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Primary Surgery of Blood Vessels in Korea

Medical Science Publication No. 4, Volume 1

PRIMARY SURGERY OF BLOOD VESSELS IN KOREA*

An Analysis of Major Artery Repairs in Korea During 1953

LIEUTENANT COLONEL CARL W. HUGHES, MC

The damage to extremity blood vessels constitutes a small but important component of war wounds. Of 2,471 such wounds collected by DeBakey and Simeone (1) from World War II, 49.6 percent of those with involvement of a major artery came to amputation. Ligation of damaged vessels was the accepted practice. They further reported 81 cases in which suture of the artery was performed. In these, the amputation rate was 35.8 percent.

Shortly after the beginning of the Korean conflict, Walter Reed Army Hospital was designated as the peripheral vascular surgery center for the Army and received a substantial number of Army personnel who had sustained traumatic arteriovenous fistulas and aneurysms. The results of reparative and reconstructive surgery of many of these lesions have been reported (2-4). On the basis of this experience, the feasibility of primary repair of damaged major blood vessels of extremities was considered practical. Personnel trained in the technic of blood vessel repair were sent to Korea as members of the Surgical Research Team of the Army Medical Service Graduate School for this investigation and the practicability of repair of major arteries of extremities as part of the definitive surgery of war wounds was established. A total of 130 major vessel injuries were repaired, followed and reported by three members of the Surgical Research Team (table 1), (5-7). The average amputation rate for these 130 vascular repairs was 10.8 percent.

Ziperman (8) analyzed the results of 234 major and minor arterial wounds collected and followed within the theater during the first 9 months of 1952 in Korea. His report includes the work of two members of the Surgical Research Team. He compared the overall findings in his collected group to the results reported by DeBakey and Simeone and reported 127 major arteries repaired by suture with an amputation rate of 20.5 percent. This represents a 42.7 percent de-


*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


444

Table 1. Controlled Follow-up Studies-Major Artery Repairs-Korea, 1952 and 1953

Investigator

Cases

Amputations

Number

Percent

Jahnke (1952)

34

3

8. 8

Howard (1952)

24

3

12. 5

Hughes (1953)

72

8

11. 1


Total


130


14


10. 8

crease in amputation rate; however, both of these series are based on relatively small numbers.

The purpose of this communication is to report an analysis of all major vascular wounds repaired in Korea from 1 January through July 1953 (exclusive of Navy and Marine personnel) during which time 211 major arterial injuries were detected in 205 patients. Two patients had three vascular injuries each and two patients had two injuries each. Seventy-two of these vascular injuries (table 1) were treated by the author and have been reported in detail (5).

Materials and Methods

Reports on all cases in the Korean Theater were centralized in the Office of the Surgeon of the Eighth U. S. Army. Three reports emanated from the forward hospitals in which the surgery was performed and from the evacuation hospitals through which these patients later passed.

The results are tabulated as immediate and late. Such division has been necessary because this series includes 61 Korean national and prisoner of war patients and other United Nations personnel many of whom were lost to late followup once they left surgical and evacuation hospitals of the U. S. Army. Late followup studies were accomplished on other Allied patients as they were returned to vascular centers in Japan and on American patients as they were returned to Walter Reed Army Hospital, where they were subsequently evaluated by arteriography, oscillometry, skin temperature and exercise tolerance studies.

In this overall theater total of 211 major vascular injuries, deaths were reported as occurring from causes other than the arterial injury, in 15 patients with 18 arterial repairs. Arteries involved in these patients were the carotid 1, axillary 1, common iliac 1, femoral (unqualified) 3, common femoral 2, superficial femoral 3, and popliteal 7. Since an adequate evaluation of the arterial repairs in these patients


445

was not possible, these 18 repairs have been eliminated, leaving 193 repaired major vascular injuries in 190 surviving patients.

Regardless of efforts made to follow every patient, 62 of the 193 repairs in surviving patients were lost to long-term followup studies because of evacuation of the patients to Korean or U. N. hospitals after operation. Thus, 193 arterial injuries were available for short-term studies and of these, 131 came to later followup studies.

Approximately 85 percent of the vascular wounds were caused by fragmenting missiles and 15 percent by nonfragmenting missiles. Of all the vessels damaged, most were lacerated with almost an equal number severed. Only a few vessels were thrombosed or in spasm (table2). The lower extremity was the most prevalent site of vascular injury (55.5 percent) with the upper extremity a close second (38.4 percent), while the neck and trunk received a very low percentage of the injuries. A distribution of injuries is shown in table 3.

Table 2. Major Vascular Injuries-Korea 1953

Type of injury

Number

Lacerated

113

Severed

89

Contusion and thrombosis

7

Spasm

2


Total


211

Table 3. Total Major Vascular Repairs-Korea 1953

Body region

Artery

Number

Percent

Neck

Carotid

7

3. 3

Upper extremity

Axillary
Brachial

13
68

38. 4

Trunk

Aorta
Common iliac
External iliac

1
3
2

 2. 8

Lower extremity

Common femoral
Superficial femoral
Popliteal

12
68
37

 55. 5


Total

 


211


100. 0

Data available from approximately one-third of the patients in this report showed that 40 percent of the group arrived in shock of varying degree and 47 percent of the group had a tourniquet applied for an average of 4 hours.

Those with vascular injuries received a high, but not first, priority evacuation unless there was uncontrolled hemorrhage or profound


446

shock which could not be treated prior to evacuation. The average time lag from injury to surgery for all cases of vascular injury in 1953 averaged 9.8 hours, almost identical to what it was in 1952 as reported by Ziperman. Approximately 6 hours of this time was spent reaching the hospital and 4 hours in preparation for surgery. This is a reflection of the degree of injury and shock in these patients.

An anatomical surgical approach was used regardless of location of the wound. An adequate incision was always made and proximal control of the damaged vessel secured first. After excision of the damaged portion of the vessel, repair was accomplished by a continuous mattress suture with 00000 braided arterial silk everting the edges of the artery, apposing intima to intima.

Most of the repairs (64.8 percent) were accomplished by direct anastomosis; with autogenous vein grafts (14.5 percent), the second most common type of repair. Lateral suture repair followed in the third place and homologous arterial grafts in the fourth place (table 4). Conservative nonoperative treatment was practiced in some instances of nonexpanding pulsating hematomas especially of the carotid artery. Ligation was utilized only where repair was not feasible in a noncritical artery or when the patient's condition did not permit further surgery.

Table 4. Type of Repair, Major Vascular Wounds-Korea 1953*

Repair

Number

Percent

Anastomosis

125

64. 8

Vein graft

28

14. 5

Artery graft

11

5. 7

Lateral repair

19

9. 8

Conservative

4

2. 1

Release spasm

2

1. 0

Remove thrombus

1

0. 5

Ligation

3

1. 6


Total


193


100. 0

*Excluding 18 repairs in patients who died.

After careful débridement, care was taken to cover the repaired vessel in order to nourish and protect it but the wound was left open for drainage and to minimize the risk of infection. Penicillin and streptomycin were used routinely in all patients. Sympathectomy was not practiced and anticoagulants were not utilized. Following surgery, only those extremities with complicating fractures were placed in casts. For a period of 2 weeks only limited active motion was permitted at the vascular repair site. If the wound remained clean, delayed closure was accomplished on the fourth to sixth postoperative day.


447

Results

Of the total 193 vascular repairs in surviving patients, 26 amputations resulted. These amputations were done following repairs of the axillary artery in 2 cases, brachial artery (unqualified) 2, femoral (unqualified) 4, common femoral 5, superficial femoral 2, and popliteal 11, most of which are considered as critical arteries. The percentage of amputations was higher in those cases requiring grafts for repairs (table 5).

Table 5. Short-term Followup-Total Major Vascular Repairs-Korea 1953*



Repair



Total-Number

No Amputation

Amputated



Died-Number

Good

Thrombosed

Number

Percent

Number

Percent

Number

Percent

Anastomosis

136

95

84. 8

17

15. 2

13

10. 4

11

Vein graft

30

14

70. 0

6

30. 0

8

28. 6

2

Artery graft

12

3

37. 5

5

62. 5

3

27. 3

1

Lateral repair

20

17

94. 4

1

5. 6

1

5. 3

1

Conservative

4

4

-----

0

-----

0

-----

0

Release spasm

2

1

-----

0

-----

1

-----

0

Remove trombus

1

1

-----

0

-----

0

-----

0

Ligation

6

3

-----

0

-----

0

-----

3


Total


211


138


82. 6


29


17. 4


26


13. 5


18

*Percentages exclude patients who underwent amputation or died.

Causes for amputation were determined where possible. Seven patients were reported as having good blood flow through necrotic muscle at the time of amputation. The muscle had undergone irreversible changes prior to reconstruction of the artery. Thrombosis was responsible for three amputations, compression of the repaired vessel by a displaced compound comminuted fracture was responsible for one amputation and venostasis was responsible for another. The reason for amputation in the remaining 14 was not recorded. Of these, five limbs were amputated over varying periods of several days to 3 months following repair of the damaged artery. In one case reported here as an amputation, the patient lost only four toes while another had a transmetatarsal amputation.

An attempt was made to correlate the rate of amputation with the presence of compound comminuted fractures but the findings are not significant. As may be expected, however, there was a direct correlation between rate of amputation and size of the wound.


448

Complications were encountered much less frequently than was expected. Hemorrhage from the suture line was quite rare. Infection at the repair site, which may result in hemorrhage or thrombosis, was rarely a problem. Latent thrombosis probably occurs more frequently than is realized but the thrombus is often slow in formation during which time the collateral circulation increases and compensates for the major artery, thereby preventing limb loss.

One of the greatest determining factors in the final results of arterial repair is the time dapse from arterial injury to repair. Even this can be quite variable depending on many factors such as size of the wound, number of collaterals involved, level of the artery involved, ambient temperature, severity of shock and antomical variations. Although it has been shown that results are proportionally better when arterial repair is done within 10 hours of injury, an extremity may undergo irreversible muscle changes much earlier or remain viable much longer, depending on the above factors. The author has previously reported five cases in which major arterial injury was repaired 11 to 24 hours (an average of 16 hours) after injury. At the time of amputation, all five extremities exhibited good blood flow through necrotic muscles. It was considered that time lag from injury to surgery was a significant factor in those five cases.

The time from injury to repairs in the 26 patients whose extremities subsequently required amputation varied from 1 to 24 hours with a mean of 10.5 hours; almost identical with the average time lag of 9.8 hours recorded for the entire series.

Numerous patients were seen with the injured limb cold, ischemic, anesthetic and paralytic, with the joints fixed. After arterial repair, as these limbs became warm and sensation and motion returned, they often began to swell, requiring fasciotomy. When fasciotomy was delayed, all degrees of muscle necrosis occurred, varying from microscopic areas of focal necrosis to loss of complete compartments. The flexor compartment of the forearm and the anterior tibial compartment of the leg seemed to be most vulnerable.

Short-term Followup

If analogous groups of cases are compared after only the limited theater followup studies, then we find that there were 127 major artery repairs in 1952, reported by Ziperman, with 26 cases, or 20.5 percent, resulting in amputation. Of the 193 major artery repairs with limited followup studies in this report from 1953 there were also 26 cases, or 13.5 percent, which resulted in amputation; an improvement of 34.1 percent in limb survival during the last year of the Korean war.


449

Thrombosis was reported as occurring in 29, or 17.4 percent, of the total surviving unamputated patients with limited studies (table 5). No arteriograms were done in these patients during their short-term studies. Thrombosis was considered as occurring when no pulse returned following arterial repair or when a pulse had been present postoperatively and later disappeared. Failure of a pulse to return following surgery may have been the result of faulty technic rather than thrombosis but the consequences are the same. Excluding the patients who underwent an amputation or died, thrombosis occurred in 15.2 percent of the vessels repaired by direct anastomosis, in 30.0 percent of those repaired by autogenous vein grafts and in 62.5 percent of those repaired by homologous artery grafts. Lateral repair resulted in only 5.6 percent thrombosis.

Late Follow-up Studies

Since 62 of the 193 repairs in surviving patients had incomplete followup studies these are eliminated and only 131 cases in which there were late followup studies are reported (table 6). Counting the same 26 amputations reported in the short-term followed group and which remain unchanged for this group of 131 late followed patients, the amputation rate is increased to 19.8 percent.

An attempt to determine the exact number of thromboses has been difficult even in this followed group because it has not been possible to do an arteriogram on every patient. This is a difficult procedure at best, high in the upper extremity. The volume of the pulse distal to the repair site is not always indicative of the condition of the repair. At some levels, collateral vessels are quite adequate or develop quite rapidly. Even though some patients with a poor pulse have been shown by arteriogram to have a patent but constricted repair, all patients with a poor pulse or absence of pulse following surgery have been recorded in this report as thrombosed.

Thrombosis was reported as occurring in 19, or 18 percent, of the 105 surviving unamputated patients on whom we have late followup studies (table 6). Of the unamputated patients whose vessels were repaired by anastomosis, 13.9 percent thrombosed. Excluding the patient amputated, none with lateral repair were reported as thrombosed. In the 21 patients whose vessels were repaired by grafts, 14 autogenous vein grafts and 7 homologous artery grafts were used. In this group 35.7 percent of the vein grafts thrombosed, compared to 57.l percent of the artery grafts. This percentage was not surprising from previous experience with homologous artery grafts but it was not expected that it would be as high with the autogenous vein grafts.


450

Table 6. Late Followup

Major Vascular Repairs-Korea 1953*



Repair



Total-Number

No Amputation

Amputated



Died-Number

Good

Thrombosed


Number


Percent

Number

Percent

Number

Percent

Anastomosis

96

62

86. 1

10

13. 9

13

15. 3

11

Vein graft

24

9

64. 3

5

35. 7

8

36. 4

2

Artery graft

11

3

42. 9

4

57. 1

3

30. 0

1

Lateral repair

8

6

100. 0

0

-----

1

14. 3

1

Conservative

3

3

-----

0

-----

0

-----

0

Release spasm

2

1

-----

0

-----

1

-----

0

Remove thrombus

1

1

-----

0

-----

0

-----

0

Ligation

4

1

-----

0

-----

0

-----

3


Total


149


86


82. 0


19


18. 0


26


19. 8


18

*Percentages exclude patients who underwent amputation or died.

Discussion

Admittedly, the Korean war offered many advantages over World War II relative to vascular repair. During its latter phase the front line was relatively stable. The surgical hospitals were within 6 to 12 miles of the front and we had ample air cover plus the advantage of more rapid helicopter evacuation. The expanded antibiotic armamentarium, availability of new vascular clamps, plus the experience gained in vascular surgery since World War II, all contributed to the success of vascular surgery in the Korean war. The Potts ductus and coarctation clamps contributed immensely to the success of the entire vascular surgery program.

Obviously, once an amputation was reported, the late followup concerning the patient's extremity was known. By far the highest percentage of amputations occurred at the initial installation and so were reported. While we have 26 amputations, or 20 percent, reported in 131 late followed surviving patients, this percentage is believed to be too high. When the 62 patients were lost to followup, and not counted in this percentage, all had viable limbs. If these cases are included and the 193 cases with limited studies with the same 26 amputations are considered, then the amputation rate is 13.5 percent. This rate is certain to be low because amputations have been recorded outside of the Korean Theater. The correct amputation rate for the entire series probably ranges between 13.5 percent and 19.8 percent or possibly near the mean of approximately 16.5 percent.


451

In order to present an accurate picture of the rate of thrombosis, findings of both the entire group of 193 patients with limited studies and the followed group of 131 patients have been presented. Ten thromboses are known to have existed in the 62 patients lost to followup. The number of thromboses in the amputated patients is unknown so the rate of thrombosis is figured for only the living unamputated patients. When rates of thrombosis of the short-term followed and late followed groups are compared, they are found to be almost identical (tables 5 and 6). If these findings are any criteria to the most satisfactory methods of repair, then the preferred methods are, in order, lateral repair, direct anastomosis, autogenous vein graft and homologous artery graft. However, it must be borne in mind that lateral repair was used for only the simplest lacerations and the more extensive the wound the more complicated the repair.

Lateral repair should be reserved for only minor, clean-cut lacerations of the artery. Large irregular lacerations are better excised with repair by direct anastomosis. By the same token, if the damage area of the vessel is large, it is often wiser to débride thoroughly and insert a graft rather than to sacrifice important collaterals in order to perform an anastomosis. An anastomosis under undue tension tends to separate or to create a spasm with resulting thrombosis.

Even though a number of limbs have come to amputations and others have been crippled by loss of muscle tissue or have complications of nerve injury or compound fractures, the salvage of limbs by repair of acute vascular injuries in Korea has been significant.

Summary

1. An attempt was made to follow every soldier with a major artery repaired in Korea during 1953. These findings are compared to findings reported from Korea during 1952.

2. During 1953 there were 211 major arterial repairs in 205 patients recorded from the Korean war. Death occurred in 15 patients with 18 repairs. Of the surviving patients, 26 required limb amputation.

3. Of the 193 repairs in surviving patients with short-term followup studies during 1953, amputation resulted in 13.5 percent. This is an improvement of 34.1 percent over an analogous series of 127 cases with 20.5 percent amputations reported from 1952.

4. Sixty-two of the 193 patients were lost to followup, leaving 131 with late followup studies of whom 26, or 19.8 percent, required amputation.

5. The correct amputation rate for the entire series ranges between 13.5 percent and 19.8 percent or possibly near the mean of approximately 16.5 percent.


452

6. A comparison of the rates of thrombosis in repairs with short-term studies and those with late studies shows the findings to be almost identical. If absence of thrombosis is an indication of superior methods of repair, then in order of preference they are, lateral repair, direct anastomosis, autogenous vein graft and homologous artery graft. These results also correlate closely with the severity of the vascular wound.

References

1. DeBakey, M. E., and Simeone, F. A.: Battle Injuries of the Arteries in World War II. Ann. Surg. 123: 534-579, 1946.

2. Seeley, S. F., Hughes, C. W., Cooke, F. N., and Elkin, D. C.: Traumatic Arteriovenous Fistulas and Aneurysms in War Wounded. Am. J. Surg. 83: 471-479, 1952.

3. Cooke, F. N., Hughes, C. W., Jahnke, E. J., Jr., and Seeley, S. F.: Homologous Arterial Grafts and Autogenous Vein Grafts Used to Bridge Large Arterial Defects in Man. Surg. 33: 183-189, 1953.

4. Seeley, S. F., Hughes, C. W., and Jahnke, E. J., Jr.: Direct Anastomosis versus Ligation and Excision of Traumatic Arteriovenous Fistulas and Aneurysms. Surg. Forum, pp. 152-154. Clin. Cong. Amer. Coll. Surg., New York City, September 23, 1952.

5. Hughes, C. W.: Acute Vascular Trauma in Korean War Casualties. Surg., Gynec. & Obst. 99: 91-100, July 1954.

6. Jahnke, E. J., Jr., and Seeley, S. F.: Acute Vascular Injuries in the Korean War. Ann. Surg. 138: 158-177, 1953.

7. Jahnke, E. J., Jr., and Howard, J. M.: Primary Repair of Major Arterial Injuries. Arch. Surg. 66: 646-649, 1953.

8. Ziperman, H. H.: Acute Arterial Injuries in the Korean War. Ann. Surg. 139: 1-8, 1954.