Clinical Medicine Insights: Trauma and Intensive Medicine

¹Resident surgeon at Madigan Army Medical Center, Tacoma, WA. ²Staff Surgeon in the Department of Surgery, Vascular Surgery Service, Brooke Army Medical Center, San Antonio, TX and assistant professor of surgery, Uniformed Services University of the Health Sciences, Bethesda, MD. ³Chief of Orthopedic Surgery, Madigan Army Medical Center, Tacoma, WA and assistant professor of surgery, Uniformed Services University of the Health Sciences, Bethesda, MD. ⁴Deputy Commander for Clinical Services, Madigan Army Medical Center, Tacoma, WA and assistant professor of surgery, Uniformed Services University of the Health Sciences, Bethesda, MD. ⁵Chief of Surgery at Madigan Army Medical Center, Tacoma, WA and assistant professor of surgery, Uniformed Services University of the Health Sciences, Bethesda, MD.

Abstract

Limb salvage in patients who have sustained major extremity vascular trauma during wartime has increased significantly over time: World War II, 50%; Korean War, 87%; and Vietnam, 92%.^1-3 This increased salvage rate is attributed to arterial reconstruction. Delay in revascularization continues to hamper limb salvage both in military settings as well as civilian trauma settings. Damage control surgery (DCS) has revolutionized modern trauma care both in the civilian arena and on the battlefield. Temporary intraluminal shunts are shown to provide adequate limb and organ perfusion in the damage control setting in the civilian trauma literature until a severely injured patient is stable enough to undergo a formal vascular repair, and/or major fractures are stabilized and devitalized soft tissue is debrided.^4,5 Rural surgeons sometimes deal with a delay in evacuation due to geographic distances between accident site and level one trauma centers as well as weather delays. Such challenges can be found in each region of the country and in current military activities throughout the world. Eger and associates were the first to report the use of temporary shunts in the damage control setting at a fixed tertiary care facility.⁶ However, there are few retrospective reports showing their successful use in the far-forward, military^7,8 field environment and none showing usefulness in a strategic evacuation. This case report of using a temporary intraluminal shunt represents one extreme aspect of damage control surgery (DCS) as applied to the austere conditions of a far-forward, military special operations environment on the modern battlefield during initial combat operations in Afghanistan.