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 COLONELCARL W. HUGHES, MC
The damage to extremity blood vessels constitutes a small but importantcomponent of war wounds. Of 2,471 such wounds collected by DeBakey andSimeone (1) from World War II, 49.6 percent of those with involvementof a major artery came to amputation. Ligation of damaged vessels was theaccepted practice. They further reported 81 cases in which suture of theartery was performed. In these, the amputation rate was 35.8 percent.
Shortly after the beginning of the Korean conflict, Walter Reed ArmyHospital was designated as the peripheral vascular surgery center for theArmy and received a substantial number of Army personnel who had sustainedtraumatic arteriovenous fistulas and aneurysms. The results of reparativeand reconstructive surgery of many of these lesions have been reported(2-4). On the basis of this experience, the feasibility of primaryrepair of damaged major blood vessels of extremities was considered practical.Personnel trained in the technic of blood vessel repair were sent to Koreaas members of the Surgical Research Team of the Army Medical Service GraduateSchool for this investigation and the practicability of repair of majorarteries of extremities as part of the definitive surgery of war woundswas established. A total of 130 major vessel injuries were repaired, followedand reported by three members of the Surgical Research Team (table 1),(5-7). The average amputation rate for these 130 vascular repairswas 10.8 percent.
Ziperman (8) analyzed the results of 234 major and minor arterialwounds collected and followed within the theater during the first 9 monthsof 1952 in Korea. His report includes the work of two members of the SurgicalResearch Team. He compared the overall findings in his collected groupto the results reported by DeBakey and Simeone and reported 127 major arteriesrepaired by suture with an amputation rate of 20.5 percent. This representsa 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.
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Table 1. Controlled Follow-up Studies-MajorArtery 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 |
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crease in amputation rate; however, both of these series are based onrelatively small numbers.
The purpose of this communication is to report an analysis of all majorvascular wounds repaired in Korea from 1 January through July 1953 (exclusiveof Navy and Marine personnel) during which time 211 major arterial injurieswere detected in 205 patients. Two patients had three vascular injurieseach and two patients had two injuries each. Seventy-two of these vascularinjuries (table 1) were treated by the author and have been reported indetail (5).
Materials and Methods
Reports on all cases in the Korean Theater were centralized in the Officeof the Surgeon of the Eighth U. S. Army. Three reports emanated from theforward hospitals in which the surgery was performed and from the evacuationhospitals through which these patients later passed.
The results are tabulated as immediate and late. Such division has beennecessary because this series includes 61 Korean national and prisonerof war patients and other United Nations personnel many of whom were lostto late followup once they left surgical and evacuation hospitals of theU. S. Army. Late followup studies were accomplished on other Allied patientsas they were returned to vascular centers in Japan and on American patientsas they were returned to Walter Reed Army Hospital, where they were subsequentlyevaluated by arteriography, oscillometry, skin temperature and exercisetolerance studies.
In this overall theater total of 211 major vascular injuries, deathswere reported as occurring from causes other than the arterial injury,in 15 patients with 18 arterial repairs. Arteries involved in these patientswere the carotid 1, axillary 1, common iliac 1, femoral (unqualified) 3,common femoral 2, superficial femoral 3, and popliteal 7. Since an adequateevaluation of the arterial repairs in these patients
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was not possible, these 18 repairs have been eliminated, leaving 193repaired major vascular injuries in 190 surviving patients.
Regardless of efforts made to follow every patient, 62 of the 193 repairsin surviving patients were lost to long-term followup studies because ofevacuation of the patients to Korean or U. N. hospitals after operation.Thus, 193 arterial injuries were available for short-term studies and ofthese, 131 came to later followup studies.
Approximately 85 percent of the vascular wounds were caused by fragmentingmissiles and 15 percent by nonfragmenting missiles. Of all the vesselsdamaged, most were lacerated with almost an equal number severed. Onlya few vessels were thrombosed or in spasm (table2). The lower extremitywas the most prevalent site of vascular injury (55.5 percent) with theupper extremity a close second (38.4 percent), while the neck and trunkreceived a very low percentage of the injuries. A distribution of injuriesis 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 |
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Table 3. Total Major Vascular Repairs-Korea1953
Body region | Artery | Number | Percent |
Neck | Carotid | 7 | 3. 3 |
Upper extremity | Axillary | 13 | 38. 4 |
Trunk | Aorta | 1 | 2. 8 |
Lower extremity | Common femoral | 12 | 55. 5 |
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Data available from approximately one-third of the patients in thisreport showed that 40 percent of the group arrived in shock of varyingdegree and 47 percent of the group had a tourniquet applied for an averageof 4 hours.
Those with vascular injuries received a high, but not first, priorityevacuation unless there was uncontrolled hemorrhage or profound
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shock which could not be treated prior to evacuation. The average timelag from injury to surgery for all cases of vascular injury in 1953 averaged9.8 hours, almost identical to what it was in 1952 as reported by Ziperman.Approximately 6 hours of this time was spent reaching the hospital and4 hours in preparation for surgery. This is a reflection of the degreeof injury and shock in these patients.
An anatomical surgical approach was used regardless of location of thewound. An adequate incision was always made and proximal control of thedamaged vessel secured first. After excision of the damaged portion ofthe vessel, repair was accomplished by a continuous mattress suture with00000 braided arterial silk everting the edges of the artery, apposingintima 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 typeof repair. Lateral suture repair followed in the third place and homologousarterial grafts in the fourth place (table 4). Conservative nonoperativetreatment was practiced in some instances of nonexpanding pulsating hematomasespecially of the carotid artery. Ligation was utilized only where repairwas not feasible in a noncritical artery or when the patient's conditiondid not permit further surgery.
Table 4. Type of Repair, Major Vascular Wounds-Korea1953*
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 |
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*Excluding 18 repairs in patients who died.
After careful débridement, care was taken to cover the repairedvessel in order to nourish and protect it but the wound was left open fordrainage and to minimize the risk of infection. Penicillin and streptomycinwere used routinely in all patients. Sympathectomy was not practiced andanticoagulants were not utilized. Following surgery, only those extremitieswith complicating fractures were placed in casts. For a period of 2 weeksonly limited active motion was permitted at the vascular repair site. Ifthe wound remained clean, delayed closure was accomplished on the fourthto sixth postoperative day.
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Results
Of the total 193 vascular repairs in surviving patients, 26 amputationsresulted. These amputations were done following repairs of the axillaryartery in 2 cases, brachial artery (unqualified) 2, femoral (unqualified)4, common femoral 5, superficial femoral 2, and popliteal 11, most of whichare considered as critical arteries. The percentage of amputations washigher in those cases requiring grafts for repairs (table 5).
Table 5. Short-term Followup-Total Major VascularRepairs-Korea 1953*
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| No Amputation | Amputated |
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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 |
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*Percentages exclude patients who underwent amputationor died.
Causes for amputation were determined where possible. Seven patientswere reported as having good blood flow through necrotic muscle at thetime of amputation. The muscle had undergone irreversible changes priorto reconstruction of the artery. Thrombosis was responsible for three amputations,compression of the repaired vessel by a displaced compound comminuted fracturewas 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 monthsfollowing repair of the damaged artery. In one case reported here as anamputation, the patient lost only four toes while another had a transmetatarsalamputation.
An attempt was made to correlate the rate of amputation with the presenceof compound comminuted fractures but the findings are not significant.As may be expected, however, there was a direct correlation between rateof amputation and size of the wound.
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Complications were encountered much less frequently than was expected.Hemorrhage from the suture line was quite rare. Infection at the repairsite, which may result in hemorrhage or thrombosis, was rarely a problem.Latent thrombosis probably occurs more frequently than is realized butthe thrombus is often slow in formation during which time the collateralcirculation increases and compensates for the major artery, thereby preventinglimb loss.
One of the greatest determining factors in the final results of arterialrepair is the time dapse from arterial injury to repair. Even this canbe 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 shownthat results are proportionally better when arterial repair is done within10 hours of injury, an extremity may undergo irreversible muscle changesmuch earlier or remain viable much longer, depending on the above factors.The author has previously reported five cases in which major arterial injurywas repaired 11 to 24 hours (an average of 16 hours) after injury. At thetime of amputation, all five extremities exhibited good blood flow throughnecrotic muscles. It was considered that time lag from injury to surgerywas a significant factor in those five cases.
The time from injury to repairs in the 26 patients whose extremitiessubsequently required amputation varied from 1 to 24 hours with a meanof 10.5 hours; almost identical with the average time lag of 9.8 hoursrecorded for the entire series.
Numerous patients were seen with the injured limb cold, ischemic, anestheticand paralytic, with the joints fixed. After arterial repair, as these limbsbecame warm and sensation and motion returned, they often began to swell,requiring fasciotomy. When fasciotomy was delayed, all degrees of musclenecrosis occurred, varying from microscopic areas of focal necrosis toloss of complete compartments. The flexor compartment of the forearm andthe 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 theaterfollowup studies, then we find that there were 127 major artery repairsin 1952, reported by Ziperman, with 26 cases, or 20.5 percent, resultingin amputation. Of the 193 major artery repairs with limited followup studiesin this report from 1953 there were also 26 cases, or 13.5 percent, whichresulted in amputation; an improvement of 34.1 percent in limb survivalduring the last year of the Korean war.
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Thrombosis was reported as occurring in 29, or 17.4 percent, of thetotal surviving unamputated patients with limited studies (table 5). Noarteriograms were done in these patients during their short-term studies.Thrombosis was considered as occurring when no pulse returned followingarterial repair or when a pulse had been present postoperatively and laterdisappeared. Failure of a pulse to return following surgery may have beenthe result of faulty technic rather than thrombosis but the consequencesare 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 62.5percent of those repaired by homologous artery grafts. Lateral repair resultedin only 5.6 percent thrombosis.
Late Follow-up Studies
Since 62 of the 193 repairs in surviving patients had incomplete followupstudies these are eliminated and only 131 cases in which there were latefollowup studies are reported (table 6). Counting the same 26 amputationsreported in the short-term followed group and which remain unchanged forthis group of 131 late followed patients, the amputation rate is increasedto 19.8 percent.
An attempt to determine the exact number of thromboses has been difficulteven in this followed group because it has not been possible to do an arteriogramon every patient. This is a difficult procedure at best, high in the upperextremity. The volume of the pulse distal to the repair site is not alwaysindicative of the condition of the repair. At some levels, collateral vesselsare quite adequate or develop quite rapidly. Even though some patientswith a poor pulse have been shown by arteriogram to have a patent but constrictedrepair, all patients with a poor pulse or absence of pulse following surgeryhave been recorded in this report as thrombosed.
Thrombosis was reported as occurring in 19, or 18 percent, of the 105surviving unamputated patients on whom we have late followup studies (table6). Of the unamputated patients whose vessels were repaired by anastomosis,13.9 percent thrombosed. Excluding the patient amputated, none with lateralrepair were reported as thrombosed. In the 21 patients whose vessels wererepaired by grafts, 14 autogenous vein grafts and 7 homologous artery graftswere used. In this group 35.7 percent of the vein grafts thrombosed, comparedto 57.l percent of the artery grafts. This percentage was not surprisingfrom previous experience with homologous artery grafts but it was not expectedthat it would be as high with the autogenous vein grafts.
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Table 6. Late Followup
Major Vascular Repairs-Korea 1953*
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| No Amputation | Amputated |
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Good | Thrombosed |
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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 |
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*Percentages exclude patients who underwent amputationor died.
Discussion
Admittedly, the Korean war offered many advantages over World War IIrelative to vascular repair. During its latter phase the front line wasrelatively stable. The surgical hospitals were within 6 to 12 miles ofthe front and we had ample air cover plus the advantage of more rapid helicopterevacuation. The expanded antibiotic armamentarium, availability of newvascular clamps, plus the experience gained in vascular surgery since WorldWar II, all contributed to the success of vascular surgery in the Koreanwar. The Potts ductus and coarctation clamps contributed immensely to thesuccess of the entire vascular surgery program.
Obviously, once an amputation was reported, the late followup concerningthe patient's extremity was known. By far the highest percentage of amputationsoccurred at the initial installation and so were reported. While we have26 amputations, or 20 percent, reported in 131 late followed survivingpatients, this percentage is believed to be too high. When the 62 patientswere lost to followup, and not counted in this percentage, all had viablelimbs. If these cases are included and the 193 cases with limited studieswith the same 26 amputations are considered, then the amputation rate is13.5 percent. This rate is certain to be low because amputations have beenrecorded outside of the Korean Theater. The correct amputation rate forthe entire series probably ranges between 13.5 percent and 19.8 percentor possibly near the mean of approximately 16.5 percent.
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In order to present an accurate picture of the rate of thrombosis, findingsof both the entire group of 193 patients with limited studies and the followedgroup of 131 patients have been presented. Ten thromboses are known tohave existed in the 62 patients lost to followup. The number of thrombosesin the amputated patients is unknown so the rate of thrombosis is figuredfor only the living unamputated patients. When rates of thrombosis of theshort-term followed and late followed groups are compared, they are foundto be almost identical (tables 5 and 6). If these findings are any criteriato the most satisfactory methods of repair, then the preferred methodsare, in order, lateral repair, direct anastomosis, autogenous vein graftand homologous artery graft. However, it must be borne in mind that lateralrepair was used for only the simplest lacerations and the more extensivethe wound the more complicated the repair.
Lateral repair should be reserved for only minor, clean-cut lacerationsof the artery. Large irregular lacerations are better excised with repairby direct anastomosis. By the same token, if the damage area of the vesselis large, it is often wiser to débride thoroughly and insert a graftrather than to sacrifice important collaterals in order to perform an anastomosis.An anastomosis under undue tension tends to separate or to create a spasmwith resulting thrombosis.
Even though a number of limbs have come to amputations and others havebeen crippled by loss of muscle tissue or have complications of nerve injuryor compound fractures, the salvage of limbs by repair of acute vascularinjuries in Korea has been significant.
Summary
1. An attempt was made to follow every soldier with a major artery repairedin Korea during 1953. These findings are compared to findings reportedfrom Korea during 1952.
2. During 1953 there were 211 major arterial repairs in 205 patientsrecorded 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 followupstudies during 1953, amputation resulted in 13.5 percent. This is an improvementof 34.1 percent over an analogous series of 127 cases with 20.5 percentamputations reported from 1952.
4. Sixty-two of the 193 patients were lost to followup, leaving 131with late followup studies of whom 26, or 19.8 percent, required amputation.
5. The correct amputation rate for the entire series ranges between13.5 percent and 19.8 percent or possibly near the mean of approximately16.5 percent.
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6. A comparison of the rates of thrombosis in repairs with short-termstudies 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 correlateclosely with the severity of the vascular wound.
References
1. DeBakey, M. E., and Simeone, F. A.: Battle Injuriesof 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., andSeeley, S. F.: Homologous Arterial Grafts and Autogenous Vein Grafts Usedto 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 ArteriovenousFistulas 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 WarCasualties. Surg., Gynec. & Obst. 99: 91-100, July 1954.
6. Jahnke, E. J., Jr., and Seeley, S. F.: Acute VascularInjuries in the Korean War. Ann. Surg. 138: 158-177, 1953.
7. Jahnke, E. J., Jr., and Howard, J. M.: Primary Repairof Major Arterial Injuries. Arch. Surg. 66: 646-649, 1953.
8. Ziperman, H. H.: Acute Arterial Injuries in the KoreanWar. Ann. Surg. 139: 1-8, 1954.
