Management of secondary hemorrhage from early graft failure in military extremity wounds

BACKGROUND: Secondary hemorrhage after a dehisced vascular reconstruction is a dreaded complication, yet few reports describe the initial management and outcome of casualties with ruptured grafts from military wounds. We aimed to report a single-center experience of graft ruptures after evacuation of casualties to a tertiary hospital in the continental United States. METHODS: Trauma records of US combat casualties were retrospectively reviewed from April 2005 to August 2007. Casualties who underwent an extremity vascular reconstruction in Iraq or Afghanistan and experienced a ruptured graft were included. RESULTS: Ten graft ruptures (mean time, 14 days) occurred during the study period. All casualties were males with penetrating injuries by secondary blast effects (5, 50%) or gunshot wounds (5, 50%). Mean age and Injury Severity Score were 28.2 years (range, 20-41 years) and 21.1 (range 10-32), respectively. Repairs were performed on the superficial femoral (4, 40%), popliteal (2, 20%), brachial (1, 10%), axillary (1, 10%), iliac (1, 10%), and common femoral (1, 10%) arteries using reversed saphenous vein grafts (10, 100%). Initial management included control of hemorrhage and extra-anatomic reconstruction with a vein graft (4), prosthetic graft (4), end-to-end anatomosis (1), or primary amputation (1). Secondary complications in those 10 limbs requiring reintervention included 4 thrombotic graft failures (40%), and 1 transfemoral amputation from a graft infection. Ruptures were frequently associated with long-bone fractures (6, 60%), large soft tissue open wounds (5, 50%) and infection (7, 70%). At a mean follow-up of 37 months, the amputation rate in this series was 30%, with an amputation-free survival of 70%. CONCLUSION: Contaminated military wounds with bony fractures may predispose a graft of any type (vein or prosthetic) to anastomotic dehiscence. Wounds must be carefully debrided, and when grafts cannot be covered with viable muscle, they should be routed around the zone of injury. LEVEL OF EVIDENCE: Therapeutic study, level V.