Injury, Int. J.

Care Injured 47 (2016) 811817

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Retrospective analysis of case series of patients with vascular

war injury treated in a district hospital
Tal Salamon a,b, Alexander Lerner b,c, David Rothem b,c, Alexander Altshuler d,
Ron Karmeli e,f, Evgeny Solomonov b,g, Seema Biswas h,*
a
Vascular Surgery Unit, Ziv Medical Centre, Safed, Israel1
b
Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
c
Department of Orthopedic Surgery, Ziv Medical Center, Safed, Israel
d
Interventional Radiology Unit, Ziv Medical Center, Safed, Israel
e
Department of Vascular Surgery, Carmel Medical Center, Haifa, Israel
f
The Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel
g
Department of General and Hepatobiliary Surgery, Ziv Medical Center, Safed, Israel
h
Department of Surgery, Ziv Medical Center, Safed, Israel

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: As the Syrian civil war continues, medical care of the injured remains a priority for health
Accepted 17 February 2016 facilities receiving casualties. Ziv Medical Centre, the closest hospital in Israel to the Syrian border,
has received 500 casualties since February 2013. Seventeen of these patients had vascular injuries. This
Keywords: research reports the care of these seventeen patients and explores the challenges of treatment in patients
War with little antecedent clinical history and improvised initial care that may be complicated by delay to
Vascular denitive care, sepsis and limb ischaemia.
Injury
Method: Electronic and paper patient records were examined. Descriptive case series data are presented.
Trauma
Results: Fifteen of the 17 patients were male. The mean age was 20 years (range 830 years). Causes of
Bypass
Amputation injury included gunshot wounds (4 patients), shrapnel (multi-fragment) injury (12 patients), and
Graft 1 patient was run over and dragged behind a car. The time from injury to transfer to denitive care
ranged from 5 h to 7 days (mean 43 h). All but one patient had associated non-vascular multiple-trauma.
Thirteen patients presented with limb ischaemia. Four patients had arterio-venous stula (AVF) or
pseudoaneurysm. There were 5 upper and 10 lower limb major vascular injuries. Three patients had neck
vessel injuries.
All patients were investigated with CT angiography and underwent surgical or endovascular
intervention. In 12 patients, 4 vessels were debrided and re-anastomosed and 13 vessels bypassed.
Endovascular repair was performed in 4 patients. After initial revascularisation, 4 patients went on to
amputation. There were no deaths.
Conclusions: The injuries treated are heterogeneous, and reect the range of high energy vascular trauma
expected in conict. The broad range of vascular solutions required to optimise outcomes, in particular,
limb salvage, in turn, reect the challenges of dealing with such injuries, especially within the context of
sepsis, ischaemia and delay.
As war continues, there is a pressing need to address the needs of patients with high energy injuries in
austere environments where there is a dearth of health resources and where denitive care may be days
away.
2016 Elsevier Ltd. All rights reserved.

Introduction

Current practice in the treatment of war-related vascular

injuries is based on military experience from recent global
* Corresponding author. Tel.: +972 50 432 7252.
conicts [13]. Although this has inuenced the management of
E-mail address: seemabiswas@msn.com (S. Biswas).
1
Department and institution to which this work should be attributed Vascular civilian trauma care [47], there is a dearth of literature on the
Surgery Unit, Ziv Medical Center, Safed, Israel. management of trauma, in particular, vascular trauma, amongst

http://dx.doi.org/10.1016/j.injury.2016.02.008
00201383/ 2016 Elsevier Ltd. All rights reserved.

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civilians with war injuries [8] who may present to healthcare
facilities after considerable delay and with advanced sepsis. Some of
these patients are chronically malnourished after years of war.
Since February 2013, over 1500 patients from Syria have been
treated in Israel. Many are women and children. Vascular injuries
amongst the 450 patients treated in an Israeli district hospital close
to the Syrian border are discussed. The range and complexity of
vascular trauma is described in relation to their causes and the
difculties in management of limbs that are grossly infected and
extensively denuded of soft tissue in patients with protracted
shock and ischaemia. These limbs may arguably have been
amputated, but with advanced and multi-disciplinary care they
were salvaged. Limb salvage in four instances was made possible
through endovascular techniques, hitherto underused in periph-
eral artery trauma. As is often the case, the necessity to treat these
challenging injuries was the driver to pursue a novel approach
using endovascular procedures not yet a standard of care.
Methods
With hospital ethics committee approval, data were collected
on all patients wounded in the Syrian civil war admitted to Ziv
Medical Centre (Ziv) from February 2013 (when the rst patients
arrived). Data from the hospital trauma registry and paper and
electronic patient les were collected and stored in a password
protected le available only to the researchers. No identifying
information was collected or stored. All data include details from
initial admission via the Trauma Room, operative and non-
operative care and nal discharge. Follow-up of most patients
was not possible as they returned to Syria.
Of 450 patients, 17 patients had vascular injury. Orthopaedic
patients who suffered traumatic amputations at the time of injury
are not included in this paper as no vascular procedure was
indicated.
Results
Table 1 summarises the clinical data of the 17 patients with
vascular injury on admission to the Trauma Room. Fifteen patients
were male. The mean age was 20 years (range 830 years). The
time from injury to transfer to denitive care in Ziv ranged from 5 h
to seven days (mean 43 h). All but one patient had associated non-
vascular multiple trauma.
Nerve injury (within the same neurovascular bundle) and bone
fracture were the most commonly encountered associated non-
vascular injuries within this cohort of patients (10 and 7 patients,
respectively Table 2). The majority of vascular injuries (21 vessels
in total) were combined arterial and venous injuries (Table 3).
Venous repair was performed before arterial repair in order to
Table 1
Initial clinical data of patients with vascular trauma.
Table 2
Associated polytrauma in patients with vascular injury.
Associated injuries Number of
patients
Nerve injury 10
Femur fracture 4
Humerus fracture 2
Abdominal trauma 3
Humerus fracture + chest wall injury + burns 1
Radius + ulna fracture + median nerve damage 1
Pelvis + femur + Tibia fractures 1
Fibula/tibia fracture 3
Pharynx 1
reduce limb congestion and to assist distal run-off in the
reperfused limb.
Vascular injuries were classied as either those causing
ischaemia (13 patients), or those resulting in arterio-venous
stula (AVF) or pseudoaneurysm (4 patients). Ischaemic limbs
were cold and pale, had reduced capillary lling, neurological
decit and advanced infection. At the time of presentation, no limb
was irreversibly ischaemic. There were ve upper and ten lower
limb major vascular injuries. Three patients had neck vessel
injuries. Thirteen patients were transferred immediately to the
Operating Room (OR) for surgical repair and four patients
underwent endovascular procedures. All but one patient under-
went fasciotomy.
In each instance vascular treatment was determined by the
nature and location of the injury, the severity of injury and the
quality of the soft tissues (affected by delay). Table 4 summarises
the vascular procedures performed. Four vessels were debrided
and re-anastomosed; thirteen bypassed (eight using allograft great
saphenous vein GSV, and one deep femoral vein (a re-do of a
former bypass performed in Syria), and three using synthetic graft).
Endovascular repair using covered stents was performed in four
patients. Two vessels were ligated in order to achieve haemorrhage
control. Table 5 shows the mangled limb severity score calculated
for each patient. Two patients with scores greater than 10 under-
went amputation after initial reperfusion procedures. All patients
accumulated scores exceeding 5 points for delays alone with over
6 h of limb ischaemia.
In terms of outcome, control of haemorrhage and initial
revascularisation were achieved in all patients. Four patients,
however, went on to amputation after failure of initial revascular-
isation procedures. There were no deaths.
Complications
Three patients out of nine who underwent vascular graft
procedures suffered infective disruption of vascular anastomoses.
Their clinical courses are described below and a strong argument
may be made for primary amputation rather than attempted limb

Range Mean

Heart rate on admission (beat/min) 100145 118 Table 3

Blood pressure on admission (mmHg) Systolic 72171 123 Vascular injuries* (vessels injured).
Diastolic 40116 78
Vascular injury Number of
Core temperature in operating room (8C) 3236.5 35.6
patients
Age (years) 830 20
Time from injury to Ziv Hospital (h) 5170 N/A Internal carotid artery + neck veins 3
Initial Haemoglobin (g/dl) 7.413.2 10.6 Brachial + radial + ulnar artery and vein 8
Initial white blood cells (WBC) (109/l) 6.426.0 17.5 Common + external iliac arteries 2
Packed cells transfusion per patient 023 10.5 Common femoral artery + Vein (CFA/CFV) 4
Albumin within 24 h from of 2.323.59 2.73 Supercial femoral artery + Vein (SFA/SFV) 9
admission (g/l) Tibial + peroneal arteries 5
Total protein within 24 h of 3.565.92 4.47 *
The number of vessel repairs does not correlate with the number of patients as
admission (g/l)
patients had more than one injury.

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Table 4
Interventions for vascular injuries.

Patient Vascular injury Method of injury Treatment/surgery Mangled Final

limb score outcome

1 SFA transection Gunshot SFA-SFA interposition Goretex 6 Patency

SFV laceration SFV Goretex patch
Fasciotomy
2 Brachial + Radial + Ulnar transection Gunshot Brachial-Radial/Ulnar interposition GSV bypass 10 Patency
Fasciotomy
3 CFA-CFV AV stula Shrapnel CFA covered stent N/A Patency
Fasciotomy
4 Penetrating (gunshot) neck injury zone 2 Gunshot Exploration and vessel ligation N/A Patency
5 SFA + SFV transection* Gunshot 1. SFA-SFA/SFV-SFV interposition GSV graft 7 Amputation
Infection and disruption of GSV 2. CFA-POP above knee extra-anatomic Dacron
(great saphenous vein) bypass bypass
Fasciotomy
6 Brachial artery transection (Left) Shrapnel Brachial artery repair (Left) 7.5 Patency
Brachial artery injury (occlusion) (Right) Brachial artery embolectomy and repair (Right)
Fasciotomy
7 SFA-SFV AV stula Shrapnel SFA covered stent 7 Patency
Fasciotomy
8 Brachial artery + vein transection Shrapnel Brachial-Brachial artery interposition vein bypass 5 Patency
Fasciotomy
9 External Iliac artery pseudoaneurysm Shrapnel EIA covered stent N/A Patency
Fasciotomy
10 Internal carotid artery pseudoaneurysm Shrapnel ICA covered stent N/A Patency
11 Iliac vessels transection Car run over Hemi-pelvectomy 10 Amputation
12 Tibialis posterior (TP) laceration Shrapnel TP-TP repair 10 Patency
Fasciotomy
13 Tibial and peroneal transection Shrapnel TP-DP repair interposition GSV graft 8 Patency
Fasciotomy
14 Brachial artery transection (Left) Shrapnel Brachial-Brachial interposition GSV bypass 10 Patency
Fasciotomy
*
15 Brachial artery transection (Left) Shrapnel 1. Brachial-Brachial interposition GSV bypass N/A Patency
2. Brachial-Brachial interposition GSV bypass
(extra-anatomic)
Fasciotomy
16 Tibialis Anterior (TA) Injury Shrapnel Debridement, embolectomy and repair N/A Patency
Fasciotomy
17 SFA transection, vein interposition Shrapnel SFA-SFA interposition vein graft 5 Patency
bypass disruption (infection) Fasciotomy
*
Same vessel repaired, after disruption due to infection after rst repair.

salvage as all patients suffered severe soft tissue (and neurological) their limbs, while successful in some patients within this cohort
damage and presented for denitive care with prolonged ischae- (with mangled limb scores of 10), clearly falls short in the face
mia after extensive delay. These patients presented with delays gross tissue loss and infection. Synthetic graft was used only when
between 5 h and 7 days and their mangled limb scores ranged from autologous graft was not available, and where possible, grafts were
5 to 10. routed extra-anatomically as far from infected tissue as feasible.
Our policy of limb salvage, based on the premise that patients Patient 2 suffered brachial, radial and ulnar artery transection
returning to Syria needed the best chance we could offer to keep resulting from penetrating and crush injury. There was a delay of
5 days in transfer to Ziv and on arrival, the patient had
Table 5
compartment syndrome of the arm (Fig. 1a), a crushed radius
Mangled limb score (MLS) calculated using scoring system available at http://www. and ulna, severe soft tissue crush injury, and vein and arterial
mdcalc.com/mangled-extremity-severity-score-mess-score/. transection (mangled limb score of 10). An external xator was
Patient Injured body part Mangled limb score
applied and arterial reconstruction performed (brachial to ulnar
and radial artery bypass, with autologous GSV graft) (Fig. 1b and c).
1 Foot 6
Postoperatively, although blood supply was restored, the hand
2 Hand 10
3 FootAmp N/A failed to regain neurological function (both motor and sensory),
4 Neck N/A and, in spite of recurrent debridement and intravenous antibiotic
5 Foot 7 therapy, local and systemic infection persisted. On the 9th
6 Hand, Hand 7.5 postoperative day, the vein graft became disrupted secondary to
7 Hand 7
8 Foot 5
infection (away from the site of the anastomosis) resulting in
9 Pelvis N/A secondary haemorrhage. In view of sepsis and loss of neurological
10 Neck N/A function, the decision was made to amputate above the elbow.
11 Foot 10 Patient 5 was injured by a high energy gunshot resulting in
12 Foot 10
supercial femoral artery and vein transection and sciatic nerve
13 Foot 8
14 Foot 10 injury. The femoral vessels had been ligated in Syria and the
15 FootAmp N/A overlying skin closed. On arrival in Ziv 24 h later, computed
16 Neck N/A tomography angiogram (CTA) conrmed minor persistent bleeding
17 Foot 5 (contained active bleeding), in spite of femoral vessel ligation and
12 limbs (other injuries non-applicable (N/A: 2 amputated limbs; 3 neck; 1 pelvis). some collateral ow (Fig. 2a). He underwent vascular bypass using

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Fig. 1. (a) Penetrating injury of the right forearm. The patient arrived 36 h after injury with compartment syndrome. (b) The hand was infected but viable. An external xator
has been placed prior to debridement. (c) Brachial to radial and ulnar artery bypass.

autologous contralateral GSV for both injured artery and vein
(Fig. 2b). After debridement of non-viable necrotic tissue, the
vascular bypasses were covered with viable muscle. A four-
compartment fasciotomy was performed in the leg. Postopera-
tively, repeated surgical debridement and lavage were performed.
On the 8th postoperative day, the arterial anastomosis became
disrupted (secondary to infection) resulting in major secondary
haemorrhage. The patient returned to the Operating Room and an
extra-anatomical bypass was fashioned between the common
femoral and popliteal artery (above the knee) using PTFE. The graft
was routed as laterally as possible due to ongoing severe infection
and oedema in the medial thigh (Fig. 2c). Three weeks later the
graft was patent and free of infection. The patient was discharged
with a well-perfused limb.
Patient 15 presented one week after severe destruction of the soft
tissues of the ante-cubital fossa and ischaemia of the forearm and
hand. Initial surgery comprised debridement and primary recon-
struction (brachial-brachial GSV interposition bypass) employing
the standard anatomical route, but coverage of the bypass with
viable soft tissues was suboptimal. Seven days post-procedure,
infection resulted in disruption of the anastomosis. A second
bypass was constructed from a second harvested GSV, routing its
course from a more proximal location on the brachial artery to the
radial artery in the mid-forearm via an extra-anatomical lateral
route. The latter anastomosis disrupted again after 10 days. After
ligation of the brachial and radial arteries, perfusion of the
forearm and hand was adequate, however (probably secondary to
collaterals originating from the deep brachial artery). Amputation
was, therefore, avoided.
Patient 17 presented with a proximal penetrating thigh injury
and critically ischaemic leg after primary surgery in Syria 24 h
earlier comprising interposition vein-graft harvested from the
ipsilateral deep femoral vein. The vein graft was thrombosed and
the deep femoral artery had been ligated. As there was extensive
proximal soft tissue necrosis, associated with bone and neural
injuries, femoral disarticulation was performed.

Fig. 2. (a) CT angiogram: the SFA and SFV were already ligated in Syria. There remains contained but active bleeding. (b) Patent arterial and venous bypass after 96 h. (c)
Synthetic extra-anatomical bypass routed as laterally as possible to avoid the infected area of injury and previous surgery.

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Discussion
The condition of the patients on arrival
It is widely reported in the media [911] and by patients who
have arrived in Ziv that the healthcare network within conict
zones in Syria has collapsed. The provision of local emergency care
is, therefore, of concern, and the care that patients received before
admission to Ziv was clearly improvised and limited by the
resources and expertise available. Some patients, patient 17, for
example, arrived after treatment that compounded his initial
injuries. Damage control measures performed in Syria, such as the
ligation of bleeding vessels, did, however, preserve life, albeit, at
the expense of rendering limbs ischaemic.
Wounds that would otherwise be left open were sutured
(presumably to stop haemorrhage) with whatever was to hand.
Four out of 17 patients with vascular injury arrived with primary
skin closure of contaminated wounds (Fig. 3). These patients,
therefore, had the combined morbidity of delay in treatment and
infection of their injuries. Heavily contaminated wounds were
wrapped in soiled blankets or clothing, patients with initial
laparotomies had missed injuries, and patients were shocked and
septic when they arrived. This was compounded by under-
nutrition evident amongst the patients (although a limitation of
this paper is a lack of documented assessment of nutrition status
on admission).
The delay in time between injury and arrival to Ziv for denitive
treatment was estimated from the information provided by
ambulance and paramedic staff of the Israeli army medical corps
stationed at the Israel-Syria border to resuscitate and transfer
patients. Patients with immediately lethal injuries were not seen at
the border.
Patterns of injury
Our cohort of patients compares favourably with Jahas account
of civilian patients with vascular injuries treated in Kosovo [8]. Most
of his patients were between 10 and 40 years old, with injuries from
stabbing, gunshot, landmines or blunt trauma. Most injuries were to
the upper limb or supercial femoral artery. Twenty-ve percent of
patients had other injuries. Most patients with penetrating trauma
Fig. 3. This 8-year-old boy presented with extensive chest wall and right arm
trauma. The skin was closed in Syria prior to transfer. The wounds are infected.
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815
were hemodynamically unstable, especially after landmine injury.
Only 4 of 120 patients underwent investigation with CTA; most
surgical decisions were based on the presence of hard or soft
vascular signs and Doppler assessment. Surgical reconstruction was
performed using autologous vein graft where possible. Most
landmine injuries resulted in primary amputation. Khan, reporting
experience from a combined civilian and military hospital,
employed angiography in only 7 of 40 patients, relying on clinical
data, Doppler and X-ray. Time from injury to presentation was up to
32 h and this was a signicant factor in outcome [12].
Vascular injuries and the role of CT angiography
All patients with vascular injury, regardless of other organs
injured, underwent CTA with arterial and venous phases. CTA was
instrumental in the investigation and planning of vascular
intervention. This is in keeping with modern Trauma practice
[4,13,14] that has seen a signicant impact of CTA on modern
vascular assessment which no longer relies solely on the presence
of hard and soft clinical signs that may be difcult to reliably elicit
after multiple trauma, sepsis and delay. In these patients the
inability to communicate optimally with patients and a lack of
information about the injury, co-morbidities and rst line
treatment that had been administered in Syria (out of 450 patients
only two arrived with transfer letters), rendered CTA ndings
crucial to management. Rapid, non-invasive assessment of both
arterial and venous trees was, therefore, possible in 3 dimensions
with information on associated bone injury, soft tissue damage,
and the presence of foreign bodies in the injured tissues.
Priorities in decision making
Algorithms in the acute management of war trauma [13,57],
while hugely inuential in the up-to-date care of civilian injuries,
do not take into account the delay and sepsis present in the
patients in this cohort with prolonged under-perfusion of tissues.
While, standard algorithms after initial resuscitation continue to
orthopaedic reduction, revascularisation, and nally orthopaedic
xation [15], in this particular cohort of patients where delay,
prolonged ischaemia, extensive skin and soft tissue loss and
complex, multi-fragmentary fractures were mitigating factors in
management, a multi-disciplinary regimen of aggressive debride-
ment and lavage, initial external xation of fractures preceding
limb perfusion with autologous vein graft [16], where possible,
formed the mainstay of treatment. After initial reperfusion
surgery, all patients were reviewed and patients with wounds in
need of second look or debridement returned to theatre. Damage
control in the form of vessel ligation had already been performed in
Syria in some cases and temporary shunting of vessels was not
required in Ziv as vessel repair was performed primarily. Patients
who suffered graft disruption in Ziv might arguably have
undergone primary amputation rather than an attempt at limb
salvage otherwise, management was in line with modern
denitive trauma surgical care principles. The time taken for
orthopaedic xation did not contribute to a signicant delay in
revascularisation [17,18]. This also made possible a single
denitive vascular repair instead of unnecessary bridging proce-
dures in order to establish temporary reperfusion. A further
advantage of orthopaedic xation beforehand was that it was
possible to plan the exact length and route of the graft in advance
of particular importance as extensive soft tissue and skin loss were
added challenges to graft positioning.
This multi-disciplinary approach was essential to the limb
salvage principal of care in the surgical team at Ziv: A 16-year-old
boy, injured in an explosion, presented with near total amputation
of the left forearm. He suffered an approximately 15-cm loss of
the distal humerus, muscles of the right arm, the brachial artery
and vein (Fig. 4). The forearm was suspended on a sliver of
816 T. Salamon et al. / Injury, Int. J. Care Injured 47 (2016) 811817
Fig. 4. This 16-year-old-boys left arm was amputated in a blast. The elbow and up
to 15-cm of the proximal radius is missing. Soft tissue trauma is extensive and the
brachial artery and vein have been lacerated.
skin, extensor tendons and neurovascular bundle. This patient
arrived relatively soon after injury (within 3 or 4 h), therefore,
revascularisation was possible. He underwent brachial-brachial
bypass with autologous GSV graft, and extensive debridement and
temporary orthopaedic xation of a shortened limb, with a view to
gradual limb lengthening in stages.
After treatment the right hand was viable with neurological
function sufcient to permit nger motion (opposing ngers and
thumb). At discharge he was able to lift a glass to drink for himself.
In most patients, revascularisation was performed after bone
reduction and xation, which prolonged limb ischaemia a further
30 to 60 min. In the case above, however, revascularisation surgery
was performed before orthopaedic treatment, as 3 to 4 h had
already elapsed since injury. This made surgery challenging,
especially in terms of planning the length and route of the bypass.
The role of endovascular treatment in war related vascular injuries
While endovascular management (angiography and embolisa-
tion) of bleeding solid organs, the pelvis, and zone 3 neck injuries,
where operative access is difcult, is well-established [19,20],
endovascular management of peripheral vascular trauma is
increasing and has been used in lower-extremity injuries both
as a bridging procedure (vascular damage control) and for
denitive repair [2123]. The advantages are reduced operating
time, reduced insult to the physiology of the multiply-injured
patient, minimisation of further disruption to already damaged
tissues and fascial compartments, and less dissection around false
aneurysms. The obvious disadvantages are the use of synthetic
graft material in septic patients and the need to anticoagulate
postoperatively.
Patients were selected for endovascular treatment if they met
the following criteria:
1. No life-threatening acute haemorrhage necessitating immediate
surgery.
2. Injuries demonstrable on CTA amenable to endovascular
treatment (AV stula and pseudoaneurysm).
Covered stents were selected for injured arteries crossing
articular surfaces, i.e. the common femoral artery or internal
carotid artery. Oversizing was not necessary in order to cover
defects and stent lengths were minimised in order not to cover
branches.
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Patient 7, a 15-year-old girl with blast injury resulting in
traumatic right below knee amputation and severe multiple
fragment injuries to the abdomen and left leg, underwent
laparotomy in Syria and presented to Ziv Medical Centre 7 days
after her injuries. On arrival, she was septic, anaemic and had ARDS
(temperature 38 8C, pulse 153 beats per minute, and haemoglobin
7 g/dl). After initial resuscitation in the Intensive Care Unit, the
abdominal cavity was reopened and lavaged, the below knee
amputation was converted to an above knee amputation due to
severe infection of the stump, and an external (Ilizarov) xator was
applied to the left leg. The patient underwent repeated second look
and debridement procedures, received intravenous antibiotics
andtransfusion of blood products within the rst 24 h of her
admission. As her clinical condition normalised, fever resolved,
haemoglobin rose to 10 g/dl, and blood pressure rose to 110/
70 mmHg, she remained tachypnoeic and tachycardic and her face
was ushed, with distended neck veins. Computed tomographic
angiogram demonstrated a large arterio-venous stula involving the
right femoral artery and vein and abdominal vein lling during the
arterial phase (demonstrating a high ow arterio-venous shunt). A
working diagnosis of heart failure secondary to a large arterio-
venous stula was made and endovascular intervention proposed.
Using the left femoral arterial approach, up-and-over access was
established. A Viabhan (Gore) endovascular stent measuring
8  100 mm was deployed inside the common femoral artery,
sealing the stula. Immediately after the procedure, the heart rate
fell from 126 to 111 beats per minute and over the next hours, the
patient made a remarkable recovery, the respiratory rate returned to
normal, and sacral and leg oedema resolved.
Conclusions
The injuries in this paper are heterogeneous, and reect the
range of vascular trauma expected amongst combatants and
civilians, and the broad range of vascular solutions required to
optimise outcomes, in particular, limb salvage. Champion, proling
combat injuries, listed high energy/lethality wounding, multiple
causes of wounding, preponderance to penetrating injury, the
persistence of the tactical threat, austere, resource-constrained
environments, and a delay in denitive care as the factors that
separate outcomes in conict from civilian vascular trauma [24]. It
would seem, however, that civilians injured in civil war have the
worst of both worldsmilitary injuries on the background of
chronic poor health with little prospect of rapid rescue and
resuscitation.
Conict of interest statement
None of the authors has a conict of interest to declare.
Seema Biswas on behalf of Tal Salamon, Alexander Lerner, David
Rothem, Alexander Altshuler, Ron Karmeli, Evgeny Solomonov (all
authors).
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