Perspectives in vascular surgery and endovascular therapy
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Perspect Vasc Surg Endovasc Ther · Jun 2011
ReviewAdvances in resuscitation in the setting of vascular injury.
Damage control surgery with the principles of expeditious control of hemorrhage and contamination, followed by predominant crystalloid resuscitation in the intensive care unit has saved the lives of many severely injured trauma patients. Unfortunately, crystalloid resuscitation has too often led to worsening of coagulopathy in the setting of vascular injury. ⋯ An alternative strategy, known as damage control resuscitation, with the principal resuscitation of a 1:1 ratio of packed red blood cells and fresh frozen plasma has been developed during these conflicts. This method is associated with decreased mortality and improved limb salvage in military and civilian trauma patients.
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Perspect Vasc Surg Endovasc Ther · Jun 2011
ReviewCompartment syndrome in the setting of vascular injury.
Compartment syndrome after extremity vascular injury has gained attention with the current conflicts in Iraq and Afghanistan. Compartment syndrome after extremity vascular injury is due to the initial ischemic insult and reperfusion injury. Complications from compartment syndrome can be lessened by fasciotomy, which is reviewed in this article.
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Blunt or penetrating trauma to the major arteries of the neck are challenging problems, however, newer diagnostic and therapeutic modalities have simplified care and largely eliminated the need for diagnostic neck exploration. High-quality computed tomographic angiography is quick and sensitive, identifying the vast majority of injuries prior to any operative intervention. Even in cases where active exsanguination or impending airway compromise mandates immediate exploration, intraoperative imaging and endovascular interventions have largely supplanted relatively morbid exposures for open repair. ⋯ Endovascular repair of the proximal carotid, proximal subclavian, and distal internal carotid arteries is increasingly accepted. However, vertebral trauma is dealt with almost exclusively by endovascular means. Recent military experiences in Iraq and Afghanistan highlight the imaging-intensive management of cervical vascular trauma and demonstrate the effectiveness of computed tomography angiography, selective arteriography, and endovascular interventions.
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Data from the Joint Theater Trauma Registry has led to changes in combat casualty care for Operations Iraqi and Enduring Freedom compared with previous wars. Currently, all recognized vascular injuries are repaired before leaving Iraq or Afghanistan. Extremity injuries are prevalent, accounting for the majority of reconstructive vascular surgery performed. ⋯ Use of autogenous or prosthetic grafts, vascular shunting, diagnostic imaging, and negative pressure wound therapy should continue to be encouraged. All of these advances contributed to an increase in amputation-free survival rates. The management of combat-related vascular injuries has progressed to the point of achieving reasonable outcomes for our country's military casualties.