Battle Casualties in Korea: Studies of the Surgical Research Team Volume III
Arterial Injuries in the Korean Conflict: Experiences with 111 Consecutive Injuries*
Captain Frank K. Inui, MC, USAR
Captain James Shannon, MC, USAR
Captain John M. Howard, MC, USAR
Among the advances made by medical officers in the Korean conflict, none were more dramatic than the successful repair of acute arterial injuries. This report is a summary of experiences at a forward surgical hospital during the last 18 months of the conflict. It was during this period that the technic of arterial repair of the battle wound was developed.1-3 As a result, this report spanned and contrasted two periods, the period of arterial ligation and the period of arterial repair (Table 1).
Table1. Summary of Method of Management of Acute Arterial In juries
Prior to April 1952, ligation of transected arteries was almost routine. The disastrous results are wellknown.4,5 Twenty-six major peripheral arteries were ligated 24 of which were in consecutive casualties, with a resultant amputation rate of 62 percent (Table 2). In two of these patients, the common carotid artery was also ligated and both developed a hemiparesis. Following ligation, two or more additional patients developed distal ischemia to such an extent that the function of the limb was seriously impaired.
*Previously published in Surgery 37:850, 1955.
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Table2. Results of Ligation
The high rate of amputation following ligation has therefore not diminished since De Bakey and Simeone reported the results of ligation in World War II (Table 3).4
Because of this high rate of major amputations resulting from arterial ligation-based on the progress made in vascular surgery since World War 11-primary repair of arterial injuries was undertaken as a formal study by the Surgical Research Team in Korea during 1952.1 3 6 Thereafter, at the 46th Surgical Hospital 75 acute arterial injuries were repaired primarily. These casualties represented consecutive arterial injuries, with the exception of two soldiers who could not be resuscitated sufficiently to permit adequate operation and a third soldier who was semicomatose following an injury to the common carotid. The latter casualty was observed and evacuated without operation. Therefore, patients were unselected, except for the crude selection based on the ability of the patient to survive operation. With this exception, all major arteries were repaired regardless of the time lag or ischemic changes in the distal extremity.
Improvement in the results was unequivocal. The amputation rate fell from 62 percent following ligation to 7 percent following repair (Fig. 1; see Table 3). A fall in the amputation rate was noted following injuries to the upper and lower extremities (Fig. 2) as well as following injury to each of the major vessels (Fig. 3; Table 4).
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Table3. Percentage of Amputation After Arterial Injuries
Table4. Results Following Restoration of Arterial Continuity
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FIGURE1. Demonstrating the decrease in the amputation rate following the institution of arterial repair.
FIGURE2. Following arterial repair, amputation of the upper extremity was unnecessary. All five amputations following arterial repair occurred with wound of the lower extremities.
FIGURE3. A striking reduction in the amputation rate was noted following the repair of each of the major arteries.
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Surgical Management
Diagnosis
The diagnosis of an arterial injury may be completely clear-cut or tantalizingly equivocal. It became obvious in our experience that a high index of suspicion was the greatest aid in the preoperative diagnosis of arterial injury. In spite of this, the. diagnosis frequently was made only at operative exploration of the vessel in question.
As a rule, inspection will reveal two or three points aiding in the diagnosis. The location of the wounds of entrance and exit should lead one to suspect the possibilities of vascular injury. Following vascular injury, the relative size of the involved extremity is sometimes greater than normal and the swelling is sometimes tense. The extremity may be pale or it may have a ruddy cyanotic appearance the former appearance indicates arterial injury and the latter perhaps both arterial and venous involvement.
Auscultation may occasionally reveal a bruit over the area of injury. Blood pressure differentials and oscillometric readings were not determined in this study.
The temperature differential is generally of diagnostic aid, but it becomes of no value in a soldier who has been lying out in subzero weather for several hours before being picked up. Absence or diminution of peripheral pulsation falls in this same category. Both lowered temperature and decreased pulsation may be present in an extremity whose major vessel has no organic injury but whose circulation is impaired by a displaced bone fragment, segmental spasm, or generalized peripheral vascular collapse. However, such an extremity must be explored if the wound lies in the proper position to have injured an artery. Of equal importance in the diagnosis is the unequivocal fact that a pulse often may be palpated distant to the site of an arterial injury.
Examination of the roentgenograms and study of the probable missile path will frequently give a clue as to the presence or absence of arterial injury. As stated previously, it is necessary to explore a vessel simply on the basis of probability determined by the position of the retained missile or path of the wound. This statement is true, even in the absence of any or all of the diagnostic signs of arterial injury; for all too frequently an arterial injury becomes evident, only when the wounds are more adequately explored and débrided.
Principles of Treatment
The first principle, that restoration of continuity must be achieved in order to save extremities, is dependent upon several time-worn but oft-ignored secondary principles. Exposure must be adequate; and it should be achieved before any clot in the vessel is dislodged.
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Once exposure and hemostasis are obtained, the success of the anastomosis depends on several factors. (1) Débridement of the soft tissues must be adequate, as infections in inadequately débrided wounds may lead to secondary thrombosis or secondary hemorrhage. (2) The defective artery itself must be adequately débrided, as intimal damage may lead to early thrombosis. Resection of the artery should include all grossly damaged areas. (3) As previously described by others,3 5 7 8 anastomosis should result in a smooth intima-to-intima approximation. (4) Anastomosis must be achieved without tension on the suture line. The success of the operation is primarily dependent upon the application of this technical discipline. Short cuts will lead to thrombosis. Grafts from the cephalic or saphenous vein were used in 16 casualties with results which, within the limits of this study, appeared completely satisfactory (Table 5). The insertion of a vein graft is far superior to anastomosis with tension.
Table5. Results of Repair of Arterial Injuries (72 Patients and 75 Injuries)
Under the conditions in Korea, a prolonged time lag before operation was not a contraindication to repair. Successful re-anastomosis was achieved as late as 20 hours after injury (Table 6). To date, observations suggest that surgical failure is dependent upon technical errors at the time of repair or ischemic changes in the distal muscle prior to operation. As previously described by others,3 6 7 an anastomosis may be technically perfect and the distal arterial pulsation full; yet gangrene of the muscles may require amputation. This clinical picture was noted twice. The skin was viable and the distal
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pulse was excellent; yet the muscles were dead. Although specific data is not vet available, this is believed to be. the result of preoperative ischemia due to arterial interruption rather than to small vessel thrombosis and continued postoperative ischemia. As in the case of incarcerated hernias, time lag prior to surgery has a relative significance rather than an absolute significance. If collateral circulation is good, a successful anastomosis may be achieved after many hours for the success, in this respect, seemingly does not depend upon changes in time artery itself but in the muscle. Conversely, following the complete interruption of the circulation for only a few hours, restoration of time arterial flow may occasionally prove futile.
Table6. Time Lag Before Restoration of Arterial Continuity
Postoperative Complications
There were two types of infections encountered in this group of patients; the first was gas gangrene involving the peripheral portions of the extremities. These patients were those in whom the surgeons took a chance on an extremity that should have been amputated originally. The second type of infection was that developing at the site or around the site of the anastomosis (Table 7). In all probability, this was primarily due to inadequate débridement of the wound. The presence of these wound infections did not necessarily result in a breakdown of the repair in every instance. However, this was the most common outcome. Secondary repair was attempted twice; but success was doubtful as far as the anastomosis was concerned. Amputation was unnecessary in these latter two patients; apparently the delay in occlusion was sufficient to permit development of adequate collateral circulation to maintain a viable and functionally useful limb.
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Table7. Major Complications of Arterial Repair
Breakdown of an arterial repair occurred only in the presence of a wound infection. The development of thrombosis at the site of repair or distal to the anastomosis was infrequent. It occurred four times in the immediate postoperative period. It occurred again in a vein graft whose distal circulation was questionable at the time operation was completed. Late thrombosis is known to have occurred in four others; but the follow-up on these patients was incomplete. The latter four retained useful limbs. Sympathectomy and anticoagulants were not used following arterial repair.
Three patients in the series died, two from associated injuries and one from a pulmonary embolus which occurred 30 days following reparative surgery of other injuries.
Problems
Iliac Arteries. One of the unsolved problems is the management of injuries of intra-abdominal arteries. Patients with aortic injuries did not reach the hospital alive. Not infrequently, however, casualties with injuries of the iliac arteries reached the hospital alive only to die of continued hemorrhage prior to operation or shortly after the induction of anesthesia. The problem of arterial injuries is not solved until the problem of intra-abdominal hemorrhage is solved.
Carotid Arteries. The authors treated six patients with injuries to the common carotid artery. One patient was unconscious and considered inoperable. He was evacuated after 2 days of observation. Two patients had the carotid ligated prior to the period of reparative therapy, and both developed a severe hemiparesis. Three casualties had the vessel repaired, one with a vein graft and two with transverse repairs; and these three patients had an uncomplicated convalescence. Additional study is required before a policy of primary repair of carotid arteries can be firmly established. At present, it appears to be the treatment of choice.
Arterial Spasm. As evidenced by the frequent delay before the distal pulse returns after anastomosis, arterial spasm is not an infre-
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quent sequela of trauma. Clinically significant spasm is an extremely difficult problem, although an infrequent one. In one instance, the spasm responded to wrapping the spastic segment for 15 minutes with a sponge soaked with 2.5 per cent papaverine.9
Two other patients were called to our attention in whom this complication occurred; and it was noted in both patients at the time of primary surgery. One did not respond to papaverine or procaine soaks. The surgeons then distended the femoral segment with intralumenal saline; but the spasm returned. Finally, the anastomosis was taken down and an additional segment of artery excised and a vein graft inserted; but this treatment was inadequate, and amputation was necessary eventually. Amputation was required in a third patient having a similar wound, in spite of lumbar sympathectomy and the use of procaine locally and intravenously. Again this is infrequent as a major complication; and it occurred only once in this series.
Conclusion
Out of the experiences in Korea, one very important general conclusion is evident, i. e., that primary, restorative surgery of major arterial injuries is feasible and mandatory. The feasibility of primary repair in a forward surgical hospital has been clearly demonstrated by the fact that, following restoration of continuity in 75 consecutive wounds, the amputation rate fell from the earlier experiences of 48 and 62 percent following ligation to 7 percent following primary repair.
References
1. Jahnke, E. J., Jr.: The Problems and Management of Acute Vascular Injuries. Preliminary Report to the Army Medical Service Graduate School, 1952.
2. Jahnke, E. J., Jr., and Howard, J. M.: Primary Repair of Major Arterial Wounds. Med. Bull. U. S. Army, Far East 1: 43, 1953.
3. Jahnke, E. J., Jr., and Howard, J. M.: Primary Repair of Major Arterial In juries. Arch. Surg. 66: 646,1953.
4. De Bakey, M. E., and Simeone, F. A.: Battle Injuries of the Arteries in World War II: An Analysis of2,471 Cases. Ann. Surg. 123: 534, 1946.
5. Ziperman, H. H.: Acute Arterial Injuries in the Korean War. A Statistical Study. Ann. Surg. 139: 1, 1954.
6. Hughes, C. W.: Acute Vascular Trauma in Korean War Casualties: An Analysis of 180 Cases. Surg., Gynec. & Obst. 99: 91, 1954. (Chapter 12 of this volume.)
7. Jahnke, E. J., Jr., and Seeley, S. F.: Acute Vascular Injuries in the Korean War. Ann. Surg. 138:158, 1953.(Chapter 8 of this volume.)
8. Jahnke, E. J., Jr.; Hughes, C.W., and Howard, J. M.: The Rationale of Arterial Repair on the Battlefield. Ani. J. Surg. 87: 396, 1954.
9. Kinmunth, J. B.: The Physiology and Relief of Traumatic Arterial Spasm. Brit. Med. J. 1: 59, 1952.
