WOUNDS OF MAGISTRAL VESSELS IN COMBAT THERMOMECHANICAL INJURIES Dubrov V.E., Gereykhanov F.G., Koltovich A.P.

Main Clinical Hospital of Ministry of Internal Affairs of Russian Federation, Moscow, Russia

Modern medical provision of military forces promotes decreasing in irretrievable combat losses and increasing in amount of patients with severe and extremely severe injuries, surgical treatment of which should be very fast and specialized [1, 2]. Such injuries include damages to magistral vessels.

Proportion of patients with injuries to magistral vessels has been gradually increasing since World War II (1939-1945). The structure of sanitary surgical losses after vascular injuries was 1-2 % during WWII (1939-1945) [3], 2-3 % in Vietnam war (1964-1973) [2], 6-8 % in Afghanistan Islamic Republic (1979-1989) [4], 3.9-6 % in local war conflicts in Northern Caucasus (1994-1996, 1999-2002) [5], 6.7-17.6 % in the Middle East (Afghanistan Islamic Republic, Iraq, Syrian Arabic Republic, State of Kuwait) (2001 - present time) [6].

Arrangement of medical care in local war conflicts (Northern Caucasus, Afghanistan Islamic Republic, Iraq, Syrian Arabic Republic) is associated with significant limitation of possibilities of medical services owing to features of mountain relief, poor network of ground communications, insufficient flotation of vehicles outside auto-roads, danger of fire damages, long distances between hospitals and alternating battle conditions [1, 7].

Combat vascular damages are mainly concomitant (68.8 %). It supposes simultaneous injury to a vessel and a wound of other anatomic region or several regions. Combined injury to extremities is diagnosed in 12-15 % of burn patients, including 0.8-1.6 % of injuries to magistral vessels. Injuries to arteries of extremities consist at least a half, and, in some cases, up to 95 % of combat injuries to vessels [7].

Development and improvement in angiosurgery, and the use of various surgical techniques for patients with magistral vascular injuries does not lead to improvement in results [1, 8]. The extremity amputation rate is high − 27-31.5 % [9]. Disability achieves 45 % and higher, lethal outcomes − 12 % [2].

Such poor results dictate the necessity for optimization of treatment of patients at the stages of medical care organization, especially in limited conditions of medical service in local war conflicts.

Objective − to assess the effect of burn injury on the results of surgical treatment of injured persons with damages to the main vessels of the limbs.

MATERIALS AND METHODS

The study was conducted as a retrospective analysis of concomitant injuries to magistral veins in 166 military men of combined forces of Northern Caucasus district. The patients received specialized surgical care in special medical detachment of Main Military Clinical Hospital of National Guard Troops of Russia in 1994-1997 and 1999-2016.

The anamnesis data were collected at the moment of admission from a patient or accompanied persons. A cause, a site, a time of an injury, and volume of first medical care were established.

Clinical examination included estimation of objective responses of the body to trauma (consciousness estimation, speech contact, size of pupils, body temperature, skin color, respiratory rate (RR), arterial pressure (AP), heart rate (HR), arrhythmia, central venous pressure (CVP)). Quantitative estimation was carried out with Military Field Surgery-Injury (Gunshot Wound) (MFS-I(GW)) and ISS by means of assignment of points for each injury, followed by summing of points. According to Military Field Surgery-Injury (State at Admission) (MFS-I(SA)), severity of condition was estimated. Frank's index was used for estimation of burn injury.

Laboratory examination included clinical (portable photometric hemoglobinometer AGF-03/540 MiniGEM) and biochemical (desktop biochemical express analyzer Reflotron Plus with Printer Roche Diagnostics) analyzes of blood and urine.

According to Directions for military field surgery (2000), the instrumental methods at the stage of final management included monitoring of main physiological values (HR, RR, oxygen saturation of arterial blood with pulse oximetry (Nihon Konden apparatus), hourly urine rate), X-ray imaging of body regions (mobile X-ray device Arman), ultrasonic examination of abdominal organs and magistral vessels (mobile device Sonosight Micromax Titan), endoscopic examination (Olympus).

The received data were retrospectively analyzed with variation statistics with EXCEL-7.0 and STATISTICA 7.0 (StatSoft, USA). Statistical analysis was conducted in volume of the mean (M) and standard deviation (SD), error of mean, 95 % confidence interval and certainty index. χ²-test and correlation analysis were used for estimation of reliability of values. Fisher's exact test and Mann-Whitney's test were used for comparison of groups with small size of the sample. Results of statistical analysis have been shown in the tables. The sign "...*" (p < 0,05) shows statistical significance in the tables.

The study was conducted in compliance with requirements of the ethical committee of the hospital and corresponded to the Helsinki Declare − Ethical Principles for Medical Research with Human Subjects 2000, and the Rules for clinical practice in the Russian Federation confirmed by the Order of Health Ministry of RF on June 19, 2003, No, 266.

RESULTS

Most (129, 77.7 %) patients were transported by helicopter and cars (37, 22.3 %) for emergency medical care. The causes of injuries were mine-blast trauma in 86 (51.8 %) persons, gun-shot injury in 58 (34.9 %), missile wound in 16 (9.6 %), blast injury in 6 (3.6 %). First and prehospital aid was performed for 150 (90.4 %) patients: analgesia − 112 (74.7 %), compression band − 94 (62.7 %), hemostatic strap − 91 (60.7 %), extremity immobilization with Cramer splint − 11 (7.3 %).

At admission, combined thermomechanic injuries were found in 9 persons (group 1), including 6 persons with burns with Frank index of 1-35 (17.8 ± 19.9 points on average), and 3 persons with burn shock with Frank index of 30-35 points. 157 persons had not any burn injuries (group 2).

Both groups were similar according to age (22.3 ± 3.4 and 26.3 ± 6.3 years), condition severity (MFS-I(SA) − 31.7 ± 9.7 and 29.5 ± 12.3), injury severity (MFS-I(GW) − 9.1 ± 4.5 and 9.8 ± 7.3, ISS 18.4 ± 12 and 17.3 ± 12.4), duration of time interval between trauma and admission (80.6 ± 61.2 min and 99.5 ± 88.2 min), time of evacuation to base hospitals (2.1 ± 1.1 days and 3.2 ± 2.1 days) at p ≥ 0.05 (table 1).

Table 1

Clinical characteristics of the study population by groups

Values	Group 1	Group 2	p
Age, years	22.3 ± 3.4	26.3 ± 6.3	0.58
Frank index	17.8 ± 19.9	-	-
Military Field Surgery-Injury (State at Admission), points	31.7 ± 9.7	29.5 ± 12.3	0.89
Military Field Surgery-Injury (Gunshot Injury), points	9.1 ± 4.5	9.8 ± 7.3	0.94
Military Field Surgery-Injury (Gunshot Injury) for extremity, points	8.0 ± 2.0	6.5 ± 3.5	0.71
Military Field Surgery-Injury (Gunshot Injury) for head, points	0.7 ± 1.2	3 ± 5.3	0.67
Military Field Surgery-Injury (Gunshot Injury) for neck, points	6.1	3.5 ± 3.3	0.63
Military Field Surgery-Injury (Gunshot Injury) for chest, points	0.3 ± 0.2	2.7 ± 4.9	0.63
Military Field Surgery-Injury (Gunshot Injury) for abdomen, points	3.1	5.6 ± 3.7	0.51
Military Field Surgery-Injury (Gunshot Injury) for pelvis, points	2.6	4.7 ± 6.6	0.75
ISS, points	18.4 ± 12	17.3 ± 12.4	0.95
Consciousness (Glasgow Coma Scale), points	11.9 ± 2.2	12.1 ± 2.4	0.95
Time of admission with ambulance car, min	80.6 ± 61.2	99 5 ± 88.2	0.86
Time of presurgical preparation	25.7 ± 19.2	33.7 ± 28.6	0.82
Time of evacuation on ambulance car, days	2.1 ± 1.1	3.5 ± 3.3	0.69

Also the groups were similar according to changes in main clinical and laboratory values at admission: HR (109.1 ± 24.4 and 108.2 ± 22.8 beats per minute), SAP (78.6 ± 15.7 and 86.5 ± 10.2 mm Hg), body temperature (36.7 ± 0.9 and 36.7 ± 0.7 ⁰С), hemoglobin (106.1 ± 28.8 and 106.8 ± 27.6 g/l), glucose (7.6 ± 0.9 and 9.1 ± 4.4 mmol/l), potassium (4.4 ± 0.6 and 3.3 ± 0.8 mmol/l) at p ≥ 0.05 (table 2).

Table2

Clinical characteristics of the study population by groups

Values	Group 1	Group 2	p
HR, min^-1	109.1 ± 24.4	108.2 ± 22.8	0.98
SAP, mm Hg	78.6 ± 15.7	86.5 ± 10.2	0.67
RR, min^-1	21 ± 4.6	21.1 ± 4.8	0.99
Т, ⁰С	36.7 ± 0.9	36.7 ± 0.7	1.0
Hb, g/l	106.1 ± 28.8	106.8 ± 27.6	0.99
Red blood cells, × 10¹²/l	3.1 ± 0.6	4.3 ± 10.6	0.91
Ht, %	30.5 ± 6.4	33.2 ± 8.8	0.8
Leukocytes, × 10⁹/l	14.5 ± 5.6	16.4 ± 6.9	0.83
Glucose, mmol/l	7.6 ± 0.9	9.1 ± 4.4	0.74
Protein, g/l	56 ± 2.8	51.9 ± 10.4	0.7
Creatinine, µmol/l	78.7 ± 23.4	106 ± 61.5	0.68
Urea, mmol/l	8.9 ± 0.6	7.5 ± 3.8	0.72
Potassium, mmol/l	4.4 ± 0.6	3.3 ± 0.9	0.31

There were not any signs of hemoconcentration at the background of gun-shot wound and a burn in both groups on the second day: hemoglobin (72.6 ± 22.4 and 86.9 ± 22.8 g/l), hematocrit (24.2 ± 10.5 and 26.5 ± 7.0), red blood cells (2.3 ± 0.9 and 2.8 ± 0.8 g/l) at p ≥ 0.05.

The group 1 included 18 vascular injuries: 10 arteries (femoral artery − 4, brachial artery − 3, posterior tibial artery − 2, carotid artery − 1), 8 veins (femoral vein − 3, brachial vein − 2, posterior tibial vein − 2, internal jugular vein − 1). Burns in the region of vascular injuries were identified in 5 (55.6 %) patients. Concomitant bone-vascular injury was diagnosed in the group 1 in 5 (55.6 %) patients, in the group 2 − in 32 (20.4 %) patients (more often, statistically significant, chi-square = 6.080, number of freedom degree = 1, p = 0.01).

The vascular surgeries in the groups 1 and 2 depended on a type of a vascular wall injury and were distributed as follows: temporary arterial prosthetics (2 (22.2 %) and 18 (11.5 %) persons), dressing (5 (55.6 %) and 109 (69.4 %) patients), boundary suture (3 (33.3 %) and 22 (14.1 %) patients), autovenous plasty (2 (22.2 %) and 2 (1.2 %) patients), circular suture (0 and 9 (5.7 %) patients), amputation due to impossibility of blood flow restoration (2 (22.2 %) and 12 (7.6 %) patients).

Considering the specifics of injuries in patients of the group 1 and, as result, various number of patients in groups, the distribution of surgical operations was not homogenous. For concomitant thermomechanic injuries, temporary prosthetics, boundary suturing and autovenous plasty were carried out more often. In the group 2, in cases without burns, ligation of injured vessels was conducted more often. However, statistical significance was found for autovenous plasty (chi-square = 4.642, number of freedom degrees = 1, p = 0.03) (table 3).

Table3

Surgery for vascular injuries

Surgery	Group 1		Group 2		p
Surgery	Abs.	%	Abs.	%	p
Temporary prosthetics	2	22.2	18	11.5	0.34
Dressing	5	55.6	109	69.4	0.38
Boundary suture	3	33.3	22	14.1	0.12
Circular suture	-	-	9	5.7	-
Autovenous plasty	2	22.2	2	1.2	0.03
Limb amputation	2	22.2	12	7.6	0.71

In the group 1, 3 patients received application of external fixation devices for fractures of extremities. 5 of 6 devices were applied through the burn wound. The approach to vascular injuries was performed through the burn wound in 5 patients.

Complications relating to vascular injuries were diagnosed in all patients in the group 1 and in 127 (80.9 %) patients in the group 2 within the first 3 days after surgery (p = 0.48) (table 4).

Table 4

Complications after vascular surgery

Surgery	Group 1		Group 2		p
Surgery	Abs.	%	Abs.	%	p
Plastic shunt thrombosis	1	50	7	38.9	0,76
Thrombosis after autovenous plasty	2	100	2	100	1
Thrombosis after circular suture	-	-	3	33.3	-
Bleeding	1	11.1	3	1.9	0.00
Wound infection	5	55.6	47	29.9	0.11
Limb ischemia	2	22.2	31	19.7	0.86
Compartment syndrome	2	22.2	15	9.6	0.22
Died	2	22.2	20	12.7	0.42

All patients of both groups had thrombosis of the autovenous insertion (2 (100 %) and 2 (100 %) correspondingly), 8 (40 %) patients − plastic shunt thrombosis (1 (50 %) and 7 (38.9 %) correspondingly), 4 (2.4 %) − bleeding from vascular surgery site after failure of hermetic state of vascular sutures (1 (11.1 %) and 3 (1.9 %)), arterial thrombosis after circular suture − only in the groups 2 (3 (33.3 %)). 52 (31.3 %) patients had wound infection (5 (55.6 %) and 47 (29.9) correspondingly), 33 (19.9 %) − extremity ischemia (2 (22.2 %) and 31 (19.7 %) correspondingly) (p ≥ 0.05).

22 (13.3 %) patients died: 2 (22.2 %) in the group 1 and 20 (12.7 %) in the group 2 (p ≥ 0,05).

DISCUSSION

In the conducted retrospective cohort study of 166 patients with vascular injures, 9 (5.4 %) patients had burn injuries of various location. It consists with the data from other authors [7].

The comparison groups with burns and without them were statistically homogenous, despite of presence of concomitant injury in the group 1. Patients of both groups had similar amount of severe and extremely severe injuries. Therefore, intensity of clinical and laboratory changes was similar. On the second day after surgical management, severity of anemia was more intense for concomitant injury.

For concomitant thermomechanic injury, associated bone-vascular injuries were more often diagnosed in the group 1 (55.6 %) as compared to the group 2 (20.4 %) (statistically significant higher incidence, chi-square = 6.080, number of freedom degrees = 1, p = 0.01). It can be determined by the fact that the cause of concomitant injuries in all patients was mine-blast injuries, which cause more destructive injuries as compared to gun-shot injuries. In the second group, mine-blast wounds presented the cause of injuries in only 49 % of persons.

In both groups, bleeding arrest for vascular damages was commonly achieved by means of ligation − 55.6 % and 69.4 % correspondingly (p = 0.38). Such high incidence of quick ligation for severe injuries allows saving the patient's life. Similar findings are presented by other authors [10, 11]. It is necessary to note that we ligated only veins and arteries of distal segments of extremities, which would not result in irreversible ischemia and gangrene after completion of blood flow.

We did not use any methods of negative pressure for treatment of patients at the stage of rendering qualified medical care. According to some authors, the use of VAC-therapy is safe in vascular injuries. It does not influence on incidence of thrombosis of temporal prostheses. Wounds show faster clearance of necrotic tissues, and granulation tissue grows faster and recovery accelerates [12].

Temporary prosthetics of vessels in both groups (20 (12 %) persons) was used not so often as primary suturing of a vascular damage (34 (20.5 %) cases). According to some authors [8], prosthetics is necessary for at least 50 % of patients with extremity damages. According to other studies [13], temporary prosthetics is used rarer − from 0 % to 8-17 % as compared to ligation of injured vessels [14]. The temporary prosthesis can fix fracture of extremities. It can delay time of final restoration of a vessel in period of traumatic shock. The technique of surgery allows visual control of the shunt both in the wound and under dressing [15].

Primary amputations of extremities after vascular injuries were carried out for 13 (7.8 %) persons that is comparable to the literature data (6.6-16 %) [6].

Complications occurred with similar rate in 81.9 %. It is higher in comparison with data from other authors where the incidence of complications was 28 % [6]. We found the statistically significant high incidence of thrombosis of autovenous grafts (100 %) as compared to temporary prosthetics (40 %) in the early period of traumatic disease (chi-square = 3.764, number of freedom degrees = 1, p = 0.05). One should note that the main proportion of surgical operations was performed by general surgeons without specialization in vascular surgery. It can be the cause of high incidence of thrombosis. Therefore, reconstructive operation should be performed rare at the stage of primary surgical assistance.

Wound infection was diagnosed in only 52 (31.3 %) patients: the same incidence in both groups (55.6 % and 29.9 %, p = 0.11). These data correlates with similar studies and are determined by severity of injuries and blood loss [6]. According to Direction for military field surgery (2000), the predictive incidence of complications for severe and extremely severe injuries is 66-90 %.

Postsurgical lethality was 13.3 % and did not depend on a cause of an injury (p = 0.42) like in series of studies of other authors [6, 8].

CONCLUSION

1. In combat thermomechanic injury, a combination of vascular injuries and fractures of extremities with burns occurs more often than without them (44.4 % and 20.4 % correspondingly, p = 0.01).

2. For concomitant thermomechanic injuries, all 100 % of patients had complications in the early posttraumatic period regardless of severity of a burn injury.

3. Temporary vascular prosthetics is the operation of choice owing to lower incidence of thrombosis (40 % after temporary prosthetics, 100 % after autovenous plasty) and possibility of visual control of the shunt in the wound. Final reconstructive vascular injuries with application of vascular anastomosis should be performed in compliance with the concept of programmed multi-stage surgical management of patients with participation of vascular surgeons.

4. Approach to a vessel and placement of Schanz screws into bone fragments through the burn wound does not increase the incidence of infectious complications after vascular injuries, gun-shot fractures and burns of the same location.

Information on financing and conflict of interests

The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.