Serbia

Introduction

For many centuries a simple ligation was the main treatment option in patients with vascular injury. The first significant series of vascular reconstructions applied for the treatment of vascular injuries was published by Serbian surgeon Vojislav Soubbotich at the beginning of the 20th century. Namely, during the Balkan wars between 1912 and 1913, 60 false traumatic aneurysms and 17 traumatic arteriovenous fistulas were treated by himself and his coworkers. In about 40% of cases some kind of vascular reconstruction was performed; they included 15 end-to-end anastomoses, making an exciting surgical step forward at that time. More than three decades later, in the series of 2471 arterial injuries from the Second World War, DeBakey and Simeone reported only 81 repairs, including three end-to-end anasthomosis. Commenting on this, Norman Rich said: “It is ironic that nearly 40 years passed before similar successful efforts were achieved during the latter part of the Korean conflict (1952–53).”

Less than 100 years after Soubbotich’s time, at the end of the 20th century, the former Yugoslavia experienced civil war, closely followed by the North Atlantic Treaty Organisation (NATO) bombing of Serbia. Due to these unpleasant facts, a whole generation of vascular surgeons, including the authors of this chapter, had the opportunity to treat a significant number of war-related vascular injuries. In addition, a significant number of civil vascular injuries have been treated in our hospital over the past few decades. What have we learned?

Lesson 1: War Versus Civil Vascular Trauma

Common opinion is that the management of vascular injuries inflicted during war is fundamentally different to those acquired during peace. However, that is not necessarily the case. Besides natural disasters (earthquakes, etc.), traffic, industrial, and agricultural trauma, as well as the increasing frequency of terrorist attacks, and even sport injuries, can all be accompanied by severe damage to blood vessels ( Fig. 33.1 ).

The insignificant differences regarding the early outcome between war and peacetime vascular injuries was also presented in our study published in 2005. That study compared 273 civil and 140 war-related vascular injuries. According to univariate analysis, out of 54 included variables, only failed revascularization, associated nonvascular injuries, secondary operation, explosive injury, war injury, arterial contusion, popliteal artery injury, and delayed treatment significantly increased the amputation rate after repair of the injured peripheral arteries. However, multivariate logistic regression analysis of the previous eight variables showed that only failed revascularization, associated nonvascular injuries, and secondary operation significantly increased the amputation rate after arterial vascular repair.

Lesson 2: Strategy During Management of Vascular Trauma

Throughout history, the management of vascular trauma has included three phases: life-saving, extremity-saving, and saving of functional extremity. It can be assumed that the order of these main objectives is still used in the modern approach to vascular injury, which is why primary bleeding control, rapid transportation of the injured person, adequate diagnosis, and timely vascular repair are necessary.

Lesson 3: Primary Bleeding Control

The first step in the successful management of vascular trauma is to control primary bleeding, which is a life-saving procedure. However, if it is not performed adequately, primary bleeding control can cause additional damage to already injured arterial vessels. The method used in the initial approach to primary hemostasis significantly influences the extent of the subsequent vascular reconstruction. However, in a crisis, first aid is often driven by only one objective: stop the bleeding at all costs. Unfortunately, vascular surgeons often have to pay the price for these crisis-driven methods of achieving hemostasis as can be seen in Fig. 33.2 .

Lesson 4: Vascular Repair or Primary Amputation?

The first question that a vascular surgeon has to answer before the treatment of vascular trauma even begins is whether there is any point in doing vascular repair. According to current guidelines, the indications for primary amputation in the case of vascular trauma include: bone fracture with loss of continuity of more than 6 cm in length; massive soft tissue damage and loss; prolonged limb ischemia; severe nerve destruction; major vein obstruction; and extensive calf wounds associated with small vessels injury. Even though these indications are quite clear, the decision regarding primary amputation following vascular trauma is quite difficult, especially in young patients ( Fig. 33.3 ).