included. The instrument was sent electronically to all integrated (0 + 5) vascular surgery residents in the United States. Univariate analyses were performed and predictors of burnout identified.

RESULTS

A total of 284 integrated vascular residents were invited to participate and 212 (75%) completed the survey. Participants were predominantly male (64%) and white (56%), with a median age of 30 years (interquartile range, 28-32 years). Seventy-nine percent of respondents endorsed some form of negative workplace experience and 30% met high-risk criteria for burnout. More than a third (38%) of residents endorsed personally experiencing GBDB, with a significant difference between men and women (14% vs 80%; P < .001). Women were more likely than men to report witnessing GBDB (76% vs 56%; P = .003). Patients and nurses were the most frequently cited sources of GBDB (80% and 64%, respectively), with vascular surgery attendings cited by 41% of trainees. One in four female resident respondents indicated being sexually harassed during the course of training; this was significantly higher than for male residents (25% vs 1%; P < .001). Nearly half (46%) of trainees who witnessed or experienced GBDB thought that quality of patient care, job satisfaction, personal well-being, and personal risk of burnout were directly affected as a result of GBDB. GBDB was predictive of burnout (odds ratio, 1.9; 95% confidence interval, 1.1-3.5; P = .04), as were longer work hours (>80 h/wk; odds ratio, 2.8; 95% confidence interval, 1.1-7.1; P = .03).

CONCLUSIONS

GBDB was experienced by 38% of integrated trainees, with women significantly more affected than men. GBDB is predictive of burnout, and this has significant implications for our specialty in the recruitment and retention of female physicians. Resources addressing these issues are needed to maintain a diverse workforce and to promote physician well-being.

Contralateral Occlusion and Concomitant Procedures Drive Risk of Non-ipsilateral Stroke After Carotid Endarterectomy

OBJECTIVES

Stroke after carotid endarterectomy (CEA) has been assessed widely. However, factors enhancing non-ipsilateral stroke risk are poorly defined. The aim of this study was to identify drivers of 30 day non-ipsilateral stroke after CEA in the Vascular Quality Initiative (VQI) and assess long-term survival based on laterality of post-operative stroke.

METHODS

The VQI was queried between April 1, 2003, and March 31, 2017, for all CEA. Bilateral carotid procedures within 30 days were excluded. Thirty day non-ipsilateral strokes were identified. Factors were examined to discriminate between patients with and without non-ipsilateral stroke. Univariable analysis followed by multivariable logistic regression was performed. Kaplan-Meier and log rank methods were used to estimate and compare survival.

RESULTS

During this 14 year period, 80,230 CEA in 74,928 patients met the criteria. The average age was 70.3 ± 9.3 years. Most were male (48,506; 60%), Caucasian (73,967; 92%), smokers (60,543; 76%), and asymptomatic (43,074; 54%). Contralateral stenosis ≥70% was present in 8033 (10%) with 2239 (3%) having contralateral occlusion. In 491 (0.6%) patients, peri-operative non-ipsilateral stroke occurred. After characterising univariable associations, logistic regression identified independent drivers of non-ipsilateral stroke after CEA. Operative urgency (p = .001), symptomatic disease (p < .001) and contralateral occlusion (p = .001) were pre-operative drivers. Operative predictors included shunt use (p = .008), CEA with cardiac surgery (p = .013), and CEA with concomitant proximal ipsilateral endovascular intervention (p = .01). Use of dextran (p = .005) and anti-angiotensin therapy (p = .03) were protective. Reperfusion syndrome (p < .001), re-exploration (p < .001), myocardial infarction (p < .001), and intravenous treatment of hypotension (p < .001) or hypertension (p < .001) were post-operative correlates. Non-ipsilateral stroke 30 day mortality was less than ipsilateral stroke (6.1% vs. 10.3%; p = .007). Five year survival after non-ipsilateral stroke was 73%, and no different from ipsilateral stroke 76% (p = .16). Both were worse than without stroke (88%; p < .001).

CONCLUSION

Non-ipsilateral stroke after CEA is rare. Features driving risk surround global disease burden, combined procedures, and haemodynamic fluctuations. Contralateral occlusion independently increases non-ipsilateral stroke risk. Regardless of laterality or location, effects of stroke after CEA on long-term survival are similar.

Regional variation in use and outcomes of combined carotid endarterectomy and coronary artery bypass

OBJECTIVE

In treating concomitant carotid and coronary disease, some recommend staged carotid endarterectomy (CEA) and coronary artery bypass grafting, whereas others favor the combined approach (CCAB). Pressure to reduce surgical variation and to improve quality is real, yet little is known about how geographic practice differences affect outcomes. Using the Vascular Quality Initiative (VQI), this study evaluated regional variation in use and outcomes of CCAB.

METHODS

All CCAB procedures in the VQI from 2003 to 2017 were reviewed and stratified into four regions, as defined by the United States Census Bureau. Primary outcomes included perioperative stroke, death, myocardial infarction (MI), and these as composite (SDM). A χ² analysis was performed.

RESULTS

There were 1495 CCAB procedures identified, representing 1.8% of the VQI CEAs. Regions included the following: Midwest (MW), 32%; Northeast (NE), 39%; South (S), 25%; and West (W), 4%. Most were male (70%) and white (92%). There was significant regional variation in proportional volume of CCABs to all CEAs (0.7% [W] to 2.5% [MW]; P < .001). Regional variation in patch use (78% [W] to 93% [MW]; P < .001), shunting (29% [W] to 71% [MW]; P < .001), and electroencephalography monitoring (13% [W] to 52% [NE]; P < .001) was also significant. Overall perioperative stroke was 3.6%; death, 3.0%; and SDM, 6.8%. No regional difference was seen in outcomes of mortality (1.5% [MW] to 4.2% [NE]; P = .05), stroke (2.8% [NE] to 4.4% [MW]; P = .52), and MI (0.6% [MW] to 1.8% [W]; P = .62). When the Bonferroni correction was used, there remained no difference in stroke, MI, or SDM across regions, but mortality became significant. Using the Society for Vascular Surgery guidelines for consideration of CCAB, the minority of patients fell within the symptomatic carotid stenosis (SYMP, 15%; n = 218) or severe (≥70%) asymptomatic bilateral carotid disease (BIL, 18%; n = 267) categories. The most common indication was asymptomatic unilateral severe carotid stenosis (UNI, 37%; n = 552). There were no differences in regional outcomes stratified by indication (SYMP, BIL, UNI). Overall, when SYMP and BIL were compared with UNI, UNI had lower rates of stroke (2.4% vs 4.9%; P = .03) but similar MI (0.7% vs 1.2%; P = .40) and mortality (2.2% vs 2.5%; P = .75).

CONCLUSIONS

Significant variation exists across VQI centers in the use of CCAB. Despite differences in volume and practices, regional perioperative outcomes are similar. UNI is the most commonly used indication and has lower stroke rates relative to SYMP and BIL. CCAB is performed well across the United States, but most patients fall outside of Society for Vascular Surgery guidelines.

A Regional Experience with Carotid Endarterectomy in Patients with a History of Neck Radiation

BACKGROUND

Historically, a history of neck radiation has been considered as an anatomic risk factor for poor outcomes after carotid endarterectomy (CEA). However, this is based on small and primarily single institution reports with few comparative series. This study uses a regional quality database to compare perioperative outcomes of CEA in patients with and without a history of neck radiation (RAD and NORAD, respectively).

METHODS

The Vascular Study Group of New England database was queried for all CEA from 2003 to 2017. The RAD group included a history of neck radiation. Primary end points included perioperative stroke (30-day), myocardial infarction (MI) (in-hospital), death (30-day), a composite end point including major adverse events (MAEs: stroke, MI, and death), and long-term survival.

RESULTS

Overall, 18,832 patients underwent CEA (18,551 NORAD, 281 RAD). Baseline demographics differed in the following: the RAD group more frequently had a history of contralateral carotid artery stenting (1.4% vs. 0.3%, P = 0.009), anatomic high risk features (12.8% vs. 1.3%, P < 0.001), and contralateral carotid occlusion (5.3% vs. 2.4%, P = 0.005). The NORAD cohort comprised mostly women (38.9% vs. 29.5%, P < 0.001), had American Society of Anesthesiologists class 4 or 5 (8.0% vs. 4.6%, P = 0.035), had higher body mass index (28.3 ± 5.6 vs. 27.1 ± 5.4, P < 0.001), on a beta blocker preoperatively (68.0% vs. 62.3%, P = 0.042), and had major cardiovascular comorbidities including coronary artery disease (29.6% vs. 22.1%, P = 0.006). There were no differences in the percent stenosis, proportion symptomatic (37.4% vs. 34.2%, P = 0.259), use of preoperative antiplatelet agents or statins. Electroencephalography monitoring was more frequently used in RAD (54.5% vs. 46.0%, P = 0.005). There was no difference in perioperative complications, including stroke (RAD 0.4% vs. NORAD 0.7%, P > 0.999), MI (0.4% vs. 0.9%, P = 0.736), death (0.7% vs. 0.6%, P = 0.683), MAE (2.1% vs. 2.2%, P > 0.999), or long-term survival (79.9% vs. 85.0%, P = 0.357). When only symptomatic or asymptomatic stenosis was considered, there remained no difference in primary end points. However, perioperative neurologic events (transient ischemic attack or stroke) was higher in symptomatic RAD versus symptomatic NORAD (6.7% vs. 2.6%, P = 0.020).

CONCLUSIONS

This regional experience with CEA in RAD patients shows similar perioperative morbidity, mortality, and long-term survival when compared with CEA for standard surgical patients (NORAD). Symptomatic presentation was associated with higher perioperative neurologic events, but this was not reflected in stroke rates. RAD is not always a contraindication to CEA and select patients can expect outcomes comparable to standard surgical patients.

Risk factor profile and anatomic features of previously asymptomatic patients presenting with carotid-related stroke

OBJECTIVE

Although carotid atherosclerotic-mediated stroke remains a major cause of morbidity and mortality, some have suggested intervention in carotid stenosis should be limited to symptomatic patients given the advances in medical therapy. The present study was conducted to assess the atherosclerotic risk factor profiles, anatomic features, and clinical outcomes of previously asymptomatic patients admitted with stroke of carotid etiology.

METHODS

We reviewed the data from 3382 patients admitted to a tertiary referral center with an ischemic stroke during 2005 to 2015. We focused on patients admitted with a radiographically confirmed infarct ipsilateral to a documented carotid artery stenosis ≥50%, with the admitting neurology team adjudicating the stroke etiology as carotid related. Patients were excluded if they had had a previous transient ischemic attack, previous infarct ipsilateral to any carotid lesion, or previous carotid revascularization, intracranial hemorrhage, or malignancy. Patient demographic data, medical treatments before stroke, stroke admission carotid imaging, and stroke treatments and outcomes were assessed.

RESULTS

A total of 219 carotid stroke patients (7% of all strokes) were identified, of whom 61% were white and 66% were men, with a mean age of 68 ± 12 years. Hypertension (79%) and smoking (33% current; 29% former) were predominant risk factors. On admission, 50% were receiving antiplatelet therapy (aspirin, n = 92 [41%]; clopidogrel, n = 9 [4%]; dual therapy, n = 11 [5%]) and 55% were receiving lipid-lowering agents (statin, n = 115 [53%]; other, n = 6 [2%]); 77 patients (35%) were receiving both antiplatelet and lipid-lowering therapy. Of the 219 patients, 156 (71%) presented with a moderate or severe stroke (National Institutes of Health stroke scale ≥5 at admission), 54 (25%) received lytic therapy, 96 (43%) presented with an occluded ipsilateral internal carotid artery, and 117 (53%) ultimately underwent carotid revascularization at a median of 4 days. Individuals receiving both antiplatelet and lipid-lowering therapy were significantly less likely to experience a moderate or severe stroke (44% vs 78%; P = .006).

CONCLUSIONS

Internal carotid artery occlusion is the culprit lesion in 43% of carotid-related strokes in those without previous symptoms. Previously asymptomatic patients not receiving combined antiplatelet and lipid-lowering medical therapy presenting with carotid-related stroke are significantly more likely to experience a severe, debilitating stroke. However, those receiving appropriate risk-reduction medical therapy are still at risk of carotid-mediated stroke. These results suggest medical therapy alone is unlikely to be sufficient stroke prevention for patients with significant carotid stenosis.

Characterization of perioperative contralateral stroke after carotid endarterectomy

OBJECTIVE

Contralateral stroke is an infrequent cause of perioperative stroke after carotid endarterectomy (CEA). Whereas the risks of ipsilateral stroke complicating CEA have been discriminated, factors that lead to contralateral stroke are poorly defined. The purpose of this study was to identify the risk of perioperative (30-day) contralateral stroke after CEA as well as predisposing preoperative and operative factors. Its specific effect on long-term survival was interrogated.

METHODS

The Vascular Study Group of New England (VSGNE) was queried from April 1, 2003, to February 29, 2016, for all CEAs. Duplicated patients and those without complete data were excluded. Patients sustaining contralateral stroke after CEA in the 30-day postoperative period were identified. Demographic, preoperative, and operative factors were analyzed to identify discriminators between those with and those without contralateral stroke. Logistic regression modeling was performed to identify factors independently associated with contralateral stroke. The effect of contralateral stroke on 5-year survival was compared with patients with ipsilateral stroke and no stroke using the Kaplan-Meier method. Log-rank testing compared survival curves.

RESULTS

There were 10,837 CEAs performed during the study. Average age was 70.4 ± 9.3 years; 6605 (61%) patients were male, and 40% (n = 4324) were performed for symptoms. Most were current or former smokers (n = 8619 [80%]). Coronary artery disease and congestive heart failure were identified in 31% and 8.6%, respectively. Overall, there were 190 strokes within 30 days of CEA (1.8%); 131 were ipsilateral (1.3%), and 59 (0.5%) patients were identified as having contralateral perioperative stroke. Thirteen patients sustained bilateral stroke (0.1%). Significant univariate associations included urgency (P = .0001), ipsilateral stenosis severity (P = .004), length of operation (P = .0001), CEA with coronary artery bypass graft (P = .0001), CEA with other arterial surgery (P = .01), and CEA with proximal endovascular procedure (P = .03). Contralateral occlusion (P = .06) and degree of contralateral carotid stenosis (P = .14) did not correlate. After logistic regression analysis of significant univariate anatomic and operative factors, length of procedure (odds ratio [OR], 1.08/15 minutes; 95% confidence interval [CI], 1.01-1.15; P = .02), urgency of operation (OR, 2.5; 95% CI, 1.3-4.6; P = .006), and concomitant proximal endovascular intervention (OR, 8.7; 95% CI, 4.5-31.2; P = .001) remained predictors of contralateral stroke after CEA. Occurrence of both ipsilateral (P < .001) and contralateral (P = .023) stroke significantly reduced 5-year survival compared with those without stroke. There was no difference in the negative survival effect based on laterality of stroke (P = .24).

CONCLUSIONS

Contralateral stroke after CEA is rare, affecting 0.5% of patients. Traditional risk reduction medical therapy does not affect occurrence. Degree of contralateral stenosis, including contralateral occlusion, does not predict perioperative contralateral stroke. Urgency of operation, length of operation, and performance of concomitant, ipsilateral endovascular intervention predict contralateral stroke risk with CEA. Contralateral stroke affects long-term survival similar to ipsilateral stroke after CEA.

Technical and early outcomes using ultrasound-guided reentry for chronic total occlusions

BACKGROUND

Subintimal angioplasty is a common treatment for chronic total occlusions (CTOs) in the iliac and infrainguinal arteries. Although technical success has been described using intravascular ultrasound-guided reentry devices (IVUS-RED), outcomes are still not well defined. This report describes the technical aspects and longitudinal follow-up after intravascular ultrasound-guided reentry of iliac and infrainguinal CTOs.

METHODS

A retrospective review was performed of 20 patients with lower extremity CTO treated with IVUS-RED from 2011 to 2013. A matched cohort of patients who underwent lower extremity interventions without the use of IVUS-RED was also identified. Procedural success, patency estimates, ankle-brachial indices (ABIs), complications, and limb salvage were analyzed.

RESULTS

Twenty patients (mean age, 69 ± 13 years), including 11 men and 9 women, underwent attempted IVUS-RED-guided recanalization. Median follow-up was 4.3 months (range, 0.4-24). Eleven patients presented with critical limb ischemia (CLI), and 9 presented with claudication. Technical success was achieved in 18 (90%) patients. Ten common iliac arteries, 3 external iliac arteries, and 5 superficial femoral arteries (SFA) were treated. No intraoperative complications resulted from device use. After procedure, ABIs significantly increased (0.5-0.9; P < 0.01) in the 13 patients with follow-up. Primary patency for the entire cohort was 62% at 12 months. No patient treated for claudication required reintervention, whereas 3 (27%) of those treated for CLI required repeat interventions. During follow-up, 2 patients died unrelated to the procedure, 1 patient required an amputation, and 1 patient eventually required open revascularization. When the IVUS-RED group was compared with a cohort matched on Trans-Atlantic Inter-Society Consensus and age, no difference was found in runoff scores and patency between the 2 groups during follow-up (P > 0.05).

CONCLUSIONS

Recanalization of CTO using IVUS-RED is safe and effective. Use of IVUS-RED does not adversely impact outcomes in conjunction with other endovascular techniques. Early follow-up demonstrates acceptable patency, especially in patients with claudication, and freedom from reintervention.

Endovascular repair of thoracic aortic injury: current thoughts and technical considerations

Thoracic aortic traumatic injury is a highly morbid event. Mortality and paraplegia rates after emergent open repair remain high. Now, however, thoracic aortic endografting for trauma (TAET) is commonly used. It is appealing due to reduction of operative stress for the multiply injured trauma victim. This minimizing of stress and risk is secondary to avoidance of thoracotomy, single-lung ventilation, aortic cross-clamping, and the more complex anesthetic techniques required. Early and midterm results from TAET delineate improved outcomes, yet access and aortic constraints continue to challenge TAET. Questions regarding longer-term durability of endografts in younger patients remain unanswered. Broader application of TAET within endovascular programs is challenged by appropriate imaging, operating suite inventories, and the logistics and personnel required for TAET. Currently developed thoracic endograft devices are not ideal for TAET due to platform size and graft diameter. This is changing, however, as new modifications have been developed and trials are ongoing. In light of these collective factors, the management paradigm for traumatic aortic injury is beginning to favor TAET.

Update on wartime vascular injury

Data from the Joint Theater Trauma Registry has led to changes in combat casualty care for Operations Iraqi and Enduring Freedom compared with previous wars. Currently, all recognized vascular injuries are repaired before leaving Iraq or Afghanistan. Extremity injuries are prevalent, accounting for the majority of reconstructive vascular surgery performed. Abdominal and chest injuries are less frequent in US forces than in local population, most likely because of the use of body armor. Increased use of tourniquets, modern advances in damage control resuscitation, and use of temporary vascular shunts are factors of increased survival. Use of autogenous or prosthetic grafts, vascular shunting, diagnostic imaging, and negative pressure wound therapy should continue to be encouraged. All of these advances contributed to an increase in amputation-free survival rates. The management of combat-related vascular injuries has progressed to the point of achieving reasonable outcomes for our country's military casualties.

Endovascular versus open management of blunt traumatic aortic disruption at two military trauma centers: comparison of in-hospital variables

BACKGROUND

Blunt traumatic aortic disruption (BTAD) carries significant mortality and morbidity. Traditional open repair has appreciable risks of perioperative mortality and spinal cord ischemic complications. Endovascular repair may reduce the incidence of these adverse outcomes. We present the experience at two military trauma centers with thoracic aortic endografting for trauma (TAET) and compare this with recent open experience.

METHODS

A review of inpatient records was performed. All patients undergoing open repair or TAET for acute BTAD were studied. Collected data included demographics, injury characteristics, and in-hospital variables. Descriptive statistics were calculated with two-tailed t-tests performed for comparison of continuous variables.

RESULTS

Five open and eight TAET repairs were performed. Mean age was 32 years (range 28-50) in the TAET group and 35 (25-57) in the open group. All patients, except one TAET, had at least one associated injury with thoracic injuries predominating. Twelve BTAD were just distal to the left subclavian artery. One injury, treated with TAET, was just proximal to the celiac. Operative blood loss averaged 298 +/- 394 mL in the TAET group vs. 2,400 +/- 3,800 mL in the open group (p = 0.18). Crystalloid infusions were similarly reduced in TAET patients, 1,019 +/- 532 mL vs. 4,860 +/- 1,547 mL, p < 0.05), as were red blood cell transfusions, 1.6 units vs. 5.0 units (p = 0.12). The majority of patients [6/8 (75%) TAET, 5/5 (100%) open] experienced an inpatient complication (p = 0.09). All open patients had at least one infectious complication. There were no inpatient deaths related to aortic injury or spinal cord ischemic complications.

CONCLUSIONS

TAET is feasible for the treatment of BTAD in military trauma centers. It is important for military centers to accomplish this with adequate results as endovascular technologies are now being taken to the battlefield. Decreased blood loss and resuscitation requirements compared to open repair are likely contributors to improved outcomes with TAET.

Outcomes of selective tibial artery repair following combat-related extremity injury

OBJECTIVE

Selective tibial revascularization refers to the practice of vessel repair vs ligation or observation based on factors observed at the time of injury. Although commonly employed, the effectiveness of this strategy and its impact on sustained limb salvage is unknown. The objective of this study is to define the factors most relevant in selective tibial artery revascularization and to characterize limb salvage following tibial-level vascular injury.

METHODS

The cohort of active-duty military patients undergoing infrapopliteal artery repair comprises the tibial Bypass group. A similarly injured cohort of patients that did not undergo operative vascular intervention (No Bypass group) was identified. All tibial vessel injuries were documented by angiography. Data were compiled via medical records and patient interview. The primary outcome measure was failure of limb salvage. Multivariate regression was performed to identify factors associated with revascularization and to describe factors associated with amputation.

RESULTS

Between March 2003 and September 2008, 135 of 1332 patients with battle-related vascular injuries had documented tibial vessel disruption or occlusion. Of these, 104 were included for analysis. Twenty-one underwent autologous vein bypass at the time of injury (Bypass group), and the remaining 83 patients were managed without revascularization (No Bypass group). Mean follow-up (39 vs 41 months; P = .27), age (25 vs 27 years; P = .66), and mechanism of injury (88% vs 92% penetrating blast; P = .56) were similar, but the No Bypass group had higher Injury Severity Scores (ISS; 16.3 vs 11.7; P < .01). Injury characteristics, including Gustilo III classification (49% vs 43%; P = .81) and nerve injury (55% vs 53%; P = 1.0), were similar. Subjects were more likely to receive tibial bypass with an increasing number of tibial vessel occlusions and documented ischemia on initial exam. However, of the 23 in the No Bypass group with initially unobtainable Doppler signals, 17 (74%) regained pedal flow following resuscitation and limb stabilization. Amputation rates were similar (23% vs 19%; P = .79), but the prevalence of chronic limb pain was lower in the Bypass group (10% vs 30%, respectively; P = .08). Cox regression analysis of amputation-free survival demonstrated an association between mangled extremity severity score >5 (hazard ratio [HR], 2.7; P = .01) and amputation.

CONCLUSIONS

This report provides outcomes data for wartime tibial vascular injury, which supports a selective approach to tibial artery revascularization. Clinical factors such as ISS and degree of ischemia guide which patients are best suited for tibial vascular repair, while injury-specific characteristics are associated with amputation regardless of revascularization status.

A national survey of evolving management patterns for vascular injury

BACKGROUND

The modern era has witnessed an increase in endovascular techniques used by physicians to treat vascular injury and age-related disease. As a consequence, the number of open vascular operations available for general surgical education has decreased dramatically. This changing paradigm threatens competence in vascular injury management achieved during surgical residency. The objective of this study is to sample perceptions on vascular injury treatment in the United States to highlight the need for planning for this important tenet of surgical education.

METHODS

An electronic survey was extended to board-certified surgeons through 3 professional societies, the Peripheral Vascular Surgery Society (PVSS), the Eastern Association for the Surgery of Trauma (EAST), and the American College of Surgeons (ACS).

RESULTS

A total of 520 respondents were self-categorized as trauma (59%; n = 307), vascular (17%; n = 90), or general (19%; n = 99) surgeons. Respondents reported that general surgeons currently manage less than 10% of vascular injuries at their respective institutions. A 2.5-fold increase in endovascular treatment of vascular injury during the past decade was reported with interventional radiologists now involved in the management of up to 25% of injuries. Few general or trauma surgeons surveyed possessed a catheter-based skill set, although 38% of trauma surgeons expressed great interest in endovascular training. Additionally, a cadre of vascular surgeons (67%) affirmed a commitment to teaching vascular injury management.

CONCLUSIONS

The results of this study confirm a diminished role for non-fellowship-trained surgeons in managing vascular injury. Despite an increased acceptance of endovascular techniques to manage trauma, general and trauma surgeons do not possess the skill set. Collaboration between surgical communities will be especially important to maintain high standards in vascular injury management.

The complete management of extremity vascular injury in a local population: A wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base, Iraq

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 noncoalition 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.

In-Theater Management of Vascular Injury: 2 Years of the Balad Vascular Registry

BACKGROUND

Wartime vascular injury management has traditionally advanced vascular surgery. Despite past military experience, and recent civilian publications, there are no reports detailing current in-theater treatment. The objective of this analysis is to describe the management of vascular injury at the central echelon III surgical facility in Iraq, and to place this experience in perspective with past conflicts.

STUDY DESIGN

Vascular injuries evaluated at our facility between September 1, 2004 and August 31, 2006 were prospectively entered into a registry and reviewed.

RESULTS

During this 24-month period, 6,801 battle-related casualties were assessed. Three hundred twenty-four (4.8%) were diagnosed with 347 vascular injuries. Extremity injuries accounted for 260 (74.9%). Vascular injuries in the neck (n = 56; 16.1%) and thoracoabdominal domain (n = 31; 8.9%) were less common. US forces accounted for 149 casualties (46%), 97 (30%) were local civilian, and 78 (24%) were Iraqi forces. One hundred seven (33%) patients with vascular injury were evacuated from forward locations after treatment initiation. Fifty-four (50%) of these had temporary shunts placed. Of 43 proximal shunts placed in-field, 37 (86%) were patent at the time of our assessment. Early amputation rate was 6.6% for those extremity injuries treated for limb salvage. Perioperative mortality was 4.3%.

CONCLUSIONS

This evaluation represents the first in-theater report of wartime vascular injury since Vietnam. Extremity injuries continue to predominate, although the incidence of vascular injury appears to be somewhat increased. Local forces and civilians now represent a substantial proportion of those injured. The principles of rapid evacuation, temporary shunting, and early reconstruction are effective, with satisfactory early in-theater limb salvage.