Use and complications of operative control of arterial inflow in combat casualties with traumatic lower-extremity amputations caused by improvised explosive devices

BACKGROUND: Proximal traumatic lower-extremity amputation has become the signature injury of the war in Afghanistan. Casualties present in extremis and often require immediate operative control of arterial inflow to prevent exsanguination. This study evaluated the use of this strategy and its complications. METHODS: This is a retrospective analysis of case notes of UK service personnel, identified from the UK Joint Theatre Trauma Registry, who sustained traumatic lower-extremity amputation requiring suprainguinal vascular control, following improvised explosive device injury in Afghanistan, between July 2008 and December 2010. RESULTS: Fifty-one casualties were identified with a median Injury Severity Score (ISS) of 30. In 10 casualties, control was obtained via an extraperitoneal approach, and in 41, control was obtained via midline laparotomy and intraperitoneal (IP) approach. The most commonly controlled vessel in extraperitoneal control was the external iliac artery, and in IP control, the common iliac artery. Within the 41 patients who had IP control, 13 also required a therapeutic laparotomy, and 9 patients had bilateral injuries at the level of the proximal femur or higher. One patient, who had undergone IP control, experienced an injury to the common iliac vein, which was repaired. There were no other immediate complications recorded, and 39 casualties survived to discharge. CONCLUSION: This is the first study to characterize the methods of proximal control in high wartime lower-extremity amputees. Although some casualties will have abdominal injuries that necessitate laparotomy, the majority in our study did not; however, in the critically ill casualty, rapid proximal control is required. Novel methods of temporary hemorrhage control may reduce the need for, and burden of, cavity surgery. LEVEL OF EVIDENCE: Epidemiologic study, level III; prognostic study, level IV.