Rich’s Vascular Trauma

Rich’s Vascular Trauma

3R D EDITION

Todd E. Rasmussen, MD, FACS

Colonel USAF MC
Director, U.S. Combat Casualty Care Research Program
Fort Detrick, Maryland;
Harris B Shumacker, Jr. Professor of Surgery
The Norman M. Rich Department of Surgery
Uniformed Services University of the Health Sciences
Bethesda, Maryland;
Attending Vascular & Trauma Surgeon
Veterans Administration Medical Center & University of Maryland
Shock Trauma Center
Baltimore, Maryland

Nigel R.M. Tai, QHS, MS, FRCS(Gen)

Colonel, L/RAMC
Clinical Director, Trauma Services
Royal London Hospital
Barts Health NHS Trust
London, United Kingdom;
Senior Lecturer
Academic Department of Military Surgery and Trauma
Royal Centre for Defence Medicine
Birmingham, United Kingdom;
Consultant Surgeon
16 Medical Regiment
Colchester, Essex, United Kingdom
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

RICH’S VASCULAR TRAUMA, THIRD EIDTION ISBN: 978-1-4557-1261-8

Copyright © 2016 by Elsevier, Inc. All rights reserved.

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Knowledge and best practice in this field are constantly changing. As new research and experience broaden
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Previous editions copyright © 2004 and 1978.

Library of Congress Cataloging-in-Publication Data

Rich’s vascular trauma / [edited by] Todd E. Rasmussen, Nigel R.M. Tai.—Third edition.
    p. ; cm.
  Vascular trauma
  Preceded by: Vascular trauma / [edited by] Norman M. Rich, Kenneth L. Mattox, Asher Hirshberg. 2nd ed.
c2004.
  Includes bibliographical references and index.
  ISBN 978-1-4557-1261-8 (hardcover : alk. paper)
  I.  Rasmussen, Todd E., editor.  II.  Tai, Nigel R. M., editor.  III.  Rich, Norman M. Vascular trauma.
Preceded by (work):  IV.  Title: Vascular trauma.
  [DNLM:  1.  Blood Vessels—injuries.  2.  Vascular Surgical Procedures.  WG 170]
  RD598.5
  617.4′13044—dc23
2014045541

Acquisitions Editor: Michael Houston

Developmental Editor: Laura Schmidt
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Rachel E. McMullen
Design Direction: Ashley Miner

Printed in China

Last digit is the print number:  9  8  7  6  5  4  3  2  1

To our families, whose love and sacrifice have made this
and so many other endeavors possible

and to the teachers who prepared us; the friends and

colleagues—close and far—whose efforts have
inspired, enabled, and sustained us; and our
patients who, in times of peace and war,
it is our privilege to know and care for
CONTRIBUTORS

Aaron C. Baker, MS, MD Frank K. Butler, MD

Clinical Fellow Chairman
Vascular and Endovascular Surgery Committee on Tactical Combat Casualty Care Director
Mayo Clinic Prehospital Trauma Care
Rochester, Minnesota U.S. Joint Trauma System
Defense Center of Excellence
Lorne H. Blackbourne, MD U.S. Army Institute of Surgical Research
Attending Trauma Surgeon Joint Base San Antonio
San Antonio Military Medical Center Ft. Sam Houston, Texas
Joint Base San Antonio
Ft. Sam Houston, Texas Jeremy W. Cannon, MD, FACS, SM
Chief, Trauma and Critical Care
Kenneth Boffard, MB, BCh, FRCS, FRCS(Edin), Department of Surgery
FRCPS(Glas), FCS(SA), FACS San Antonio Military Medical Center
Professor Emeritus Joint Base San Antonio
Department of Surgery Ft. Sam Houston, Texas;
University of the Witwatersrand; Associate Professor of Surgery
Trauma Director The Norman M. Rich Department of Surgery
Milpark Hospital Uniformed Services University of the Health Sciences
Johannesburg, South Africa Bethesda, Maryland

Oswaldo Borraez, MD Ian D. Civil, MBChB, FRACS, FACS

Mayo Clinic
Vascular Surgery
Rochester Minnesota
Mark W. Bowyer, MD, FACS
Professor of Surgery
Chief of Trauma and Combat Surgery
Surgical Director of Simulation
The Norman M. Rich Department of Surgery
Uniformed Services University
Bethesda, Maryland
Karim Brohi, FRCA, FRCS
Professor of Trauma Sciences
Queen Mary University of London
Consultant Trauma and Vascular Surgeon
Royal London Hospital
Barts Health NHS Trust
London, United Kingdom
Director of Trauma Services
Trauma Services
Auckland City Hospital
Auckland, New Zealand
Jon Clasper, MBA, DPhil, DM, FRCSEd(Orth)
Defence Professor Trauma and Orthopaedics
Visiting Professor in Bioengineering, Imperial College
London
London, United Kingdom
Marcus Cleanthis, BSc(Hons), MBBS, MD, FRCS
Consultant Vascular Surgeon
Department of Vascular Surgery
Frimley Park Hospital
Surrey, United Kingdom

vii
viii Contributors

W. Darrin Clouse, MD, FACS Charles J. Fox, MD, FACS

Professor of Surgery Chief, Vascular Surgery
The Norman M. Rich Department of Surgery Denver Health Medical Center;
Uniformed Services University of the Health Sciences Associate Professor of Surgery
Bethesda, Maryland; University of Colorado School of Medicine
Associate Visiting Surgeon Denver, Colorado
Division of Vascular and Endovascular Surgery
Massachusetts General Hospital David L. Gillespie, MD, RVT, FACS
Boston, Massachusetts Chief, Department of Vascular and Endovascular Surgery
Cardiovascular Care Center
Lazar B. Davidovic, MD, PhD, FETCS Southcoast Health System
Head of the Clinic Fall River, Massachusetts
Clinic for Vascular and Endovascular Surgery
Clinical Center of Serbia Gabriel Herscu, MD
Full Professor of Vascular Surgery Fellow, Vascular Surgery
Faculty of Medicine Division of Vascular Surgery and Endovascular Therapy
University of Belgrade Keck Medical Center
Belgrade, Serbia University of Southern California
Los Angeles, California
David L. Dawson, MD, FACS, RVT, RPVI
Professor of Surgery Shehan Hettiaratchy, MA(Oxon), DM,
University of California, Davis FRCS(Plast)
Sacramento, California; Chief of Service
Special Clinical Consultant, Surgery Plastic, Orthopaedic, ENT, and Major Trauma Services
David Grant Medical Center Imperial College Healthcare NHS Trust
Travis Air Force Base London, United Kingdom;
Fairfield, California Senior Lecturer
Academic Department of Military Surgery and Trauma
Demetrios Demetriades, MD, PhD, FACS Royal Centre for Defence Medicine
Professor of Surgery Birmingham, United Kingdom
University of Southern California;
Director, Acute Care Surgery Timothy Hodgetts, PhD, MMEd, MBA, MBBS,
Los Angeles County and University of Southern California FRCP, FRCSEd, FCEM
Medical Center Honorary Professor of Emergency Medicine
Los Angeles, California University of Birmingham
Birmingham, United Kingdom;
Joseph J. DuBose, MD, FACS Medical Director
Chief Vascular Fellow UK Defence Medical Services
University of Texas Health Science Center—Houston Glouccester, United Kingdom
Associate Professor of Surgery
The Norman M. Rich Department of Surgery Aaron Hoffman, MD
Uniformed Services University of the Health Sciences Director
Houston, Texas Department of Vascular Surgery and Transplantation
Rambam Health Care Campus;
Timothy C. Fabian, MD, FACS Associate Professor
Harwell Wilson Professor and Chairman Rappaport Faculty of Medicine
Surgery Technion
University of Tennessee Health Science Center Haifa, Israel
Memphis, Tennessee
John B. Holcomb, MD, FACS
David V. Feliciano, MD, FACS Center for Translational Injury Research
Battersby Professor and Chief, Division of General Surgery Division of Acute Care Surgery
Chief of Surgery Department of Surgery
Indiana University Hospital University of Texas Health Science Center
Department of Surgery Houston, Texas
Indiana University Medical Center
Indianapolis, Indiana
 Contributors ix

Kenji Inaba, MD, FRCSC, FACS Luis A. Moreno, MD

Associate Professor of Surgery Medical Doctor and Surgeon General
University of Southern California; National University
Division of Acute Care Surgery Vascular Surgeon
Director Surgical Critical Fellowship Bosque University
Los Angeles County and University of Southern California Bogota, Columbia
Medical Center
Los Angeles, California Jonathan J. Morrison, MB ChB, MRCS
Surgical Registrar, West of Scotland Surgical Rotation
Donald H. Jenkins, MD, FACS Research Fellow
Consultant Academic Department of Military Surgery & Trauma,
Associate Professor of Surgery Royal Centre for Defence Medicine,
Division of Trauma, Critical Care and General Surgery Birmingham, United Kingdom
Trauma Center Mayo Clinic
Rochester, Minnesota Rossi Murilo, MD
Professor of Surgery
Michael Jenkins, BSc, MS, FRCS, FEBVS University of Valença
Consultant Vascular Surgeon School of Medicine;
Chief of Service Vascular Surgery & Director of Trauma Director of IECAC (State Institute of Cardiology Aloísio de
Imperial College Healthcare NHS Trust Castro)
St Mary’s Hospital Master’s Degree in Vascular Surgery
London, United Kingdom Federal University of Rio de Janeiro (UFRJ)
Rio de Janeiro, Brazil
Tony Karram, MD
Department of Vascular Surgery and Organ Transplantation Samy Nitecki, MD
Rambam Health Care Campus Director
Haifa, Israel Peripheral Vascular Surgery Unit Vice Chair
Department of Vascular Surgery and Organ Transplantation
Brian S. Knipp, MD Rambam Health Care Campus
Lieutenant Commander Haifa, Israel
Medical Corps, U.S. Navy
NMC Portsmouth David M. Nott, OBE, OStJ, DMCC, BSc, MD, FRCS
Staff Vascular Surgeon Consultant General Surgeon
Portsmouth, Virginia Department of Surgery
Chelsea and Westminster Hospital
Neil G. Kumar, MD Consultant Trauma and Vascular Surgeon
Resident, Vascular Surgery Department of Surgery
Department of Surgery St Mary’s Hospital
Division of Vascular Surgery London, United Kingdom
University of Rochester Medical Center
Rochester, New York Chirag M. Patel, BSc (Hons), MBBS, MRCP, FRCR
Department of Diagnostic and Interventional Radiology
Ari K. Leppäniemi, MD, PhD Barts and the London NHS Trust
Chief of Emergency Surgery London, United Kingdom
Abdominal Surgery
University of Helsinki Predrag Pavić, MD
Meilahti Hospital Vascular Surgery
Helsinki, Finland University Hospital Dubrava
Zagreb, Croatia
Zvonimir Lovrić, PhD, MD
Professor Michael A. Peck, MD
Chief Surgeon of Traumatology Division Peripheral Vascular Associates
Department for Surgery San Antonio, Texas
University Hospital Dubrava
Zagreb, Croatia Rina Porta, MD
Doctorate in Vascular Surgery—FMUSP (Federal University
Mark Midwinter, MB BS, BMedSci(Hons), of São Paulo)
MD, FRCS Vacular Surgery of Emergency Unit of USP
Defence Professor of Surgery São Paulo, Brazil
Academic Department of Military Surgery and Trauma
Royal Centre for Defence Medicine
Birmingham, United Kingdom
x Contributors

Alexander A. Pronchenko, MD, PhD Igor M. Samokhvalov, MD, PhD, Prof.

War Surgery Department Colonel M.C. (Ret)
Kirov Military Medical Academy Chief Surgeon of the Russian Army
Saint-Petersburg, Russia Ministry of Defense of the Russian Federation
Moscow, Russia
Reagan W. Quan, MD Professor and Chair
Chief of Vascular Surgery Department and Clinic of War Surgery
Wellspan Heart and Vascular Center Military Medical Academy named after S.M. Kirov
York, Pennsylvania Saint-Petersburg, Russia

Dinesh G. Ranatunga, MBBS(Hon), FRANZCR Stephanie A. Savage, MD, MS, FACS

Specialist Registrar Associate Professor of Surgery
Department of Diagnostic and Interventional Radiology University of Tennessee Health Science Center
The Royal London Hospital Memphis, Tennessee
Barts Health NHS Trust
London, United Kingdom Hannu Savolainen, MD, PhD
Professor of Vascular Surgery
Todd E. Rasmussen, MD, FACS University of the West Indies
Colonel USAF MC Academic Department of Surgery
Director, U.S. Combat Casualty Care Research Program Queen Elizabeth Hospital
Fort Detrick, Maryland; Bridgetown, Barbados
Harris B Shumacker, Jr. Professor of Surgery
The Norman M. Rich Department of Surgery Daniel J. Scott, MD
Uniformed Services University of the Health Sciences General and Peripheral Vascular Surgery Resident
Bethesda, Maryland; San Antonio Military Medical Center
Attending Vascular & Trauma Surgeon Joint Base San Antonio
Veterans Administration Medical Center & University of Ft. Sam Houston, Texas
Maryland
Shock Trauma Center Sherene Shalhub, MD, MPH
Baltimore, Maryland Assistant Professor
Cardiothoracic and Vascular Surgery
Amila S. Ratnayake, MBBS, MS The University of Texas Medical School
Lieutenant Colonel Houston, Texas
Consultant General & Trauma Surgeon
Army Hospital Abdul H. Sheriffdeen, MBBS(Ceylon), FRCS(Eng)
Colombo 05 Emeritus Professor of Surgery
Sri Lanka University of Colombo
Colombo, Sri Lanka
Ian Renfrew, MRCP, FRCR
Consultant in Interventional Radiology Niten Singh, MD, FACS
Department of Diagnostic and Interventional Radiology Associate Professor of Surgery
The Royal London Hospital Vascular Surgery
Barts Health NHS Trust University of Washington
London, United Kingdom Seattle, Washington;
Associate Professor of Surgery
Viktor A. Reva, MD Uniformed Services of Surgery
Fellow Bethesda, Maryland
Department of War Surgery
Kirov Military Medical Academy Michael J. Sise, MD, FACS
Saint-Petersburg, Russia Clinical Professor
Surgery
Norman M. Rich, MD, FACS, DMCC UCSD Medical Center
Leonard Heaton and David Packard Professor Medical Director
The Norman M. Rich Department of Surgery Division of Trauma
F. Edward Hébert School of Medicine Scripps Mercy Hospital
Uniformed Services University of the Health Sciences San Diego, California
Bethesda, MD

Bandula Samarasinghe, MBBS, MS

Senior Lecturer
University of Peradeniya
Peradeniya, Sri Lanka
 Contributors xi

Benjamin Starnes, MD, FACS Carole Y. Villamaria, MD

Chief, Vascular Surgery Division Surgical Resident
Department of Surgery Department of Surgery
University of Washington University of Texas Health Sciences Center at San Antonio
Seattle, Washington San Antonio, Texas

Nigel R.M. Tai, QHS, MS, FRCS(Gen) Alasdair J. Walker, OBE, QHS, MB ChB, FRCS
Colonel, L/RAMC Medical Director and Consultant Vascular Surgeon
Clinical Director, Trauma Services Joint Medical Command
Royal London Hospital Ministry of Defence
Barts Health NHS Trust Birmingham, United Kingdom
London, United Kingdom;
Senior Lecturer Fred A. Weaver, MD, MMM, FACS
Academic Department of Military Surgery and Trauma Professor and Chief
Royal Centre for Defence Medicine Division of Vascular Surgery and Endovascular Therapy
Birmingham, United Kingdom; Keck School of Medicine, University of Southern California
Consultant Surgeon Los Angeles, California
16 Medical Regiment
Colchester, Essex, United Kingdom Mandika Wijeyaratne, MBBS, MS(Surg),
MD(Leeds UK), FRCS(Eng)
Peep Talving, MD, PhD, FACS Professor of Surgery
Assistant Professor of Surgery Department of Surgery
University of Southern California University of Colombo
Division of Acute Care Surgery Colombo, Sri Lanka
Keck School of Medicine
Los Angeles, California

Jorge H. Ulloa, MD, FACS

Director
Venous Surgery
Clinica de Venas
Associate Professor
Vascular Surgery
Universidad El Bosque
Bogota, Columbia
FOREWORD
The military medical experience of the United States of
America and the United Kingdom during the first decade
of the 21st century has resulted in notable advancements in
the management of vascular trauma.1 Air superiority during
the wars in Afghanistan and Iraq has allowed rapid and, in the
case of the Medical Emergency Response Teams (MERTs)
often advanced, medical evacuation of injured service person-
nel. During the wars, a large number of patients with vascular
trauma have been cared at forward Level II or more definitive
Level III surgical facilities fairly rapidly after the time of injury.
Subsequent transcontinental aeromedical evacuation with
sophisticated Critical Care Air Transport Teams (CCATT) has
permitted wounded troops to be transported half way around
the world in record time while receiving high levels of inten-
sive monitoring and care.
The wars in Afghanistan and Iraq have also witnessed the
broad use of modern body armor and newly designed tour-
niquets by those in harm’s way. The role of temporary vascular
shunts, the optimal types and ratios of fluids for resuscitation,
and the types of conduits for segmental vascular replacement
have been redefined during this decade of war. As the first
prolonged period of combat operations in which specialty
trained vascular and endovascular surgeons have been
deployed, this decade has witnessed the use of endovascular
procedures to manage select patterns of vascular trauma and
a modern reappraisal of endovascular balloon occlusion of the
aorta for the management of hemorrhagic shock. Despite
these and other advances, significant new questions have
arisen including how best to assure adequate training and
readiness of military surgeons to manage the complex injury
pattern that is vascular trauma.2
Making optimal use of Mayo Clinic training and early
assignments at Walter Reed Army Medical Center and the
Uniformed Services University, Air Force Colonel Todd E. Ras-
mussen has been an effective leader, a role model, and a
respected mentor in all aspects of this experience. He has com-
municated successfully with and benefited greatly from highly
skilled allies and friends such as Colonel Nigel R.M. Tai of the
Royal Army Medical Corps. Michael E. DeBakey, whose mili-
tary experience originated in World War II (1941–1945), Carl
W. Hughes in the Korean Conflict (1951–1953), and Norman
M. Rich during the Vietnam War (1965–1972) emphasized the
contributions of Rasmussen and colleagues in 2007. In their
manuscript entitled “Recognition of Air Force Surgeons at
Wilford Hall Medical Center-Supported 332nd Air Force
Theater Hospital, Balad Air Base, Iraq,” DeBakey, Hughes, and
Rich recognized this modern “Band of Brothers” and their
impact on vascular trauma.3
This third edition of Rich’s Vascular Trauma adds a novel
and highly appropriate International Perspectives section to its
already impressive archive of recognized authors and chapters.
Co-editors Rasmussen and Tai have reached out to and have
secured exclusive contributions from military and civilian
leaders in vascular trauma around the globe. This new Inter-
national Perspectives section provides a mix of personal and
regional experiences from surgeons whose partnership in the
management of vascular trauma was and will continue to be
highly valued. As global health, including the management of
injury, becomes a focus of health care professionals around
the world, the third edition of Rich’s Vascular Trauma by the
Society for Vascular Surgery, along with the appointment of
Todd E. Rasmussen as Chief Editor, will provide a current and
comprehensive reference.
Finally, I would like to acknowledge the valuable contribu-
tions of Frank Spencer, Kenneth Mattox, and Asher Hirsch-
berg that helped us establish a firm foundation in the
management of vascular trauma on which surgeons such as
Todd E. Rasmussen, Nigel R.M. Tai, and their colleagues,
trainees, and students can continue to build.
Norman M. Rich, MD
REFERENCES
1. Pruitt BA, Rasmussen TE: Vietnam (1972) to Afghanistan (2014): the state
of military trauma care and research, past to present. J Trauma Acute Care
Surg 77(3 Suppl 2):S57–S65, 2014.
2. Rasmussen TE, Woodson J, Rich NM, et al: Vascular injury at a crossroads.
J Trauma 70(5):1291–1293, 2011.
3. Rich NM, Hughes CW, DeBakey ME: Recognition of Air Force surgeons
at Wilford Hall Medical Center-supported 332nd EMDG/Air Force Theater
Hospital, Balad Air Base, Iraq. J Vasc Surg 46:1312–1313, 2007.
xiii
PREFACE
The third edition of Rich’s Vascular Trauma follows in the
singular lineage of two prior editions from Rich, Mattox, and
Hirshberg, texts that defined the pattern and treatment of
vascular injury and that characterized its global significance.
In keeping with the tone of the original edition, which was
rooted in knowledge gained from the wartime environment,
this edition is similarly founded upon a decade of clinical
experience resulting from the wars in Afghanistan and Iraq.1,2
Modern studies of combat-related injury and, indeed, civilian
trauma studies have redefined and emphasized the impor-
tance of vascular injury in taking the lives of the severely
injured. Epidemiologic study of the burden of injury from a
decade of war has more clearly identified vascular disruption
and subsequent hemorrhage as the leading causes of death in
patients with otherwise survivable injuries.3 Additionally, vas-
cular injury resulting in ischemia has been demonstrated a
leading cause of extremity amputation and disability.
Observations in modern wartime and civilian environ-
ments confirm the beneficial effects of organized trauma
systems in improving survival and decreasing morbidity.4,5 As
such, and to provide a broader perspective, we have set out to
ensure that the third edition explores the clinical implications
of vascular injury throughout all phases of trauma care and
not just in the operating theater. Unlike almost any other
injury pattern, vascular trauma carries direct life- and limb-
threatening implications that extend from the point of injury
and prehospital settings through to the emergency depart-
ment, operating room, and intensive care unit. Any contem-
porary dissertation on vascular trauma that failed to address
the spectrum of patient care would be incomplete. A prime
goal of this edition is to portray vascular trauma with refer-
ence to the trauma-systems approach and, by so doing, offer
information and tools not merely for the surgeon but for
all providers who contribute to the management of this
formidable injury pattern.
To provide this wide-ranging perspective, the third edition
of Rich’s Vascular Trauma draws on civilian and military
authorities from around the world. These experts have come
together to author chapters arranged in the following sections:
Background, Diagnosis and Early Management, Definitive
Management, and Hot Topics in Vascular Injury and Manage-
ment. To allow for a diverse viewpoint the editors have
embraced chapters from those with a range of backgrounds
including prehospital care, emergency medicine, trauma
systems, and intensive care, as well as general, trauma, vascu-
lar, orthopedic, and plastic surgery. It is the editors’ hope that
this edition, as a whole, will not only provide important infor-
mation for those seeking specific solutions but will also prove
compelling reading in areas bordering on the fringes of one’s
traditional practice.
Finally and in recognition of the truly global legacy of
vascular trauma, both the text and the injury pattern, the third
edition concludes with an original International Perspectives
Section. In this section, the editors are privileged to present
individual accounts of vascular trauma from leading surgeons
around the world. The international contributors to this
section hail from nearly every continent on the globe and
represent military and civilian friends and colleagues whose
contributions are fundamental and enduring parts of this text.
This section, more than any other, embodies the heritage that
this new edition draws from its namesake: surgeon, gentle-
man, and ambassador —Norman M. Rich, MD.
Todd E. Rasmussen, MD
Nigel R.M. Tai, QHS, MS, FRCS(Gen)
REFERENCES
1. Stannard A, Brown K, Benson C, et al: Outcome after vascular trauma in
a deployed military trauma system. Br J Surg 98(2):228–234, 2011.
2. White JM, Stannard A, Burkhardt GE, et al: The epidemiology of vascular
injury in the wars in Iraq and Afghanistan. Ann Surg 253(6):1184–1189,
2011.
3. Eastridge BJ, Mabry RL, Seguin P, et al: Death on the battlefield (2001–
2011): implications for the future of combat casualty care. J Trauma Acute
Care Surg 73(6 Suppl 5):S431–S437, 2012.
4. Rasmussen TE, Gross KR, Baer DG: Where do we go from here? J Trauma
Acute Care Surg 75(2 Suppl 2):S105–S106, 2013.
5. Bailey JA, Morrison JJ, Rasmussen TE: Military trauma system in Afghani-
stan: lessons for civil systems? Curr Opin Crit Care 19(6):569–577, 2013.
xv
xvi Preface

This photo shows an image of the 332nd Expeditionary Medical Group, Air Force Theater
Hospital in Balad Iraq (circa 2005). During the war in Iraq from this location, the Balad
Vascular Registry provided information into various aspects of the management of vascular
trauma including reports on the use of temporary vascular shunts, endovascular tech-
niques, and the management of specific anatomic patterns (upper extremity, femoral-
popliteal, and tibial level injuries).1 The clinical and academic efforts of the operative work
force at the Air Force Theater Hospital in Balad were recognized in a commentary by Drs.
Rich, Hughes, and DeBakey in the Journal of Vascular Surgery in 2007.2

This photo shows an image of the United Kingdom’s Role III facility at Camp Bastion,
Afghanistan (circa 2008). The British-led efforts at Camp Bastion, consistently the busiest
surgical hospital in Afghanistan, resulted in reports on not only extremity vascular trauma
but also more complex injury patterns such as noncompressible torso hemorrhage, peri-
traumatic pulmonary thrombosis, junctional vascular injury, and dismounted complex
blast injury.3,4 The term “right turn resuscitation” was also coined at Bastion referring to
the physical space of the hospital in which “turning right” on entry to the emergency
department led one immediately to the operating room. This immediate “right turn”
bypassed the traditional emergency department, affording simultaneous blood and proce-
dural (i.e., operative) resuscitation in the operating theater in the most severely injured of
patients.5

1. Clouse WD, Rasmussen TE, Peck MA, et al: In theater management of
wartime vascular injury: 2 years of the Balad Vascular Registry. J Am Coll
Surg 204(4):625-632, 2007.
2. Rich NM, Hughes CW, Debakey ME: Recognition of Air Force surgeons at
Wilford Hall Medical Center-supported 332nd EMDG/Air Force Theater
Hospital, Balad Air Base, Iraq. J Vasc Surg 46(6):1312–1313, 2007; author
reply 1313.
3. Stannard A1, Brown K, Benson C, et al: Outcome after vascular trauma in
a deployed military trauma system. Br J Surg 98(2):228–234, 2011.
4. Jansen JO, Thomas GO, Adams SA, et al: Early management of proximal
traumatic lower extremity amputation and pelvic injury caused by impro-
vised explosive devices (IEDs). Injury 43(7):976–979, 2012. doi: 10.1016/j.
injury.2011.08.027. Epub 2011 Sep 9.
5. Tai NR1, Russell R: Right turn resuscitation: frequently asked questions.
J R Army Med Corps 157(3 Suppl 1):S310–S314, 2011.
SECTION 1

Background
The Vascular Injury Legacy
NORMAN M. RICH AND ALASDAIR J. WALKER
Although the first crude arteriorrhaphy was performed more
than 250 years ago, it is only within the past 50 years that
vascular surgery has been practiced both widely and consis-
tently with anticipation of good results. Historically, it is of
particular interest that by the turn of the 20th century many
if not most of the techniques of modern vascular surgery had
already been explored through extensive experimental work
and early clinical application. In retrospect it is therefore
almost astonishing that it took nearly another 50 years before
the work of such early pioneers as Murphy, Goyanes, Carrel,
Guthrie, and Lexer was widely accepted and applied in the
treatment of vascular injuries. However, adoption of the
thought processes and practices of these enlightened surgeons
was hampered by the technological limitations of their era and
had to await the dramatic advances in graft materials and
imaging seen during the 1950s and beyond.1,2
Since the days of Ambroise Paré in the mid–16th century,
major advances in the surgery of trauma have occurred during
times of armed conflict when it was necessary to treat large
numbers of severely injured patients, often under far-from-
ideal conditions. This has been especially true with vascular
injuries.
Although German surgeons accomplished arterial repairs
in the early part of World War I, it was not until the Korean
Conflict and the early 1950s that ligation of major arteries was
abandoned as the standard treatment for arterial trauma. The
results of ligation of major arteries following trauma were
clearly recorded in the classic manuscript by DeBakey and
Simeone in 1946, who found only 81 repairs in 2471 arterial
injuries among American troops in Europe in World War II.3
All but three of the arterial repairs were performed by lateral
suture. Ligation was followed by gangrene and amputation in
nearly half of the cases. The pessimistic conclusion reached by
many was expressed by Sir James Learmonth, who said that
there was little place for definitive arterial repair in the combat
wound.
Within a few years, however, in the Korean Conflict, the
possibility of successfully repairing arterial injuries was estab-
lished conclusively, stemming especially from the work of
Hughes, Howard, Jahnke, and Spencer. In 1958 Hughes
emphasized the significance of this contribution in a review
of the Korean experience, finding that the overall amputation
rate was lowered to about 13%, compared to the approxi-
mately 49% amputation rate that followed ligation in World
War II.4
During the Vietnam hostilities, more than 500 young
American surgeons, who represented most of the major surgi-
cal training programs in the United States, treated more than
1 
7500 vascular injuries. In 1969 Rich and Hughes reported the
preliminary statistics from the Vietnam Vascular Registry,
which was established in 1966 at Walter Reed General Hospital
to document and follow all servicemen who sustained vascular
trauma in Vietnam.5 An interim Registry report that encom-
passed 1000 major acute arterial injuries showed little change
from the overall statistics presented in the preliminary report.6
Considering all major extremity arteries, the amputation rate
remained near 13%. Although high-velocity missiles created
more soft-tissue destruction in injuries seen in Vietnam, the
combination of a stable hospital environment and rapid evac-
uation of casualties (similar to that in Korea) made successful
repair possible. Injuries of the popliteal artery, however,
remained an enigma, with an amputation rate remaining
near 30%.
In the past 50 years, civilian experience with vascular
trauma has developed rapidly under conditions much more
favorable than those of warfare. Results are better than those
achieved with military casualties in Korea and Vietnam.
Initial Control of Hemorrhage
Control of hemorrhage following injury has been of prime
concern to man since his beginning. Methods for control have
included various animal and vegetable tissues, hot irons,
boiling pitch, cold instruments, styptics, bandaging, and com-
pression. These methods were described in a historical review
by Schwartz in 1958.7 Celsus was the first to record an accurate
account of the use of ligature for hemostasis in 25 ad. During
the first three centuries, Galen, Heliodorus, Rufus of Ephsus,
and Archigenes advocated ligation or compression of a bleed-
ing vessel to control hemorrhage.
Ancient methods of hemostasis used by Egyptians about
1600 bc are described in the Ebers’ papyrus, discovered by
Ebers at Luxor in 1873.7 Styptics prepared from mineral or
vegetable matter were popular, including lead sulfate, anti-
mony, and copper sulfate. Several hundred years later during
the Middle Ages in Europe, copper sulfate again became
popular and was known as the hemostatic “button.” In ancient
India, compression, cold, elevation, and hot oil were used to
control hemorrhage, while about 1000 bc, the Chinese used
tight bandaging and styptics.
The writings of Celsus provide most of the knowledge of
methods of hemostasis in the first and second centuries ad.7
When amputation was done for gangrene, the prevailing sur-
gical practice was to amputate at the line of demarcation to
prevent hemorrhage. In the first century ad, Archigenes was
apparently the first to advocate amputating above the line of
3
 1  /  The Vascular Injury Legacy 3.e1

ABSTRACT
For more than 2000 years, control of battlefield hemor-
rhage relied on compressive dressings. Added to this were
the use of cautery, styptics, boiling oil, and a variety of
other partially effective adjuncts. In Rome 2000 years ago,
Galen advocated ligature of bleeding vessels. However, this
was lost during the Dark Ages, and it was not until the 16th
century that Ambroise Paré “reinvented” ligature of bleed-
ing vessels when he ran out of boiling oil. Paré was also
one of the first to devise instruments, including the bec de
corbin to grasp bleeding vessels to assist with the ligature.
At the turn of the 20th century, the development of clinical
and experimental concepts related to vascular surgery pro-
gressed, and during the Korean Conflict (1950-1953) suc-
cessful repair of injured arteries and veins was accomplished
consistently in the treatment of battlefield casualties. Over
the past 50 years, additional advances in managing vascu-
lar trauma have been made in both civilian and military
practices. These have included experiences with endovas-
cular procedures, particularly over the past decade, trans-
ferring civilian experience to the management of battlefield
casualties by coalition forces in Afghanistan and Iraq.

Key Words:  vascular trauma,

arterial trauma,
venous trauma,
arterial and venous injuries,
vascular repair,
vascular graft,
endovascular procedures
4 SECTION 1  /  BACKGROUND
demarcation for tumors and gangrene, using ligature of the
artery to control hemorrhage.
Rufus of Ephesus (first century ad) noted that an artery
would continue to bleed when partially severed, but when
completely severed it would contract and stop bleeding within
a short period of time.7 Galen, the leading physician of Rome
in the second century ad, advised placing a finger on the
orifice of a bleeding superficial vessel for a period of time to
initiate the formation of a thrombus and the cessation of
bleeding. He noted, however, that if the vessel were deeper, it
was important to determine whether the bleeding was coming
from an artery or a vein. If coming from a vein, pressure or a
styptic usually sufficed, but ligation with linen was recom-
mended for an arterial injury.
Following the initial contributions of Celsus, Galen, and
their contemporaries, the use of ligature was essentially for-
gotten for almost 1200 years in western medicine. A tension
developed between traditional church teachings and enlight-
ened thought, perhaps holding back any advancement in west-
ern medicine or surgery. Use of the knife was considered
wrong on living tissue; consequently amputation was below
the line of ischemic demarcation. Abu al-Qasim al-Zahrawi,
a prominent Arab physician from Moorish Spain (10th cen-
tury ad), advocated ligation in his great work Kitab Al-Tasrif
almost 600 years before Paré.7
Throughout the Middle Ages, cautery was used almost
exclusively to control hemorrhage. Jerome of Brunswick
(Hieronymus Brunschwig), an Alsatian army surgeon, actually
preceded Paré in describing the use of ligatures as the best way
to stop hemorrhage.7 His recommendations were recorded in
a textbook published in 1497 and provided a detailed account
of the treatment of gunshot wounds. Ambroise Paré, with a
wide experience in the surgery of trauma, especially on the
battlefield, firmly established the use of ligature for control of
hemorrhage from open blood vessels. In 1552 he startled the
surgical world by amputating a leg above the line of demarca-
tion, repeating the demonstration of Archigenes 1400 years
earlier. The vessels were ligated with linen, leaving the ends
long. Paré also developed the bec de corbin, ancestor of the
modern hemostat, to grasp the vessel before ligating it (Fig.
1-1).7 Previously, vessels had been grasped with hooks, tenacu-
lums, or the assistant’s fingers. He designed artificial limbs and
advanced dressing technique. During the siege of Turin (1536),
Paré ran out of oil, which was traditionally used to cauterize.
He mixed egg yolk, rose oil, and turpentine and discovered
this dressing had better outcomes than oil.
FIGURE 1-1  Artist’s concept of the bec de corbin, developed by Paré
and Scultetus in the mid–16th century. It was used to grasp the vessel
before ligating it. (From Schwartz AM: The historical development of
methods of hemostasis. Surgery 44:604, 1958.)
In the 17th century, Harvey’s monumental contribution
describing circulation of blood greatly aided the understand-
ing of vascular injuries.7 Although Rufus of Ephesus appar-
ently discussed arteriovenous communications in the first
century ad, it was not until 1757 that William Hunter first
described the arteriovenous fistula as a pathological entity.8
This was despite the fact that, as early as the second century
ad, Antyllus had described the physical findings, clinical man-
agement (by proximal and distal ligation) and the significance
of collateral circulation.9
The development of the tourniquet was another advance
that played an important role in the control of hemorrhage.
Tight bandages had been applied since antiquity, but subse-
quent development of the tourniquet was slow. Finally, in
1674 a military surgeon named Morel introduced a stick into
the bandage and twisted it until arterial flow stopped.7 The
screw tourniquet came into use shortly thereafter. This method
of temporary control of hemorrhage encouraged more fre-
quent use of the ligature by providing sufficient time for its
application. In 1873 Freidrich von Esmarch, a student of Lan-
genbeck, introduced his elastic tourniquet bandage for first
aid use on the battlefield.10 Previously it was thought that such
compression would injure vessels irreversibly. His discovery
permitted surgeons to operate electively on extremities in a
dry, bloodless field.
Ligation was not without its complications as British
Admiral Horatio Nelson discovered after amputation of his
right arm after the attack at Tenerife, “A nerve had been taken
up in one of the ligatures at the time of the operation,” causing
considerable pain and slowing his recovery.11 Furthermore the
long ligatures meant delayed wound healing. It was Haire, an
assistant surgeon at the Royal Naval Hospital Haslar, who took
the risk of cutting sutures short (rather than leaving them
long) to allow suppuration, necrosis, and granulation before
the suture was pulled away. He observed that “the ligatures
sometimes became troublesome and retarded the cure” and
that cutting them short allowed stumps to heal in the course
10 days.
In addition to the control of hemorrhage at the time of
injury, the second major area of concern for centuries was the
prevention of secondary hemorrhage. Because of its great fre-
quency, styptics, compression, and pressure were used for
several centuries after ligation of injured vessels became pos-
sible. Undoubtedly the high rate of secondary hemorrhage
after ligation was due to infection of the wound often pro-
moted by dressing choices or infection spread by well-meaning
attendants. Although John Hunter demonstrated the value of
proximal ligation for control of a false aneurysm in 1757,
failure to control secondary hemorrhage resulted in the use of
ligature only for secondary bleeding from the amputation
stump.12 Subsequently, Bell (1801) and Guthrie (1815) per-
formed ligation both proximal and distal to the arterial wound
with better results than those previously obtained.13,14
Some of the first clear records of ligation of major arteries
were written in the 19th century and are of particular interest.
The first successful ligation of the common carotid artery for
hemorrhage was performed in 1803 by Fleming, but was not
reported until 14 years later by Coley (1817), because Fleming
died a short time after the operation was performed.15 A
servant aboard the HMS Tonnant attempted suicide by slash-
ing his throat. When Fleming saw the patient, it appeared that
he had exsanguinated. There was no pulse at the wrist and the

pupils were dilated. It was possible to ligate two superior
thyroid arteries and one internal jugular vein. A laceration of
the outer and muscular layers of the carotid artery was noted,
as well as a laceration of the trachea between the thyroid and
cricoid cartilages. This allowed drainage from the wound to
enter the trachea, provoking violent seizures of coughing,
although the patient seemed to be improving. Approximately
1 week following the injury, Fleming recorded: “On the
evening of the 17th, during a violent paroxysm of coughing,
the artery burst, and my poor patient was, in an instant,
deluged with blood!”15
The dilemma of the surgeon is appreciated by the following
statement: “In this dreadful situation I concluded that there
was but one step to take, with any prospect of success; mainly,
to cut down on, and tie the carotid artery below the wound. I
had never heard of such an operation being performed; but
conceived that its effects might be less formidable, in this case,
than in a person not reduced by hemorrhage.”15 The wound
rapidly healed following ligation of the carotid artery and the
patient recovered.
Ellis (1845) reported the astonishing experience of success-
ful ligation of both carotid arteries in a 21-year-old patient
who sustained a gunshot wound of the neck while he was
setting a trap in the woods in 1844, near Grand Rapids, Michi-
gan, when he was unfortunately mistaken for a bear by a
companion.16 Approximately 1 week later, Ellis had to ligate
the patient’s left carotid artery because of hemorrhage. An
appreciation of the surgeon’s problem can be gained by Ellis’
description of the operation: “We placed him on a table, and
with the assistance of Dr. Platt and a student, I ligatured the
left carotid artery, below the omohyoideus muscle; an opera-
tion attended with a good deal of difficulty, owing to the
swollen state of the parts, the necessity of keeping up pressure,
the bad position of the parts owing to the necessity of keeping
the mouth in a certain position to prevent his being strangu-
lated by the blood, and the necessity of operating by candle
light.”16
There was recurrent hemorrhage on the eleventh day after
the accident, and right carotid artery pressure helped control
the blood loss. It was, therefore, necessary also to ligate the
right carotid artery 4 1 2 days after the left carotid artery had
been ligated. Ellis remarked: “For convenience, we had him in
the sitting posture during the operation; when we tightened
the ligature, no disagreeable effects followed; no fainting; no
bad feeling about the head; and all the perceptible change was
a slight paleness, a cessation of pulsation in both temporal
arteries, and of the hemorrhage.”16
The patient recovered rapidly with good wound healing
and returned to normal daily activity. There was no percep-
tible pulsation in either superficial temporal artery.16
The importance of collateral circulation in preserving via-
bility of the limb after ligation was well understood for cen-
turies, as identified by Antyllus nearly 2000 years ago.9 The
fact that time was necessary for establishment of this collateral
circulation was recognized. Halsted (1912) reported cure of
an iliofemoral aneurysm by application of an aluminum band
to the proximal artery without seriously affecting the circula-
tion or function of the lower extremity.17 Asepsis had been
recognized, and the frequency of secondary hemorrhage and
gangrene following ligation promptly decreased as an under-
standing of transmission of infectious disease and its manage-
ment was developed through Pasteur and Lister. Subsequently,
1  /  The Vascular Injury Legacy 5
Halsted (1912) demonstrated the role of collateral circulation
by gradually completely occluding the aorta and other large
arteries in dogs by means of silver or aluminum bands that
were gradually tightened over a period of time.18
Early Vascular Surgery
About 2 centuries after Paré established the use of the ligature,
the first direct repair of an injured artery was accomplished.
This event more than 250 years ago is credited as the first
documented vascular repair. Hallowell, acting on a suggestion
by Lambert in 1759, repaired a wound of the brachial artery
by placing a pin through the arterial walls and holding the
edges in apposition by applying a suture in a figure-of-eight
fashion about the pin (Fig. 1-2).19 This technique (known as
the farrier’s stitch) had been utilized by veterinarians but had
fallen into disrepute following unsuccessful experiments.
Table 1-1 outlines early vascular techniques.
Unfortunately, others could not duplicate Hallowell’s suc-
cessful experience, almost surely because of the multiple prob-
lems of infection and lack of anesthesia. There was one report
by Broca (1762) of a successful suture of a longitudinal inci-
sion in an artery.20 However, according to Shumacker (1969),
an additional 127 years passed following the Hallowell-
Lambert arterial repair before a second instance of arterial
repair of an artery by lateral suture in man was reported by
Postemski in 1886.20
With the combined developments of anesthesia and asepsis,
several reports of attempts to repair arteries appeared in the
latter part of the 19th century. The work of Jassinowsky, who
is credited in 1889 for experimentally proving that arterial
Figure-of-eight suture
Laceration
Pin
Brachial artery
FIGURE 1-2  The first arterial repair performed by Hallowell, acting
on a suggestion by Lambert in 1759. The technique, known as the
farrier’s (veterinarian’s) stitch, was followed in repairing the brachial
artery by placing a pin through the arterial walls and holding the
edges in apposition with a suture in a figure-of-eight fashion about
the pin. (Drawn from the original description by Mr. Lambert, Med Obser
and Inq 2:30–360, 1762.)
Table 1-1 Vascular Repair Before 1900*
Technique Year Surgeon
Pin and thread 1759 Hallowell
Small ivory clamps 1883 Gluck
Fine needles and silk 1889 Jassinowsky
Continuous suture 1890 Burci
Invagination 1896 Murphy
Suture all layers 1899 Dörfler
*Adapted from Guthrie GC: Blood vessel surgery and its applications,
New York, 1912, Longmans, Green and Co.
6 SECTION 1  /  BACKGROUND

wounds could be sutured with preservation of the lumen, was

later judged by Murphy in 1897 as the best experimental work
published at that time.21,22 In 1865 Henry Lee of London
attempted repair of arterial lacerations without suture.23 Glück Femoral artery
in 1883 reported 19 experiments with arterial suture, but all
experiments failed because of bleeding from the holes made Femoral vein Posterior
by the suture needles.24 He also devised aluminum and ivory Anterior
clamps to unite longitudinal incisions in a vessel, and it was
recorded that the ivory clamps succeeded in one experiment
on the femoral artery of a large dog. Von Horoch of Vienna
reported six experiments, including one end-to-end union, all
of which thrombosed.23 In 1889 Bruci sutured six longitudinal Aneurysmal pockets
arteriotomies in dogs; the procedure was successful in four.20 on the anterior and
In 1890 Muscatello successfully sutured a partial transection posterior surface of
of the abdominal aorta in a dog.20 In 1894 Heidenhain closed B the femoral artery
by catgut suture a 1-cm opening in the axillary artery made
accidentally while removing adherent carcinomatous glands.25
The patient recovered without any circulatory disturbance. In
1883 Israel, in a discussion of a paper by Glück, described
closing a laceration in the common iliac artery created during A
an operation for perityphlitic abscess.24,26 The closure was
accomplished by five silk sutures. However, from his personal
observations, Murphy (1897) did not believe it could be pos-
sible to have success in this type of arterial repair.22 In 1896
Sabanyeff successfully closed small openings in the femoral
artery with sutures.20
The classic studies of J.B. Murphy of Chicago (1897) con-
tributed greatly to the development of arterial repair and cul-
minated in the first successful end-to-end anastomosis of an
artery in 1896.22 Previously, Murphy had carefully reviewed
earlier clinical and experimental studies of arterial repair and
had evaluated different techniques extensively in laboratory C
studies. Murphy attempted to determine experimentally how FIGURE 1-3  The first successful clinical end-to-end anastomosis
much artery could be removed and still allow an anastomosis. of an artery was performed in 1896. Sutures were placed in the proxi-
He found that 1 inch of a calf ’s carotid artery could be removed mal artery, including only the few outer coats; three sutures were
and the ends still approximated by invagination suture tech- used to I. (From Murphy JB: Resection of arteries and veins injured in
continuity—end-to-end suture-experimental clinical research. Med Record
nique because of the elasticity of the artery. He concluded that 51:73, 1897.)
arterial repair could be done with safety when no more than
3/4 inch of an artery had been removed, except in certain
locations such as the popliteal fossa or the axillary, space Because of the historical significance, the operation report is
where the limb could be moved to relieve tension on the quoted:
repair. He also concluded that when more than half of the
artery was destroyed, it was better to perform an end-to-end Operation, October 7, 1896. An incision five inches long
anastomosis by invagination rather than to attempt repair of was made from Poupart’s ligament along the course of the
the laceration. This repair was done by introducing sutures femoral artery. The artery was readily exposed about one
into the proximal artery, including only the two outer coats, inch above Poupart’s ligament; it was separated from its
and using three sutures to invaginate the proximal artery into sheath and a provisional ligature thrown about it but not
the distal one, reinforcing the closure with an interrupted tied. A careful dissection was then made down along the
suture (Fig. 1-3).22 In 1896 Murphy was unable to find a wall of the vessel to the pulsating clot. The artery was
similar recorded case involving the suture of an artery after exposed to one inch below the point and a ligature thrown
complete division, and he consequently reported his experi- around it but not tied: a careful dissection was made
ence (1897) and carried out a number of experiments to upward to the point of the clot. The artery was then closed
determine the feasibility of his procedure. Murphy’s patient above and below with gentle compression clamps and was
was a 29-year-old male shot twice with one bullet entering the elevated, at which time there was a profuse hemorrhage
femoral triangle. The patient was admitted to Cook County from an opening in the vein. A cavity, about the size of a
Hospital in Chicago on September 19, 1896, approximately 2 filbert, was found posterior to the artery communicating
hours after wounding. There was no hemorrhage or increased with its caliber, the aneurysmal pocket. A small aneurysmal
pulsation noted at the time. Murphy first saw the patient 15 sac about the same size was found on the anterior surface of
days later, October 4, 1896, and found a large bruit surround- the artery over the point of perforation. The hemorrhage
ing the site of injury. Distal pulses were barely perceptible. from the vein was very profuse and was controlled by digital
When demonstrating this patient to students 2 days later, a compression. It was found that one-eighth of an inch of the
thrill was also detected. An operative repair was decided on. arterial wall on the outer side of the opening remained, and

on the inner side of the perforation only a band of one-
sixteenth of an inch of adventitia was intact. The bullet had
passed through the center of the artery, carried away all of
its wall except the strands described above, and passed
downward and backward making a large hole in the vein in
its posterior and external side just above the junction of the
vena profunda. Great difficulty was experienced in
controlling the hemorrhage from the vein. After dissecting
the vein above and below the point of laceration and
placing a temporary ligature on the vena profunda, the
hemorrhage was controlled so that the vein could be
sutured. At the point of suture the vein was greatly
diminished in size, but when the clamps were removed it
dilated about one-third the normal diameter or one-third
the diameter of the vein above and below. There was no
bleeding from the vein when the clamps were removed. Our
attention was then turned to the artery. Two inches of it
had been exposed and freed from all surroundings. The
opening in the artery was three-eighths of an inch in length;
one-half inch was resected and the proximal was
invaginated into the distal for one-third of an inch with
four double needle threads which penetrated all of the walls
of the artery. The adventitia was peeled off the invaginated
portion for a distance of one-third of an inch: a row of
sutures was placed around the edge of the overlapping distal
end, the sutures penetrating only the media of the proximal
portion; the adventitia was then brought over the end of the
union and sutured. The clamps were removed. Not a drop
of blood escaped at the line of suture. Pulsation was
immediately restored in the artery below the line of
approximation and it could be felt feebly in the posterior
tibial and dorsalis pedis pulses. The sheath and connective
tissue around the artery were then approximated at the
position of the suture with catgut, so as to support the wall
of the artery. The whole cavity was washed out with a five
percent solution of carbolic acid and the edges of the wound
were accurately approximated with silk worm-gut sutures.
No drainage. The time of the operation was approximately
two and one-half hours, most of the time being consumed
in suturing the vein. The artery was easily secured and
sutured, and the hemorrhage from it readily controlled. The
patient was placed in bed with the leg elevated and
wrapped in cotton.22
The anatomic location of the injuries, the gross pathology
involved, and the detailed repair contributed to Murphy’s his-
torically successful arterial anastomosis. Murphy mentioned
that a pulsation could be felt in the dorsalis pedis artery 4 days
following the operation. The patient had no edema and no
disturbance of his circulation during the reported 3 months
of observation.22
Subsequently, Murphy (1897) reviewed the results of liga-
ture of large arteries before the turn of the century.22 He found
that the abdominal aorta had been ligated 10 times with only
1 patient surviving for 10 days. Lidell reported only 16 recov-
eries after ligation of the common iliac artery 68 times, a
mortality of 77%.20 Balance and Edmunds reported a 40%
mortality following ligation of a femoral artery aneurysm in
31 patients. Billroth reported secondary hemorrhage from
50%% of large arteries ligated in continuity. Wyeth collected
106 cases of carotid artery aneurysms treated by proximal
ligation, with a mortality rate of 35%.
1  /  The Vascular Injury Legacy 7
In 1897 Murphy summarized techniques he considered
necessary for arterial suture. They bore a close resemblance to
principles generally followed today:
1. Complete asepsis
2. Exposure of the vessel with as little injury as possible
3. Temporary suppression of the blood current
4. Control of the vessel while applying the suture
5. Accurate approximation of the walls
6. Perfect hemostasis by pressure after the clamps are
taken off
7. Toilet of the wound
Murphy also reported that Billroth, Schede, Braun, Schmidt,
and others had successfully sutured wounds in veins.22 He
personally had used five silk sutures to close an opening 3/8-
inch long in the common jugular vein.
Several significant accomplishments occurred in vascular
surgery within the next few years. In 1903 Matas described his
endoaneurysmorrhaphy technique, which remained the stan-
dard technique for aneurysms for over 40 years.27 In 1906
Carrel and Guthrie performed classic experimental studies
over a period of time with many significant results.28 These
included direct suture repair of arteries, vein transplantation,
and transplantation of blood vessels as well as organs and
limbs. In 1912 Guthrie independently published his continu-
ing work on vascular surgery.14 Following Murphy’s successful
case in 1896, the next successful repair of an arterial defect
came 10 years later when Goyanes used a vein graft to bridge
an arterial defect in 1906.22,29 Working in Madrid, Goyanes
excised a popliteal artery aneurysm and used the accompany-
ing popliteal vein to restore continuity (Fig. 1-4).29 He used
the suture technique developed by Carrel and Guthrie of
Artery
A V
g
FIGURE 1-4  The first successful repair of an arterial defect utilizing
a vein graft. Using the triangulation technique of Carrel with endo-
thelial coaptation, a segment of the adjacent popliteal vein was used
to repair the popliteal artery. A, Artery; V, vein; g, graft. (From Goyanes
DJ: Nuevos trabajos chirugia vascular. El Siglo Med 53:561, 1906.)
8 SECTION 1  /  BACKGROUND
triangulating the arterial orifice with three sutures, followed
by continuous suture between each of the three areas. A year
later in 1907, Lexer in Germany first used the saphenous vein
as an arterial substitute to restore continuity after excision of
an aneurysm of the axillary artery.29 In his 1969 review, Shu-
macker commented that within the first few years of the 20th
century the triangulation stitch of Carrel (1902), the quadran-
gulation method of Frouin (1908), and the Mourin modifica-
tion (1914) had been developed.20
By 1910 Stich had reported more than 100 cases of arterial
reconstruction by lateral suture.30 His review included 46
repairs, either by end-to-end anastomosis or by insertion of a
vein graft.31 With this promising start, it is curious that over
30 years elapsed before vascular surgery was widely employed.
A high failure rate, usually by thrombosis, attended early
attempts at repair; and few surgeons were convinced that
repair of an artery was worthwhile. In 1913 Matas stated that
vascular injuries, particularly arteriovenous aneurysms, had
become conspicuous features of modern military surgery; and
he felt that this class of injury must command the closest
attention of the modern military surgeon: “A most timely and
valuable contribution to the surgery of blood vessels resulted
from wounds in war. Unusual opportunities for the observa-
tion of vascular wounds inflicted with modern military
weapons . . . based on material fresh from the field of action,
and fully confirmed the belief that this last war, waged in close
proximity to well-equipped surgical centers, would also offer
an unusual opportunity for the study of the most advanced
methods of treating injuries of blood vessels.”27
Matas described Soubbotitch’s experience of Serbian mili-
tary surgery during the Serbo-Turkish and Serbo-Bulgarian
Wars at the 1913 London International Congress.27 He
reported that 77 false aneurysms and arteriovenous fistulas
were treated. There were 45 ligations; but 32 vessels were
repaired, including 19 arteriorrhaphies, 13 venorrhaphies, and
15 end-to-end anastomoses (11 arteries and 4 veins). It is
impressive that infection and secondary hemorrhage were
avoided. In 1915 Matas, in discussing Soubbotitch’s report,
emphasized that a notable feature was the suture (circular and
lateral repair) of blood vessels and the fact that it had been
utilized more frequently in the Balkan conflict than in previ-
ous wars.27 He also noted that, judging by Soubbotitch’s sta-
tistics, the success obtained by surgeons in the Serbian Army
Hospital in Belgrade far surpassed those obtained by other
military surgeons in previous wars, with the exception perhaps
of the remarkably favorable results in the Japanese Reserve
Hospitals reported by Kikuzi.
World War I Experience
During the early part of World War I, with the new techniques
of vascular surgery well established, the German surgeons
attempted repair of acutely injured arteries and were success-
ful in more than 100 cases.31 During the first 9 months of
World War I, low-velocity missiles caused arterial trauma of a
limited extent. In 1915, however, the widespread use of high
explosives and high-velocity bullets, combined with mass
casualties and slow evacuation of the wounded, made arterial
repair impractical.
In 1920 Bernheim went to France with the specific intent
of repairing arterial injuries.32 Despite extensive prior experi-
ence and equipment, however, he concluded that attempts at
vascular repair were unwise. He wrote: “Opportunities for
carrying out the more modern procedures for repair or recon-
struction of damaged blood vessels were conspicuous by their
absence during the recent military activities. Not that blood
vessels were immune from injury; not that gaping arteries and
veins and vicariously united vessels did not cry out for relief
by fine suture or anastomosis. They did, most eloquently, and
in great numbers, but he would have been a foolhardy man
who would have essayed sutures of arterial or venous trunks
in the presence of such infections as were the rule in practi-
cally all of the battle wounded.”32
The great frequency of infection with secondary hemor-
rhage virtually precluded arterial repair. In addition, there
were inadequate statistics about the frequency of gangrene
following ligation, and initial reports subsequently proved to
be unduly optimistic. In 1927 Poole, in the Medical Depart-
ment History of World War I, remarked that if gangrene
were a danger following arterial ligation, primary suture
should be performed and the patient should be watched very
carefully.
Despite the discouragement of managing acute arterial
injuries in World War I, fairly frequent repairs of false aneu-
rysms and arteriovenous fistulas were carried out by many
surgeons. These cases were treated after the acute period of
injury, when collateral circulation had developed with the
passage of time and assured viability of extremities. In 1921
Matas recorded that the majority of these repairs consisted of
arteriorrhaphy by lateral or circular suture, with excision of
the sac or endoaneurysmorrhaphy.33
In 1919 Makins, who served in World War I as a British
surgeon, recommended ligating the concomitant vein when it
was necessary to ligate a major artery.34 He thought that this
reduced the frequency of gangrene by retaining within the
limb for a longer period the small amount of blood supplied
by the collateral circulation. This hypothesis was debated for
more than 20 years before it was finally abandoned.
Payr in 1900, Carrel, and the French surgeon Tuffier
described temporary arterial anastomoses with silver and glass
tubes that were inserted with some success by Makins and
other WWI military surgeons, but patency was limited to 4
days merely allowing some collateral development.20,34
World War II Experience
Experiences with vascular surgery in World War II are well
recorded in the review by DeBakey and Simeone in1946, ana-
lyzing 2471 arterial injuries.3 Almost all were treated by liga-
tion, with a subsequent amputation rate near 49%. There were
only 81 repairs attempted—78 by lateral suture and 3 by end-
to-end anastomosis—with an amputation rate of approxi-
mately 35%. The use of vein grafts was even more disappointing;
they were attempted in 40 cases with an amputation rate of
nearly 58%.
The controversial question of ligation of the concomitant
vein remained, though few observers were convinced that the
procedure enhanced circulation. The varying opinions were
summarized by Linton in 1949.35
A refreshing exception to the dismal World War II experi-
ence in regard to ligation and gangrene was the case operated
on by Dr. Allen M. Boyden—an acute arteriovenous fistula
of the femoral vessels repaired shortly after D-Day in
Normandy.

The following comments are taken by Boyden from his
own original field notes (approximately 26 years later in 1970)
and emphasize the value of adequate records, even in military
combat:
“High explosive wound left groin, 14 June 1944, at 2200
hours. Acute arteriovenous aneurysm femoral artery.
Preoperative blood pressure 140-70; pulse 104.
Operation: 16 June 1944, nitrous oxide and oxygen.
Operation: 1910 to 22 hours.
One unit of blood transfused during the opera-tion.
Arteriovenous aneurysms isolated near junction with
profunda femoris artery.
Considerable hemorrhage.
Openings in both artery and vein were sutured with fine
silk.
Postoperative blood pressure 120-68; pulse 118.
Circulation of the extremity remained intact
until evacuation.”
As this case demonstrated Boyden’s interest in vascular
surgery, the Consulting Surgeon for the First Army presented
him with half of the latter’s supply of vascular instruments
and material. This supply consisted of two sets of Blakemore
(Vitallium) tubes, two bulldog forceps, and a 2-mL ampoule
of heparin!
The conclusion that ligation was the treatment of choice
for an injured artery was summarized by DeBakey and
Simeone in 1946: “It is clear that no procedure other than
ligation is applicable to the majority of vascular injuries which
come under the military surgeons’ observation. It is not a
procedure of choice. It is a procedure of stern necessity, for
the basic purpose of controlling hemorrhage, as well as
because of the location, type, size and character of most battle
injuries of the arteries.”3
In retrospect it should be remembered that the average
time lag between wounding and surgical treatment was over
10 hours in World War II, virtually precluding successful arte-
rial repair in most patients. Of historical interest is the non-
suture method of arterial repair used during World War II
(Fig. 1-5).
Experiences During the
Korean Conflict
In pleasant contrast to the experiences of World War II, the
successful repairs of arterial injuries in the Korean Conflict
were due to several factors. There had been substantial prog-
ress in the techniques of vascular surgery, accompanied by
improvements in anesthesia, blood transfusion, and antibi-
otics. Perhaps of greatest importance was the rapid evacua-
tion of wounded men, often by helicopter, which often
allowed their transport from time of wounding to surgical
care within 1-2 hours. In addition, a thorough understand-
ing of the importance of débridement, delayed primary
closure, and antibiotics greatly decreased the hazards of
infection.
Initially in the Korean Conflict, attempts at arterial repair
were disappointing. During one report of experiences at a
surgical hospital for 8 months between September 1951 and
April 1952, only 11 of 40 attempted arterial repairs were
thought to be successful, as reported by Hughes in 1959.36
1  /  The Vascular Injury Legacy 9
1
2
Saline Proximal
Rubber shod
Artery clamp
Vein
Kelly clamp
3 Distal end of
4 vein placed into
proximal end of artery
Distal
5
6 7
FIGURE 1-5  The various steps of a nonsuture method of bridging
arterial defects designed during World War II. (1) The Vitallium tube
with its two ridges (sometimes grooves). (2) The exposed femoral
artery and vein with the vein retracted and clamps placed on a branch.
(3) The removed segment of vein is irrigated with saline solution. (4)
The vein has been pushed through the inside of the Vitallium tube,
and the two ends have been everted over the ends of the tube held
in place with one or two ligatures of fine silk. (5) The distal end of the
segment of the vein is placed into the proximal end of the artery and
held there by two ligatures of fine silk. (6) The snug ligature near the
end of the Vitallium tube is tied to provide apposition of the artery
and the vein. (7) The completed operation, showing the bridging of
a 2-cm gap in the femoral artery. (Modified description of the original
drawings from Blakemore AH, Lord JW, Jr., Stefko PL: The severed primary
artery in war wounded. Surgery 12:488, 1942.)
Only 6 of 29 end-to-end anastomoses were considered initially
successful, and all 6 venous grafts failed. In another report
from a similar period of time, only 4 of 18 attempted repairs
were considered successful. In 1952 Warren emphasized that
an aggressive approach was needed, with the establishment of
a research team headed by a surgeon experienced in vascular
grafting.37 Surgical research teams were established in the
Army, and there was improvement in results of vascular
repairs by 1952. Significant reports were published by Jahnke
and Seeley in 1953; Hughes in 1955 and 1958; and Inui,
Shannon, and Howard in 1955.4,38-40 Similar work in the Navy
was done with the U.S. Marines during 1952 and 1953 by
Spencer and Grewe and reported in 1955.41 These surgeons
worked in specialized research groups under fairly stabilized
conditions, considering that they were in a combat zone. Brig-
adier General Sam Seeley, who was Chief of the Department
of Surgery at Walter Reed Army Hospital in 1950, had the
foresight to establish Walter Reed Army Hospital as a vascular
surgery center; and this made it possible for patients with
vascular injuries to be returned there for later study. In a total
experience with 304 arterial injuries, 269 were repaired and 35
10 SECTION 1  /  BACKGROUND

Table 1-2 Management of Arterial Trauma in Vietnam Casualties Preliminary Report from the
Vietnam Vascular Registry*
End-to-End Prosthetic Throm-
Artery Anastomosis Vein Graft Lateral Suture Graft Bectomy Ligation
Common carotid 2 6 (2) 3 (2) 1
Internal carotid 2 1
Subclavian 1
Axillary 6 (3) 12 (3) 2 (3) (1) (3) (1)
Brachial 57 (8) 32 (10) 2 (1) 1 (9) 1 (2)
Aorta 3 (1)
Renal 1
Iliac 1 1 1 (1) (1) (1)
Common femoral 4 (2) 11 (1) 4 (1) 1 (2) (2) (4)
Superficial femoral 63 (5) 37 (14) 7 (7) (4) 2 (6) (4)
Popliteal 31 (5) 28 (13) 6 (4) (10) 2 (4)
Total 165 (23) 127 (43) 29 (17) 2 (8) 3 (33) 6 (16)

Modified from Rich NM, Hughes CW: Vietnam vascular registry: a preliminary report. Surgery 65(1):218–226, 1969.
*Numbers in parenthesis represent additional procedures performed after the initial repair in Vietnam and repair of major arterial injuries not
initially treated in Vietnam.

ligated, as reported by Hughes in 1958.4 The overall amputa-
tion rate was 13%, a marked contrast to that of about 49% in
World War II. Because amputation rate is only one method of
determining ultimate success or failure in arterial repair, it is
important to emphasize that Jahnke revealed in 1958 that, in
addition to the lowered rate of limb loss, limbs functioned
normally when arterial repair was successful.42
Experience in Vietnam
In Vietnam the time lag between injury and treatment was
reduced even further by the almost routine evacuation by
helicopter, combined with the widespread availability of sur-
geons experienced in vascular surgery. In a 1968 study by Rich,
95% of 750 patients with missile wounds sustained in Vietnam
reached the hospital by helicopter.43 This promptness of evac-
uation, however, created an adverse effect on the overall
results, for patients with severe injuries from high-velocity
missiles survived to reach the hospital but often expired
during initial care. These patients would never have reached
the hospital alive in previous military conflicts.
Between October 1, 1965, and June 30, 1966, there were 177
known vascular injuries in American casualties, excluding
those with traumatic amputation, as reported by Heaton and
colleagues.44 There were 116 operations performed on 106
patients with 108 injuries. These results included the personal
experience of one of us (NMR) at the 2nd Surgical Hospital.
The results reported included a short-term follow-up of
approximately 7-10 days in Vietnam. In Vietnam, amputa-
tions were required for only 9 of the 108 vascular injuries—a
rate of about 8%. Subsequently, following detailed analysis of
the Vietnam Vascular Registry by Rich and colleagues in 1969
and then in 1970, the amputation rate was found to be approx-
imately 13%—identical to that of the Korean Conflict.5,6
Almost all amputations were performed within the first month
after wounding.
The Vietnam Vascular Registry was established at Walter
Reed General Hospital in 1966 to document and analyze all
vascular injuries treated in Army Hospitals in Vietnam. A
preliminary report by Rich and Hughes in 1969 involved the
complete follow-up of 500 patients who sustained 718 vascu-
lar injuries (Table 1-2).5 Although vascular repairs on Viet-
namese and allied military personnel were not included, the
Registry effort was soon expanded to include all American
service personnel, rather than limiting the effort to soldiers.
In 1967 Fisher collected 154 acute arterial injuries in
Vietnam covering the 1965-1966 periods.45 There were 108
arterial injuries with significant information for the initial
review from Army hospitals. In 1967 Chandler and Knapp
reported results in managing acute vascular injuries in the U.S.
Navy hospitals in Vietnam.46 These patients were not included
in the initial Vietnam Vascular Registry report; but, after 1967,
an attempt was made to include all military personnel sustain-
ing vascular trauma in Vietnam. This included active duty
members of the U.S. Armed Forces treated at approximately
25 Army hospitals, 6 Navy hospitals, and 1 Air Force
hospital.
As with any registry, success of the Vietnam Vascular Reg-
istry has depended on the cooperation of hundreds of indi-
viduals within the military and civilian communities. In the
initial report from the Registry, 20 surgeons who had done
more than 5 vascular repairs were identified. As can be seen
by the list of more than 500 surgeons within the front and
back covers of the first edition of this book, many surgeons in
every training program in the United States contributed to the
generally good results obtained in Vietnam.5
In addition to the surgeons already cited, hundreds of
individuals have been directly contacted through the Regis-
try. The cooperative effort that has been obtained has not
only provided long-term follow-up information for the indi-
vidual surgeon, but it has also given the names of additional
patients who have previously been missed, and additional
specific information has been added where needed regarding
individual patients. A major success in the Registry effort
was obtained at the American College of Surgeons’ Clinical
Congress in Chicago in 1970, where 110 surgeons who had
previously performed arterial repairs in Vietnam signed in at
the Vietnam Vascular Registry exhibit. The exhibit attempted
to represent some of the activities and presented some of