Iliac vessel injuries: Difficult injuries and difficult management problems

Historical perspective

Significant advances in the field of trauma surgery have emerged from both military and civilian arenas of warfare. The earliest known documents concerning vascular trauma date from 1600 bc . The Ebers papyrus reported the Egyptians use of styptics consisting of vegetable matter, lead sulfate, and copper sulfate to stanch hemorrhage. The Chinese in the year 1000 bc were first to use tight bandaging to control hemorrhage from wounds in conjunction with the use of styptics for hemorrhage. The treatment of choice for vascular injuries throughout the Middle Ages consisted of cautery with boiling oil. In 1497, Jerome of Brunswick published his work on ligatures as treatment for bleeding gunshot wounds. Ambroise Paré was first to report the use of ligatures to control hemorrhage from vessels during amputation. Paré was also credited with the development of the first hemostat “le bec de corbin” (crow’s beak). The first attempt at vascular reconstruction was attempted by Hallowell in 1759 when he reported the repair of a brachial artery with the Farrier’s or veterinarian’s stitch. Some 127 years would pass until vascular repair was again attempted.

The latter part of the 19th century saw such pioneers as Jassinowsky and Postemski revive the idea of direct vascular repair. Isreal, in 1883, described the first successful primary repair of a laceration to the iliac artery. In 1897 Murphy of Chicago completed the first successful end-to-end anastomosis of a femoral artery, and Goyanes of Spain in 1906 was first to report the use of a saphenous vein graft to repair a popliteal artery.

Attempts at vascular repair emerged during the Balkan Wars (1912–1913) when Soubbotitch reported a series of 77 false aneurysms and arteriovenous fistulas from penetrating injuries, which were managed with ligation (45), arteriorrhaphies (19), and venorrhaphies (13); 11 used end-to-end arterial anastomosis and 4 used end-to-end venous anastomoses. In this series there were few repair failures reported and infection was avoided in almost all of the procedures. Further advances and refinements in the technique of vascular anastomosis were reported by Carrel in 1902 with the tripartite suture and by Frouin in 1908 with his quadrangulation method.

During World War I vascular repair saw a promising emergence with German surgeons attempting and successfully treating more than 100 arterial injuries in multiple vessels. However, the face of this conflict was about to change with the introduction of high explosive ordnance into the battlefields of World War I. The increase in the numbers of wounded at a single time added to the poor evacuation process and, accompanied by a high rate of gangrene, curbed the initial experiences of German military surgeons. By the same token the poor follow-up of those who were successfully treated led many to question the long-term patency of those repairs.

Despite these setbacks there were those who proceeded with promising results. Weglowski presented a series consisting of over 600 patients during his service in the Russian army and subsequently as the surgeon general of the Polish army. In his 1919 report, he recommended all arterial injuries and associated posttraumatic aneurysms be repaired immediately after the injury or, if not feasible, 1 month later for any pulsatile masses. This included all extremity injuries as well as injuries to carotid, aortic, subclavian, and iliac arteries. In 1924 he reported his personal experience with 193 vascular repairs, including 46 lateral repairs, 12 end-to-end anastomoses, and 56 venous grafts. Wound infection forced him to revert to ligation for the remaining 79 patients. His results and data were surprisingly good and have been unfortunately overlooked.

During World War II DeBakey and Simeone reported results that were not as promising when compared to World War I results. A total of 2471 arterial injuries were collected; nearly all were treated with ligation resulting in an amputation rate of 49%. There were only 81 attempts at repair, of which 78 required lateral suture repair and only 3 end-to-end anastomoses were performed. The authors summarized their findings by pronouncing that ligation of the damaged artery was applicable and no other procedure should be attempted. “It is not a procedure of choice. It is a procedure of stern necessity, for the basic purpose of controlling hemorrhage.”

Despite these findings there were isolated attempts from both sides of the conflict that reported some success with arterial repair. Possible reasons for such poor results included irreparable injuries from multiple types of high-velocity weaponry; increased destructive power of ordnance, resulting in higher numbers of casualties; and significant delays in transport, resulting in irreversible ischemia. Inadequate timely evacuation to higher echelons of surgical care along with understaffed and poorly supplied field hospitals added to the high incidence of ligation rates and high rate of amputations.

The Korean conflict saw greater success in arterial repairs based not only on the advances made in the surgical techniques of the past wars; other factors such as improvements in anesthesia, the advent of antibiotics, and the development of blood transfusions were responsible for improving the success rate of vascular repairs. Perhaps the single greatest factor was the development of forward aid stations accompanied by rapid evacuation of the wounded by helicopter. Wound infection was less rampant due to acceptance and practice of débridement of dead tissue, delayed primary closure, and antibiotics. The U.S. Army established specialized research groups to improve treatment of vascular injuries in 1952. There were significant contributions from Jahnke in 1953, followed by Hughes in 1955 and 1958. During the Korean conflict a series by Hughes reported 304 arterial injuries of which 269 were repaired and 35 ligated. The overall amputation rate was significantly reduced from the World War II rate of 49% to 13%.

During the Vietnam conflict advances in evacuation and transport along with a higher number of surgeons trained to perform vascular repairs resulted in improved outcomes along with the creation of the Vietnam Vascular Registry at Walter Reed Army Medical Center to provide follow-up for the wounded sustaining vascular injuries starting with the first 500 patients who had sustained 718 vascular injuries, including injury to carotid, subclavian, axillary, brachial, aorta, renal, iliac, femoral, and popliteal vessels. Rich, in 1969, reported the amputation rate during the Vietnam conflict at approximately 8%; this number was subsequently revised by Rich and Hughes to 13%, who included amputations performed within the first month following injury. During the initial report, 126 end-to-end anastomoses, 127 vein grafts, 29 lateral sutures, and 2 prosthetic grafts were recorded. The registry was expanded several times to include many patients treated by other branches of the military, becoming an invaluable resource to the development of vascular surgery.

Incidence

DeBakey and Simeone reported a total 43 iliac artery injuries out of 2471 patients for an incidence of 1.7%. The incidence of iliac injury was similar for both the Korean and Vietnam Wars. Hughes in 1958 reported an incidence of 2.3% for the Korean conflict and Rich in 1970 reported an incidence of 2.6% for the Vietnam War. Interestingly enough, a number of different institutions have reported their own experiences with iliac vessel injuries over the past several decades with surprisingly similar incidence, morbidity, and mortality rates ( Tables 1 and 2 ).

The incidence of iliac vessel injuries has increased in the civilian arena secondary to increases in violence seen in urban trauma centers. Overall, the incidence of iliac vessel injury has been reported at approximately 10% for penetrating injury and gunshot wounds. Stab wounds and impalement account for 2% of iliac vessel injuries. The most infrequent injuries are those due to blunt trauma, accounting for 5% of injuries in Asensio’s series consisting of 185 iliac vessel injuries. The internal iliac vessels were most commonly injured from blunt trauma; the mechanism of injury results in stretching of the vessel over the bony pelvis resulting in intimal tears and thrombosis.

The incidence of iliac vessel injuries during major military conflicts has remained the same. DeBakey reported an incidence of 1.7% of iliac vessel injuries in World War II. Hughes reported an incidence of 2.3% for the Korean conflict, and Rich reported an incidence of iliac vessel injury of 2.6% for the Vietnam War.