Rich’s Vascular Trauma E-Book


524 Pages
Read an excerpt
Gain access to the library to view online
Learn more


Published in association with the Society for Vascular Surgery (SVS), the newly updated edition of Rich’s Vascular Trauma draws on civilian and military authorities from around the world to offer comprehensive and up-to-date coverage of the management of vascular injury. Anatomic patterns of vascular trauma including extremity, torso and cervical injury are reviewed in detail, including the latest techniques to manage non-compressible torso hemorrhage. You’ll have access to all of the current innovations across the broad spectrum of vascular trauma, presented in a well-organized fashion that allows you to quickly hone-in on the most important issues in patient care and management.

  • Emphasizes the current management of civilian vascular injuries with an historical reflection of pioneering contributions from the battlefield.
  • Combines the largest existing database of military vascular trauma with the experience of one of the nation's premier civilian trauma centers.
  • Examines operative techniques and "damage control" for vascular traumas.
  • For the first time, includes a novel International Perspectives section featuring fascinating accounts of vascular trauma from nine leading surgeons from five continents. This section focuses on innovative surgical treatments tailored to locally developed pathways of care, training solutions, and regional injury patterns.
  • End-to-end coverage of all phases of acute vascular injury care, including a new assessment of the implications of vascular trauma in the pre-hospital setting (i.e. point of injury and en-route care).
  • Covers the emerging hot topics, including endovascular procedures to manage trauma, contemporary use of vascular shunts, and a modern reappraisal of resuscitative endovascular balloon occlusion of the aorta for shock.
  • An innovative chapter on the systems approach and quality improvement in vascular trauma, offering information and tactics for all providers wishing to understand how clinical systems underpin patient outcome and recovery from this challenging injury pattern.
  • A combined civilian and military authorship from internationally recognized authorities draws on the best available evidence, experience, and lessons-learned from Afghanistan, Iraq, and the "urban battlefield."
  • Medicine eBook is accessible on a variety of devices.



Published by
Published 15 April 2015
Reads 0
EAN13 9780323359115
Language English
Document size 4 MB

Legal information: rental price per page 0.0759€. This information is given for information only in accordance with current legislation.

Report a problem

Rich's Vascular Trauma
Todd E. Rasmussen, MD, FACS
Colonel USAF MC
Director, U.S. Combat Casualty Care Research Program
Fort Detrick, Maryland;
Harris B Shumacker, Jr. Professor of Surgery
The Norman M. Rich Department of Surgery
Uniformed Services University of the Health Sciences
Bethesda, Maryland;
Attending Vascular & Trauma Surgeon
Veterans Administration Medical Center & University of Maryland
Shock Trauma Center
Baltimore, Maryland
Nigel R.M. Tai, QHS, MS, FRCS(Gen)
Colonel, L/RAMC
Clinical Director, Trauma Services
Royal London Hospital
Barts Health NHS Trust
London, United Kingdom;
Senior Lecturer
Academic Department of Military Surgery and Trauma
Royal Centre for Defence Medicine
Birmingham, United Kingdom;
Consultant Surgeon
16 Medical Regiment
Colchester, Essex, United KingdomTable of Contents
Cover image
Title page
Section 1 Background
1 The Vascular Injury Legacy
Initial Control of Hemorrhage
Early Vascular Surgery
World War I Experience
World War II Experience
Experiences During the Korean Conflict
Vietnam via Gulf War 1991 to Afghanistan and IRAQ
Civilian Experience
References2 Epidemiology of Vascular Injury
Context and Categorization of Vascular Trauma
Vascular Trauma and Military Conflict
Vascular Trauma and Civilian Populations
Vascular Trauma and Patient Age
Iatrogenic Vascular Trauma
Vascular Trauma, Lifestyle, and Socioeconomic Factors
3 Systems of Care in the Management of Vascular Injury
Trauma Systems Overview
Key Components of a Trauma System
Trauma Center Function
Trauma Systems in Combat Casualty Care
Organization of the Joint Theater Trauma System
Challenges of Systemizing Vascular-Injury Care
4 Pathophysiology of Vascular Trauma
Pathogenesis of Ischemia and Reperfusion
Clinical Practice on the Battlefield
The Ischemic Threshold
Damage Control Resuscitation
Section 2 Diagnosis and Early Management
5 Diagnosis of Vascular Injury
The Mechanism, Setting, and Patterns of Injury
Injury Pattern Recognition
Physical Examination
Clearing the Trauma Patient for the Presence of Vascular Injury
Definitive Diagnosis of Vascular Injury
Compartment Syndrome
6 Imaging for the Evaluation and Treatment of Vascular Trauma
Historical Background
Imaging Modalities
7 Damage Control and Immediate Resuscitation for Vascular Trauma
Resuscitation Paradigms
Horizontal Versus Vertical Resuscitation
Three-Dimensional Versus Two-Dimensional Resuscitation
Techniques and Procedures
Fluids and MedicationsImaging
Resuscitation End Points
Resuscitation Ethics
8 Vascular Disruption and Noncompressible Torso Hemorrhage
The Military and Civilian Epidemiology of Torso Hemorrhage
Defining Noncompressible Torso Hemorrhage
Epidemiology of Noncompressible Torso Hemorrhage
Clinical Management Strategies in Torso Hemorrhage Control
Damage Control Surgery and Damage Control Resuscitation
Resuscitative Surgical Maneuvers
Operative Exposures and Control of Nontraditional Vascular Trauma and
Section 3 Definitive Management
9 Cardiac, Great Vessel, and Pulmonary Injuries
Evaluation and Management in the Emergency Center
The Injured Heart
Injuries to the Great Vessels
Injuries to the Lungs
Thoracic Damage Control
10 Blunt Thoracic Aortic Injury
Historical Background
Site and Type of Aortic Injury
Natural History of Blunt Thoracic Aortic Injuries
Screening and Diagnosis
Initial Management of Thoracic Aortic Injuries
Timing of Definitive Management
Definitive Management of Thoracic Aortic Injuries
Open Surgical Repair
Endovascular Aortic Repair
Advances in Endograft Design
Nonoperative Management
11 Abdominal Aortic Trauma, Iliac and Visceral Vessel Injuries
Mechanism of Injury
Clinical Presentation
Surgical Techniques
Aortic Injuries
Injuries to the Visceral Arteries
Injuries to the Iliac Artery
Surgical Management
Complications of Vascular Trauma
Endovascular Treatment of Intraabdominal Trauma
References12 Inferior Vena Cava, Portal, and Mesenteric Venous Systems
Historical Background
Preoperative Preparation
Operative Management
Alternative Management Options
Postoperative Care and Complications
13 Neck and Thoracic Outlet
Preoperative Preparation
Pitfalls and Danger Points
Operative Strategy and Technique
Postoperative Care, Complications, and Outcomes
14 Upper Extremity and Junctional Zone Injuries
Epidemiology of Upper Extremity Vascular Injury
Indications, Presentations, and Diagnoses
Preoperative Preparation
Operative Strategy
Operative Technique
Postoperative Care
Outcomes and Complications
References15 Lower Extremity Vascular Trauma
History and Background
Presentation and Diagnosis
Preoperative Preparation
Helpful Considerations to Avoid Pitfalls
Operative Strategy and Technique
Considerations for Extremity Venous Injury
Postoperative Care
Section 4 Hot Topics in Vascular Injury and Management
16 Damage Control: Prehospital Care of the Patient With Vascular Injury*
Preventable Death
General Aspects of Care
Control of Extremity Hemorrhage: Tourniquets
Control of External Nonextremity Hemorrhage
Junctional Bleeding
Hemorrhage Control: Direct Pressure
Noncompressible Hemorrhage
Prevention and Treatment of the Coagulopathy of Trauma
Prehospital Fluid Resuscitation: Crystalloids and Colloids
Prehospital Fluid Resuscitation: Plasma
Care During Transport
17 Surgical Damage Control and Temporary Vascular Shunts
Historical Use of Intravascular Shunts
Modern Use of Intravascular Shunts
Shunt Materials
Insertion Technique
Dwell Time
Special Considerations
18 Damage Control: Considerations for Vascular Conduit in the Repair of Vascular
Definition of Problem Identification of the Optimal Vascular Conduit
Types of Conduit
Decision Making in the Choice of Conduit
Available Conduit in Austere and Military Settings
Future Considerations
19 Endovascular Management of Acute Vascular Injury
Endovascular Management of Carotid Arterial Injury
Endovascular Management of Vertebral Artery InjuryEndovascular Management of Blunt Thoracic Aortic Injury
Repair Versus Observation
Endovascular Management of Blunt Abdominal Aortic Injury
Endovascular Management of Axillosubclavian Artery Injury
Endovascular Management of Extremity Vascular Injury
Aortic Occlusion Balloons for Penetrating Trauma and Blunt Trauma
Long-Term Follow-Up
20 Pediatric Vascular Injury
Demographics and Etiology
Anatomic and Physiologic Considerations
Diagnostic Evaluation
Management of Pediatric Vascular Injuries
Adjuncts to the Management of Vascular Injuries in Children
Postoperative Management
Outcomes Following Pediatric Vascular Injuries
Future Directions
21 Inferior Vena Cava Filters
Filters and Terminology
References22 Soft-Tissue and Skeletal Wound Management in the Setting of Vascular Injury
Epidemiological Factors
Grading of Orthopedic Fractures
Salvage Versus Amputation
Strategies in Managing the Severely Injured Limb
Assessment of the Injured Extremity
Initial Surgical Management
Outcomes of Limb Salvage
23 Vascular Surgery in the Austere Environment
Neck Injuries
Upper Limb Vascular Injuries
Abdominal Vascular Injuries
Lower Limb Vascular Injuries
Futility of Treatment
Soft-Tissue Injury
Vascularized Composite Muscle Flaps for Coverage of Vascular Reconstruction
Forearm Amputation
Working in Austere Environments
24 Vascular Trauma: Training the Surgeon of the Future
Vascular Training in Evolution
Vascular Trauma Training Considerations
Vascular Trauma Training Tools
Team-Based Training for Vascular Trauma
Simulation-Based Training for Vascular Trauma
Current Vascular Surgery Training Curricula
The Definitive Surgical Trauma Care Course
Definitive Surgical Trauma Skills (DSTS)
Advanced Trauma Operative Management
Advanced Surgical Skills for Exposures in Trauma (ASSET)
The Military Operational Surgical Training Course
European Vascular Masterclass (the Pontresina Course)
Section 5 International Perspectives
25 Australia and New Zealand
Region-Specific Epidemiology
Region-Specific Systems of Care
Surgical Training and Certification
Access to Care
Prehospital Care
Region-Specific Considerations for Diagnosis
Region-Specific Treatment Strategies
Strategies to Sustain and Train the Next Generation of Trauma Surgeons
26 Asia: Sri LankaAbstract
Systems of Care and Transport
Considerations for Diagnosis
Treatment Strategies
Sustain and Train the Next Generation
27 Europe: Croatia
Region-Specific Epidemiology
War Vascular Injuries
Region-Specific System of Care
Region-Specific Considerations for Diagnosis
Region-Specific Treatment Strategies
Strategies to Sustain and Train the Next Generation of Trauma Surgeons
28 Scandinavia and Northern Europe
Region-Specific Epidemiology
Region-Specific Systems of Care
Region-Specific Considerations for Diagnosis
Region-Specific Treatment Strategies
Strategies to Sustain and Train the Next Generation of Trauma Surgeons
29 Europe: Russia
The North Caucasus
30 Europe: Serbia
Region-Specific Epidemiology
Region-Specific Systems of Care
Region-Specific Considerations for Diagnosis
Region-Specific Treatment Strategies
Endovascular Repair of Vascular Trauma
31 Vascular Trauma in Israel
Epidemiologic Considerations
Incidence of Vascular Trauma
Israeli Vascular System of Care
Considerations for Diagnosis
Treatment Strategies
Mortality from Vascular Injuries
Prospects for the Future
32 South Africa
Region-Specific Epidemiology
Region-Specific Systems of Care
Region-Specific Considerations for Diagnosis
Region-Specific Treatment StrategiesStrategies to Sustain and to Train the Next Generation of Trauma Surgeons
33 Vascular Trauma in Latin America
Specific Systems of Care in the Region
Regional Considerations for the Diagnosis and Management of Vascular Trauma
Strategies to Train the Next Generation of Trauma Surgeons
34 Implications of Vascular Trauma in Brazil
Trauma in Brazil
Evaluation and Diagnosis of Vascular Injury in Brazil
Region-Specific Treatment Strategies (Acute Vascular Hemorrhage and Acute
Specific Vascular-Injury Patterns
Regional Strategies to Sustain and Train the Next Generation of Trauma Surgeons
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
Copyright © 2016 by Elsevier, Inc. All rights reserved.
The content of this text does not represent official viewpoints of the U.S.
Department of Defense or the U.K. Ministry of Defense.
No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any
information storage and retrieval system, without permission in writing from the
publisher. Details on how to seek permission, further information about the
Publisher's permissions policies and our arrangements with organizations such as the
Copyright Clearance Center and the Copyright Licensing Agency, can be found at our
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should
be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised
to check the most current information provided (i) on procedures featured or (ii) by
the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety
To the fullest extent of the law, neither the Publisher nor the authors, contributors,or editors, assume any liability for any injury and/or damage to persons or property
as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material
Previous editions copyright © 2004 and 1978.
Library of Congress Cataloging-in-Publication Data
Rich's vascular trauma / [edited by] Todd E. Rasmussen, Nigel R.M. Tai.—Third
p. ; cm.
Vascular trauma
Preceded by: Vascular trauma / [edited by] Norman M. Rich, Kenneth L. Mattox,
Asher Hirshberg. 2nd ed. c2004.
Includes bibliographical references and index.
ISBN 978-1-4557-1261-8 (hardcover : alk. paper)
I. Rasmussen, Todd E., editor. II. Tai, Nigel R. M., editor. III. Rich, Norman M.
Vascular trauma. Preceded by (work): IV. Title: Vascular trauma.
[DNLM: 1. Blood Vessels—injuries. 2. Vascular Surgical Procedures. WG 170]
Acquisitions Editor: Michael Houston
Developmental Editor: Laura Schmidt
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Rachel E. McMullen
Design Direction: Ashley Miner
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1D e d i c a t i o n
To our families, whose love and sacrifice have made this and so many other endeavors
and to the teachers who prepared us; the friends and colleagues—close and far—whose efforts
have inspired, enabled, and sustained us; and our patients who, in times of peace and war, it
is our privilege to know and care forContributors
Aaron C. Baker MS, MD
Clinical Fellow
Vascular and Endovascular Surgery
Mayo Clinic
Rochester, Minnesota
Lorne H. Blackbourne MD
Attending Trauma Surgeon
San Antonio Military Medical Center
Joint Base San Antonio
Ft. Sam Houston, Texas
Kenneth Boffard MB, BCh, FRCS, FRCS(Edin), FRCPS(Glas), FCS(SA), FACS
Professor Emeritus
Department of Surgery
University of the Witwatersrand;
Trauma Director
Milpark Hospital
Johannesburg, South Africa
Oswaldo Borraez MD
Mayo Clinic
Vascular Surgery
Rochester Minnesota
Mark W. Bowyer MD, FACS
Professor of Surgery
Chief of Trauma and Combat Surgery
Surgical Director of Simulation
The Norman M. Rich Department of Surgery
Uniformed Services University
Bethesda, Maryland
Karim Brohi FRCA, FRCS
Professor of Trauma Sciences
Queen Mary University of London
Consultant Trauma and Vascular Surgeon
Royal London Hospital
Barts Health NHS Trust
London, United Kingdom
Frank K. Butler MD
Committee on Tactical Combat Casualty Care DirectorPrehospital Trauma Care
U.S. Joint Trauma System
Defense Center of Excellence
U.S. Army Institute of Surgical Research
Joint Base San Antonio
Ft. Sam Houston, Texas
Jeremy W. Cannon MD, FACS, SM
Chief, Trauma and Critical Care
Department of Surgery
San Antonio Military Medical Center
Joint Base San Antonio
Ft. Sam Houston, Texas;
Associate Professor of Surgery
The Norman M. Rich Department of Surgery
Uniformed Services University of the Health Sciences
Bethesda, Maryland
Director of Trauma Services
Trauma Services
Auckland City Hospital
Auckland, New Zealand
Jon Clasper MBA, DPhil, DM, FRCSEd(Orth)
Defence Professor Trauma and Orthopaedics
Visiting Professor in Bioengineering, Imperial College London
London, United Kingdom
Marcus Cleanthis BSc(Hons), MBBS, MD, FRCS
Consultant Vascular Surgeon
Department of Vascular Surgery
Frimley Park Hospital
Surrey, United Kingdom
W. Darrin Clouse MD, FACS
Professor of Surgery
The Norman M. Rich Department of Surgery
Uniformed Services University of the Health Sciences
Bethesda, Maryland;
Associate Visiting Surgeon
Division of Vascular and Endovascular Surgery
Massachusetts General Hospital
Boston, Massachusetts
Lazar B. Davidovic MD, PhD, FETCS
Head of the Clinic
Clinic for Vascular and Endovascular Surgery
Clinical Center of Serbia
Full Professor of Vascular Surgery
Faculty of Medicine
University of Belgrade
Belgrade, SerbiaDavid L. Dawson MD, FACS, RVT, RPVI
Professor of Surgery
University of California, Davis
Sacramento, California;
Special Clinical Consultant, Surgery
David Grant Medical Center
Travis Air Force Base
Fairfield, California
Demetrios Demetriades MD, PhD, FACS
Professor of Surgery
University of Southern California;
Director, Acute Care Surgery
Los Angeles County and University of Southern California Medical Center
Los Angeles, California
Joseph J. DuBose MD, FACS
Chief Vascular Fellow
University of Texas Health Science Center—Houston
Associate Professor of Surgery
The Norman M. Rich Department of Surgery
Uniformed Services University of the Health Sciences
Houston, Texas
Timothy C. Fabian MD, FACS
Harwell Wilson Professor and Chairman
University of Tennessee Health Science Center
Memphis, Tennessee
David V. Feliciano MD, FACS
Battersby Professor and Chief, Division of General Surgery
Chief of Surgery
Indiana University Hospital
Department of Surgery
Indiana University Medical Center
Indianapolis, Indiana
Charles J. Fox MD, FACS
Chief, Vascular Surgery
Denver Health Medical Center;
Associate Professor of Surgery
University of Colorado School of Medicine
Denver, Colorado
David L. Gillespie MD, RVT, FACS
Chief, Department of Vascular and Endovascular Surgery
Cardiovascular Care Center
Southcoast Health System
Fall River, Massachusetts
Gabriel Herscu MD
Fellow, Vascular Surgery
Division of Vascular Surgery and Endovascular TherapyKeck Medical Center
University of Southern California
Los Angeles, California
Shehan Hettiaratchy MA(Oxon), DM, FRCS(Plast)
Chief of Service
Plastic, Orthopaedic, ENT, and Major Trauma Services
Imperial College Healthcare NHS Trust
London, United Kingdom;
Senior Lecturer
Academic Department of Military Surgery and Trauma
Royal Centre for Defence Medicine
Birmingham, United Kingdom
Timothy Hodgetts PhD, MMEd, MBA, MBBS, FRCP, FRCSEd, FCEM
Honorary Professor of Emergency Medicine
University of Birmingham
Birmingham, United Kingdom;
Medical Director
UK Defence Medical Services
Glouccester, United Kingdom
Aaron Hoffman MD
Department of Vascular Surgery and Transplantation
Rambam Health Care Campus;
Associate Professor
Rappaport Faculty of Medicine
Haifa, Israel
John B. Holcomb MD, FACS
Center for Translational Injury Research
Division of Acute Care Surgery
Department of Surgery
University of Texas Health Science Center
Houston, Texas
Kenji Inaba MD, FRCSC, FACS
Associate Professor of Surgery
University of Southern California;
Division of Acute Care Surgery
Director Surgical Critical Fellowship
Los Angeles County and University of Southern California Medical Center
Los Angeles, California
Donald H. Jenkins MD, FACS
Associate Professor of Surgery
Division of Trauma, Critical Care and General Surgery
Trauma Center Mayo Clinic
Rochester, Minnesota
Michael Jenkins BSc, MS, FRCS, FEBVSConsultant Vascular Surgeon
Chief of Service Vascular Surgery & Director of Trauma
Imperial College Healthcare NHS Trust
St Mary's Hospital
London, United Kingdom
Tony Karram MD
Department of Vascular Surgery and Organ Transplantation
Rambam Health Care Campus
Haifa, Israel
Brian S. Knipp MD
Lieutenant Commander
Medical Corps, U.S. Navy
NMC Portsmouth
Staff Vascular Surgeon
Portsmouth, Virginia
Neil G. Kumar MD
Resident, Vascular Surgery
Department of Surgery
Division of Vascular Surgery
University of Rochester Medical Center
Rochester, New York
Ari K. Leppäniemi MD, PhD
Chief of Emergency Surgery
Abdominal Surgery
University of Helsinki
Meilahti Hospital
Helsinki, Finland
Zvonimir Lovrić PhD, MD
Chief Surgeon of Traumatology Division
Department for Surgery
University Hospital Dubrava
Zagreb, Croatia
Mark Midwinter MB BS, BMedSci(Hons), MD, FRCS
Defence Professor of Surgery
Academic Department of Military Surgery and Trauma
Royal Centre for Defence Medicine
Birmingham, United Kingdom
Luis A. Moreno MD
Medical Doctor and Surgeon General
National University
Vascular Surgeon
Bosque University
Bogota, Columbia
Jonathan J. Morrison MB ChB, MRCS
Surgical Registrar, West of Scotland Surgical RotationResearch Fellow
Academic Department of Military Surgery & Trauma,
Royal Centre for Defence Medicine,
Birmingham, United Kingdom
Rossi Murilo MD
Professor of Surgery
University of Valença
School of Medicine;
Director of IECAC (State Institute of Cardiology Aloísio de Castro)
Master's Degree in Vascular Surgery
Federal University of Rio de Janeiro (UFRJ)
Rio de Janeiro, Brazil
Samy Nitecki MD
Peripheral Vascular Surgery Unit Vice Chair
Department of Vascular Surgery and Organ Transplantation
Rambam Health Care Campus
Haifa, Israel
David M. Nott OBE, OStJ, DMCC, BSc, MD, FRCS
Consultant General Surgeon
Department of Surgery
Chelsea and Westminster Hospital
Consultant Trauma and Vascular Surgeon
Department of Surgery
St Mary's Hospital
London, United Kingdom
Chirag M. Patel BSc (Hons), MBBS, MRCP, FRCR
Department of Diagnostic and Interventional Radiology
Barts and the London NHS Trust
London, United Kingdom
Predrag Pavić MD
Vascular Surgery
University Hospital Dubrava
Zagreb, Croatia
Michael A. Peck MD
Peripheral Vascular Associates
San Antonio, Texas
Rina Porta MD
Doctorate in Vascular Surgery—FMUSP (Federal University of São Paulo)
Vacular Surgery of Emergency Unit of USP
São Paulo, Brazil
Alexander A. Pronchenko MD, PhD
War Surgery Department
Kirov Military Medical Academy
Saint-Petersburg, Russia
Reagan W. Quan MDChief of Vascular Surgery
Wellspan Heart and Vascular Center
York, Pennsylvania
Dinesh G. Ranatunga MBBS(Hon), FRANZCR
Specialist Registrar
Department of Diagnostic and Interventional Radiology
The Royal London Hospital
Barts Health NHS Trust
London, United Kingdom
Todd E. Rasmussen MD, FACS
Colonel USAF MC
Director, U.S. Combat Casualty Care Research Program
Fort Detrick, Maryland;
Harris B Shumacker, Jr. Professor of Surgery
The Norman M. Rich Department of Surgery
Uniformed Services University of the Health Sciences
Bethesda, Maryland;
Attending Vascular & Trauma Surgeon
Veterans Administration Medical Center & University of Maryland
Shock Trauma Center
Baltimore, Maryland
Amila S. Ratnayake MBBS, MS
Lieutenant Colonel
Consultant General & Trauma Surgeon
Army Hospital
Colombo 05
Sri Lanka
Ian Renfrew MRCP, FRCR
Consultant in Interventional Radiology
Department of Diagnostic and Interventional Radiology
The Royal London Hospital
Barts Health NHS Trust
London, United Kingdom
Viktor A. Reva MD
Department of War Surgery
Kirov Military Medical Academy
Saint-Petersburg, Russia
Norman M. Rich MD, FACS, DMCC
Leonard Heaton and David Packard Professor
The Norman M. Rich Department of Surgery
F. Edward Hébert School of Medicine
Uniformed Services University of the Health Sciences
Bethesda, MD
Bandula Samarasinghe MBBS, MS
Senior Lecturer
University of PeradeniyaPeradeniya, Sri Lanka
Igor M. Samokhvalov MD, PhD, Prof.
Colonel M.C. (Ret)
Chief Surgeon of the Russian Army
Ministry of Defense of the Russian Federation
Moscow, Russia
Professor and Chair
Department and Clinic of War Surgery
Military Medical Academy named after S.M. Kirov
Saint-Petersburg, Russia
Stephanie A. Savage MD, MS, FACS
Associate Professor of Surgery
University of Tennessee Health Science Center
Memphis, Tennessee
Hannu Savolainen MD, PhD
Professor of Vascular Surgery
University of the West Indies
Academic Department of Surgery
Queen Elizabeth Hospital
Bridgetown, Barbados
Daniel J. Scott MD
General and Peripheral Vascular Surgery Resident
San Antonio Military Medical Center
Joint Base San Antonio
Ft. Sam Houston, Texas
Sherene Shalhub MD, MPH
Assistant Professor
Cardiothoracic and Vascular Surgery
The University of Texas Medical School
Houston, Texas
Abdul H. Sheriffdeen MBBS(Ceylon), FRCS(Eng)
Emeritus Professor of Surgery
University of Colombo
Colombo, Sri Lanka
Niten Singh MD, FACS
Associate Professor of Surgery
Vascular Surgery
University of Washington
Seattle, Washington;
Associate Professor of Surgery
Uniformed Services of Surgery
Bethesda, Maryland
Michael J. Sise MD, FACS
Clinical Professor
UCSD Medical CenterMedical Director
Division of Trauma
Scripps Mercy Hospital
San Diego, California
Benjamin Starnes MD, FACS
Chief, Vascular Surgery Division
Department of Surgery
University of Washington
Seattle, Washington
Nigel R.M. Tai QHS, MS, FRCS(Gen)
Colonel, L/RAMC
Clinical Director, Trauma Services
Royal London Hospital
Barts Health NHS Trust
London, United Kingdom;
Senior Lecturer
Academic Department of Military Surgery and Trauma
Royal Centre for Defence Medicine
Birmingham, United Kingdom;
Consultant Surgeon
16 Medical Regiment
Colchester, Essex, United Kingdom
Peep Talving MD, PhD, FACS
Assistant Professor of Surgery
University of Southern California
Division of Acute Care Surgery
Keck School of Medicine
Los Angeles, California
Jorge H. Ulloa MD, FACS
Venous Surgery
Clinica de Venas
Associate Professor
Vascular Surgery
Universidad El Bosque
Bogota, Columbia
Carole Y. Villamaria MD
Surgical Resident
Department of Surgery
University of Texas Health Sciences Center at San Antonio
San Antonio, Texas
Alasdair J. Walker OBE, QHS, MB ChB, FRCS
Medical Director and Consultant Vascular Surgeon
Joint Medical Command
Ministry of Defence
Birmingham, United Kingdom
Fred A. Weaver MD, MMM, FACSProfessor and Chief
Division of Vascular Surgery and Endovascular Therapy
Keck School of Medicine, University of Southern California
Los Angeles, California
Mandika Wijeyaratne MBBS, MS(Surg), MD(Leeds UK), FRCS(Eng)
Professor of Surgery
Department of Surgery
University of Colombo
Colombo, Sri LankaF o r e w o r d
The military medical experience of the United S tates of A merica and the United
Kingdom during the first decade of the 21st century has resulted in notable
1advancements in the management of vascular trauma. A ir superiority during the
wars in A fghanistan and I raq has allowed rapid and, in the case of the Medical
Emergency Response Teams (MERTs) often advanced, medical evacuation of injured
service personnel. D uring the wars, a large number of patients with vascular trauma
have been cared at forward Level I I or more definitive Level I I I surgical facilities
fairly rapidly after the time of injury. S ubsequent transcontinental aeromedical
evacuation with sophisticated Critical Care A ir Transport Teams (CCATT) has
permi- ed wounded troops to be transported half way around the world in record
time while receiving high levels of intensive monitoring and care.
The wars in A fghanistan and I raq have also witnessed the broad use of modern
body armor and newly designed tourniquets by those in harm's way. The role of
temporary vascular shunts, the optimal types and ratios of fluids for resuscitation,
and the types of conduits for segmental vascular replacement have been redefined
during this decade of war. A s the first prolonged period of combat operations in
which specialty trained vascular and endovascular surgeons have been deployed, this
decade has witnessed the use of endovascular procedures to manage select pa- erns
of vascular trauma and a modern reappraisal of endovascular balloon occlusion of the
aorta for the management of hemorrhagic shock. D espite these and other advances,
significant new questions have arisen including how best to assure adequate training
and readiness of military surgeons to manage the complex injury pa- ern that is
2vascular trauma.
Making optimal use of Mayo Clinic training and early assignments at Walter Reed
A rmy Medical Center and the Uniformed S ervices University, A ir Force Colonel Todd
E. Rasmussen has been an effective leader, a role model, and a respected mentor in all
aspects of this experience. He has communicated successfully with and benefited
greatly from highly skilled allies and friends such as Colonel N igel R.M. Tai of the
Royal A rmy Medical Corps. Michael E. D eBakey, whose military experience originated
in World War I I (1941–1945), Carl W. Hughes in the Korean Conflict (1951–1953), and
N orman M. Rich during the Vietnam War (1965–1972) emphasized the contributions
of Rasmussen and colleagues in 2007. In their manuscript entitled “Recognition of Air
ndForce S urgeons at Wilford Hall Medical Center-S upported 332 A ir Force Theater
Hospital, Balad A ir Base, I raq,” D eBakey, Hughes, and Rich recognized this modern
3“Band of Brothers” and their impact on vascular trauma.
This third edition of Rich's Vascular Trauma adds a novel and highly appropriate
International Perspectives section to its already impressive archive of recognized
authors and chapters. Co-editors Rasmussen and Tai have reached out to and havesecured exclusive contributions from military and civilian leaders in vascular trauma
around the globe. This new International Perspectives section provides a mix of
personal and regional experiences from surgeons whose partnership in the
management of vascular trauma was and will continue to be highly valued. A s global
health, including the management of injury, becomes a focus of health care
professionals around the world, the third edition of Rich's Vascular Trauma by the
S ociety for Vascular S urgery, along with the appointment of Todd E. Rasmussen as
Chief Editor, will provide a current and comprehensive reference.
Finally, I would like to acknowledge the valuable contributions of Frank S pencer,
Kenneth Ma- ox, and A sher Hirschberg that helped us establish a firm foundation in
the management of vascular trauma on which surgeons such as Todd E. Rasmussen,
Nigel R.M. Tai, and their colleagues, trainees, and students can continue to build.
Norman M. Rich MD
R e f e r e n c e s
1. Pruitt BA, Rasmussen TE. Vietnam (1972) to Afghanistan (2014): the state of
military trauma care and research, past to present. J Trauma Acute Care Surg.
2014;77(3 Suppl 2):S57–S65.
2. Rasmussen TE, Woodson J, Rich NM, et al. Vascular injury at a crossroads. J
Trauma. 2011;70(5):1291–1293.
3. Rich NM, Hughes CW, DeBakey ME. Recognition of Air Force surgeons at
ndWilford Hall Medical Center-supported 332 EMDG/Air Force Theater
Hospital, Balad Air Base, Iraq. J Vasc Surg. 2007;46:1312–1313.

P r e f a c e
The third edition of Rich's Vascular Trauma follows in the singular lineage of two prior
editions from Rich, Ma ox, and Hirshberg, texts that defined the pa ern and
treatment of vascular injury and that characterized its global significance. I n keeping
with the tone of the original edition, which was rooted in knowledge gained from the
wartime environment, this edition is similarly founded upon a decade of clinical
1,2experience resulting from the wars in A fghanistan and I raq. Modern studies of
combat-related injury and, indeed, civilian trauma studies have redefined and
emphasized the importance of vascular injury in taking the lives of the severely
injured. Epidemiologic study of the burden of injury from a decade of war has more
clearly identified vascular disruption and subsequent hemorrhage as the leading
3causes of death in patients with otherwise survivable injuries. A dditionally, vascular
injury resulting in ischemia has been demonstrated a leading cause of extremity
amputation and disability.
Observations in modern wartime and civilian environments confirm the beneficial
effects of organized trauma systems in improving survival and decreasing
4,5morbidity. A s such, and to provide a broader perspective, we have set out to
ensure that the third edition explores the clinical implications of vascular injury
throughout all phases of trauma care and not just in the operating theater. Unlike
almost any other injury pa ern, vascular trauma carries direct life- and
limbthreatening implications that extend from the point of injury and prehospital se ings
through to the emergency department, operating room, and intensive care unit. A ny
contemporary dissertation on vascular trauma that failed to address the spectrum of
patient care would be incomplete. A prime goal of this edition is to portray vascular
trauma with reference to the trauma-systems approach and, by so doing, offer
information and tools not merely for the surgeon but for all providers who contribute
to the management of this formidable injury pattern.
To provide this wide-ranging perspective, the third edition of Rich's Vascular
Trauma draws on civilian and military authorities from around the world. These
experts have come together to author chapters arranged in the following sections:
Background, D iagnosis and Early Management, D efinitive Management, and H ot Topics in
Vascular Injury and Management. To allow for a diverse viewpoint the editors have
embraced chapters from those with a range of backgrounds including prehospital
care, emergency medicine, trauma systems, and intensive care, as well as general,
trauma, vascular, orthopedic, and plastic surgery. I t is the editors' hope that this
edition, as a whole, will not only provide important information for those seeking
specific solutions but will also prove compelling reading in areas bordering on the
fringes of one's traditional practice.
Finally and in recognition of the truly global legacy of vascular trauma, both the
text and the injury pa ern, the third edition concludes with an original InternationalPerspectives Section. I n this section, the editors are privileged to present individual
accounts of vascular trauma from leading surgeons around the world. The
international contributors to this section hail from nearly every continent on the
globe and represent military and civilian friends and colleagues whose contributions
are fundamental and enduring parts of this text. This section, more than any other,
embodies the heritage that this new edition draws from its namesake: surgeon,
gentleman, and ambassador —Norman M. Rich, MD.
This photo shows an image of the 332nd Expeditionary Medical
Group, Air Force Theater Hospital in Balad Iraq (circa 2005).
During the war in Iraq from this location, the Balad Vascular
Registry provided information into various aspects of the
management of vascular trauma including reports on the use of
temporary vascular shunts, endovascular techniques, and the
management of specific anatomic patterns (upper extremity,
1femoral-popliteal, and tibial level injuries). The clinical and
academic efforts of the operative work force at the Air Force
Theater Hospital in Balad were recognized in a commentary by
Drs. Rich, Hughes, and DeBakey in the Journal of Vascular
2Surgery in 2007.This photo shows an image of the United Kingdom's Role III
facility at Camp Bastion, Afghanistan (circa 2008). The British-led
efforts at Camp Bastion, consistently the busiest surgical hospital
in Afghanistan, resulted in reports on not only extremity vascular
trauma but also more complex injury patterns such as
noncompressible torso hemorrhage, peritraumatic pulmonary
thrombosis, junctional vascular injury, and dismounted complex
3,4blast injury. The term “right turn resuscitation” was also coined
at Bastion referring to the physical space of the hospital in which
“turning right” on entry to the emergency department led one
immediately to the operating room. This immediate “right turn”
bypassed the traditional emergency department, affording
simultaneous blood and procedural (i.e., operative) resuscitation
5in the operating theater in the most severely injured of patients.
1. Clouse WD, Rasmussen TE, Peck MA, et al: In theater management of wartime
vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg
204(4):625632, 2007.
2. Rich NM, Hughes CW, Debakey ME: Recognition of Air Force surgeons at Wilford
Hall Medical Center-supported 332nd EMDG/Air Force Theater Hospital, Balad Air
Base, Iraq. J Vasc Surg 46(6):1312–1313, 2007; author reply 1313.
3. Stannard A1, Brown K, Benson C, et al: Outcome after vascular trauma in a
deployed military trauma system. Br J Surg 98(2):228–234, 2011.
4. Jansen JO, Thomas GO, Adams SA, et al: Early management of proximal traumatic
lower extremity amputation and pelvic injury caused by improvised explosive
devices (IEDs). Injury 43(7):976–979, 2012. doi: 10.1016/j.injury.2011.08.027. Epub
2011 Sep 9.
5. Tai NR1, Russell R: Right turn resuscitation: frequently asked questions. J R Army
Med Corps 157(3 Suppl 1):S310–S314, 2011.
Todd E. Rasmussen MD
Nigel R.M. Tai QHS, MS, FRCS(Gen)
R e f e r e n c e s1. Stannard A, Brown K, Benson C, et al. Outcome after vascular trauma in a
deployed military trauma system. Br J Surg. 2011;98(2):228–234.
2. White JM, Stannard A, Burkhardt GE, et al. The epidemiology of vascular
injury in the wars in Iraq and Afghanistan. Ann Surg. 2011;253(6):1184–1189.
3. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001–2011):
implications for the future of combat casualty care. J Trauma Acute Care Surg.
2012;73(6 Suppl 5):S431–S437.
4. Rasmussen TE, Gross KR, Baer DG. Where do we go from here? J Trauma
Acute Care Surg. 2013;75(2 Suppl 2):S105–S106.
5. Bailey JA, Morrison JJ, Rasmussen TE. Military trauma system in Afghanistan:
lessons for civil systems? Curr Opin Crit Care. 2013;19(6):569–577.S E C T I O N 1
B a c k g r o u n d
1 The Vascular Injury Legacy
2 Epidemiology of Vascular Injury
3 Systems of Care in the Management of Vascular Injury
4 Pathophysiology of Vascular Trauma

The Vascular Injury Legacy
Norman M. Rich, Alasdair J. Walker
For more than 2000 years, control of ba lefield hemorrhage relied on
compressive dressings. A dded to this were the use of cautery, styptics, boiling
oil, and a variety of other partially effective adjuncts. I n Rome 2000 years ago,
Galen advocated ligature of bleeding vessels. However, this was lost during the
D ark A ges, and it was not until the 16th century that A mbroise Paré
“reinvented” ligature of bleeding vessels when he ran out of boiling oil. Paré was
also one of the first to devise instruments, including the bec de corbin to grasp
bleeding vessels to assist with the ligature. At the turn of the 20th century, the
development of clinical and experimental concepts related to vascular surgery
progressed, and during the Korean Conflict (1950-1953) successful repair of
injured arteries and veins was accomplished consistently in the treatment of
ba lefield casualties. Over the past 50 years, additional advances in managing
vascular trauma have been made in both civilian and military practices. These
have included experiences with endovascular procedures, particularly over the
past decade, transferring civilian experience to the management of ba lefield
casualties by coalition forces in Afghanistan and Iraq.
vascular trauma; arterial trauma; venous trauma; arterial and venous injuries;
vascular repair; vascular graft; endovascular procedures
A lthough the first crude arteriorrhaphy was performed more than 250 years ago, it is
only within the past 50 years that vascular surgery has been practiced both widely and
consistently with anticipation of good results. Historically, it is of particular interest
that by the turn of the 20th century many if not most of the techniques of modern
vascular surgery had already been explored through extensive experimental work and
early clinical application. I n retrospect it is therefore almost astonishing that it took
nearly another 50 years before the work of such early pioneers as Murphy, Goyanes,
Carrel, Guthrie, and Lexer was widely accepted and applied in the treatment of
vascular injuries. However, adoption of the thought processes and practices of these
enlightened surgeons was hampered by the technological limitations of their era and
had to await the dramatic advances in graft materials and imaging seen during the
1,21950s and beyond.
S ince the days of A mbroise Paré in the mid–16th century, major advances in the
surgery of trauma have occurred during times of armed conflict when it was

necessary to treat large numbers of severely injured patients, often under
far-fromideal conditions. This has been especially true with vascular injuries.
A lthough German surgeons accomplished arterial repairs in the early part of World
War I , it was not until the Korean Conflict and the early 1950s that ligation of major
arteries was abandoned as the standard treatment for arterial trauma. The results of
ligation of major arteries following trauma were clearly recorded in the classic
manuscript by D eBakey and S imeone in 1946, who found only 81 repairs in 2471
3arterial injuries among A merican troops in Europe in World War I I . A ll but three of
the arterial repairs were performed by lateral suture. Ligation was followed by
gangrene and amputation in nearly half of the cases. The pessimistic conclusion
reached by many was expressed by S ir J ames Learmonth, who said that there was
little place for definitive arterial repair in the combat wound.
Within a few years, however, in the Korean Conflict, the possibility of successfully
repairing arterial injuries was established conclusively, stemming especially from the
work of Hughes, Howard, J ahnke, and S pencer. I n 1958 Hughes emphasized the
significance of this contribution in a review of the Korean experience, finding that the
overall amputation rate was lowered to about 13%, compared to the approximately
449% amputation rate that followed ligation in World War II.
D uring the Vietnam hostilities, more than 500 young A merican surgeons, who
represented most of the major surgical training programs in the United S tates,
treated more than 7500 vascular injuries. I n 1969 Rich and Hughes reported the
preliminary statistics from the Vietnam Vascular Registry, which was established in
1966 at Walter Reed General Hospital to document and follow all servicemen who
5sustained vascular trauma in Vietnam. A n interim Registry report that encompassed
1000 major acute arterial injuries showed li le change from the overall statistics
6presented in the preliminary report. Considering all major extremity arteries, the
amputation rate remained near 13%. A lthough high-velocity missiles created more
soft-tissue destruction in injuries seen in Vietnam, the combination of a stable
hospital environment and rapid evacuation of casualties (similar to that in Korea)
made successful repair possible. I njuries of the popliteal artery, however, remained
an enigma, with an amputation rate remaining near 30%.
I n the past 50 years, civilian experience with vascular trauma has developed rapidly
under conditions much more favorable than those of warfare. Results are be er than
those achieved with military casualties in Korea and Vietnam.
Initial Control of Hemorrhage
Control of hemorrhage following injury has been of prime concern to man since his
beginning. Methods for control have included various animal and vegetable tissues,
hot irons, boiling pitch, cold instruments, styptics, bandaging, and compression.
7These methods were described in a historical review by S chwarI in 1958. Celsus was
the first to record an accurate account of the use of ligature for hemostasis in 25 AD.
D uring the first three centuries, Galen, Heliodorus, Rufus of Ephsus, and A rchigenes
advocated ligation or compression of a bleeding vessel to control hemorrhage.
A ncient methods of hemostasis used by Egyptians about 1600 BC are described in
7the Ebers' papyrus, discovered by Ebers at Luxor in 1873. S typtics prepared from
mineral or vegetable ma er were popular, including lead sulfate, antimony, and
copper sulfate. S everal hundred years later during the Middle A ges in Europe, copper

sulfate again became popular and was known as the hemostatic “bu on.” I n ancient
I ndia, compression, cold, elevation, and hot oil were used to control hemorrhage,
while about 1000 BC, the Chinese used tight bandaging and styptics.
The writings of Celsus provide most of the knowledge of methods of hemostasis in
7the first and second centuries AD. When amputation was done for gangrene, the
prevailing surgical practice was to amputate at the line of demarcation to prevent
hemorrhage. I n the first century AD, A rchigenes was apparently the first to advocate
amputating above the line of demarcation for tumors and gangrene, using ligature of
the artery to control hemorrhage.
Rufus of Ephesus (first century AD) noted that an artery would continue to bleed
when partially severed, but when completely severed it would contract and stop
7bleeding within a short period of time. Galen, the leading physician of Rome in the
second century AD, advised placing a finger on the orifice of a bleeding superficial
vessel for a period of time to initiate the formation of a thrombus and the cessation of
bleeding. He noted, however, that if the vessel were deeper, it was important to
determine whether the bleeding was coming from an artery or a vein. I f coming from
a vein, pressure or a styptic usually sufficed, but ligation with linen was
recommended for an arterial injury.
Following the initial contributions of Celsus, Galen, and their contemporaries, the
use of ligature was essentially forgo en for almost 1200 years in western medicine. A
tension developed between traditional church teachings and enlightened thought,
perhaps holding back any advancement in western medicine or surgery. Use of the
knife was considered wrong on living tissue; consequently amputation was below the
line of ischemic demarcation. A bu al-Qasim al-Zahrawi, a prominent A rab physician
from Moorish S pain (10th century AD), advocated ligation in his great work Kitab
Al7Tasrif almost 600 years before Paré.
Throughout the Middle A ges, cautery was used almost exclusively to control
hemorrhage. J erome of Brunswick (Hieronymus Brunschwig), an A lsatian army
surgeon, actually preceded Paré in describing the use of ligatures as the best way to
7stop hemorrhage. His recommendations were recorded in a textbook published in
1497 and provided a detailed account of the treatment of gunshot wounds. A mbroise
Paré, with a wide experience in the surgery of trauma, especially on the ba lefield,
firmly established the use of ligature for control of hemorrhage from open blood
vessels. I n 1552 he startled the surgical world by amputating a leg above the line of
demarcation, repeating the demonstration of A rchigenes 1400 years earlier. The
vessels were ligated with linen, leaving the ends long. Paré also developed the bec de
corbin, ancestor of the modern hemostat, to grasp the vessel before ligating it (Fig.
171). Previously, vessels had been grasped with hooks, tenaculums, or the assistant's
fingers. He designed artificial limbs and advanced dressing technique. D uring the
siege of Turin (1536), Paré ran out of oil, which was traditionally used to cauterize. He
mixed egg yolk, rose oil, and turpentine and discovered this dressing had be er
outcomes than oil.

FIGURE 1-1 Artist's concept of the bec de corbin, developed by
Paré and Scultetus in the mid–16th century. It was used to grasp
the vessel before ligating it. (From Schwartz AM: The historical
development of methods of hemostasis. Surgery 44:604, 1958.)
I n the 17th century, Harvey's monumental contribution describing circulation of
7blood greatly aided the understanding of vascular injuries. A lthough Rufus of
Ephesus apparently discussed arteriovenous communications in the first century AD,
it was not until 1757 that William Hunter first described the arteriovenous fistula as a
8pathological entity. This was despite the fact that, as early as the second century AD,
A ntyllus had described the physical findings, clinical management (by proximal and
9distal ligation) and the significance of collateral circulation.
The development of the tourniquet was another advance that played an important
role in the control of hemorrhage. Tight bandages had been applied since antiquity,
but subsequent development of the tourniquet was slow. Finally, in 1674 a military
surgeon named Morel introduced a stick into the bandage and twisted it until arterial
7flow stopped. The screw tourniquet came into use shortly thereafter. This method of
temporary control of hemorrhage encouraged more frequent use of the ligature by
providing sufficient time for its application. I n 1873 Freidrich von Esmarch, a student
of Langenbeck, introduced his elastic tourniquet bandage for first aid use on the
10battlefield. Previously it was thought that such compression would injure vessels
irreversibly. His discovery permi ed surgeons to operate electively on extremities in a
dry, bloodless field.
Ligation was not without its complications as British A dmiral Horatio N elson
discovered after amputation of his right arm after the a ack at Tenerife, “A nerve had
been taken up in one of the ligatures at the time of the operation,” causing
11considerable pain and slowing his recovery. Furthermore the long ligatures meant
delayed wound healing. It was Haire, an assistant surgeon at the Royal Naval Hospital
Haslar, who took the risk of cu ing sutures short (rather than leaving them long) to
allow suppuration, necrosis, and granulation before the suture was pulled away. He
observed that “the ligatures sometimes became troublesome and retarded the cure”
and that cutting them short allowed stumps to heal in the course 10 days.
I n addition to the control of hemorrhage at the time of injury, the second major
area of concern for centuries was the prevention of secondary hemorrhage. Because of
its great frequency, styptics, compression, and pressure were used for several
centuries after ligation of injured vessels became possible. Undoubtedly the high rate

of secondary hemorrhage after ligation was due to infection of the wound often
promoted by dressing choices or infection spread by well-meaning a endants.
A lthough J ohn Hunter demonstrated the value of proximal ligation for control of a
false aneurysm in 1757, failure to control secondary hemorrhage resulted in the use of
12ligature only for secondary bleeding from the amputation stump. S ubsequently,
Bell (1801) and Guthrie (1815) performed ligation both proximal and distal to the
13,14arterial wound with better results than those previously obtained.
S ome of the first clear records of ligation of major arteries were wri en in the 19th
century and are of particular interest. The first successful ligation of the common
carotid artery for hemorrhage was performed in 1803 by Fleming, but was not
reported until 14 years later by Coley (1817), because Fleming died a short time after
15the operation was performed. A servant aboard the HMS Tonnant a empted
suicide by slashing his throat. When Fleming saw the patient, it appeared that he had
exsanguinated. There was no pulse at the wrist and the pupils were dilated. I t was
possible to ligate two superior thyroid arteries and one internal jugular vein. A
laceration of the outer and muscular layers of the carotid artery was noted, as well as
a laceration of the trachea between the thyroid and cricoid cartilages. This allowed
drainage from the wound to enter the trachea, provoking violent seizures of
coughing, although the patient seemed to be improving. A pproximately 1 week
following the injury, Fleming recorded: “On the evening of the 17th, during a violent
paroxysm of coughing, the artery burst, and my poor patient was, in an instant,
15deluged with blood!”
The dilemma of the surgeon is appreciated by the following statement: “I n this
dreadful situation I concluded that there was but one step to take, with any prospect
of success; mainly, to cut down on, and tie the carotid artery below the wound. I had
never heard of such an operation being performed; but conceived that its effects
might be less formidable, in this case, than in a person not reduced by
15hemorrhage.” The wound rapidly healed following ligation of the carotid artery and
the patient recovered.
Ellis (1845) reported the astonishing experience of successful ligation of both
carotid arteries in a 21-year-old patient who sustained a gunshot wound of the neck
while he was se ing a trap in the woods in 1844, near Grand Rapids, Michigan, when
16he was unfortunately mistaken for a bear by a companion. A pproximately 1 week
later, Ellis had to ligate the patient's left carotid artery because of hemorrhage. A n
appreciation of the surgeon's problem can be gained by Ellis' description of the
operation: “We placed him on a table, and with the assistance of D r. Pla and a
student, I ligatured the left carotid artery, below the omohyoideus muscle; an
operation a ended with a good deal of difficulty, owing to the swollen state of the
parts, the necessity of keeping up pressure, the bad position of the parts owing to the
necessity of keeping the mouth in a certain position to prevent his being strangulated
16by the blood, and the necessity of operating by candle light.”
There was recurrent hemorrhage on the eleventh day after the accident, and right
carotid artery pressure helped control the blood loss. I t was, therefore, necessary also
to ligate the right carotid artery days after the left carotid artery had been ligated.
Ellis remarked: “For convenience, we had him in the si ing posture during the
operation; when we tightened the ligature, no disagreeable effects followed; no
fainting; no bad feeling about the head; and all the perceptible change was a slightpaleness, a cessation of pulsation in both temporal arteries, and of the
The patient recovered rapidly with good wound healing and returned to normal
daily activity. There was no perceptible pulsation in either superficial temporal
The importance of collateral circulation in preserving viability of the limb after
ligation was well understood for centuries, as identified by A ntyllus nearly 2000 years
9ago. The fact that time was necessary for establishment of this collateral circulation
was recognized. Halsted (1912) reported cure of an iliofemoral aneurysm by
application of an aluminum band to the proximal artery without seriously affecting
17the circulation or function of the lower extremity. A sepsis had been recognized,
and the frequency of secondary hemorrhage and gangrene following ligation
promptly decreased as an understanding of transmission of infectious disease and its
management was developed through Pasteur and Lister. Subsequently, Halsted (1912)
demonstrated the role of collateral circulation by gradually completely occluding the
aorta and other large arteries in dogs by means of silver or aluminum bands that were
18gradually tightened over a period of time.
Early Vascular Surgery
A bout 2 centuries after Paré established the use of the ligature, the first direct repair
of an injured artery was accomplished. This event more than 250 years ago is credited
as the first documented vascular repair. Hallowell, acting on a suggestion by Lambert
in 1759, repaired a wound of the brachial artery by placing a pin through the arterial
walls and holding the edges in apposition by applying a suture in a figure-of-eight
19fashion about the pin (Fig. 1-2). This technique (known as the farrier's stitch) had
been utilized by veterinarians but had fallen into disrepute following unsuccessful
experiments. Table 1-1 outlines early vascular techniques.
FIGURE 1-2 The first arterial repair performed by Hallowell,
acting on a suggestion by Lambert in 1759. The technique, known
as the farrier's (veterinarian's) stitch, was followed in repairing
the brachial artery by placing a pin through the arterial walls and
holding the edges in apposition with a suture in a figure-of-eight
fashion about the pin. (Drawn from the original description by Mr.
Lambert, Med Obser and Inq 2:30–360, 1762.)

Table 1-1
Vascular Repair Before 1900*
Technique Year Surgeon
Pin and thread 1759 Hallowell
Small ivory clamps 1883 Gluck
Fine needles and silk 1889 Jassinowsky
Continuous suture 1890 Burci
Invagination 1896 Murphy
Suture all layers 1899 Dörfler
*Adapted from Guthrie GC: Blood vessel surgery and its applications, New York, 1912,
Longmans, Green and Co.
Unfortunately, others could not duplicate Hallowell's successful experience, almost
surely because of the multiple problems of infection and lack of anesthesia. There
was one report by Broca (1762) of a successful suture of a longitudinal incision in an
20artery. However, according to S humacker (1969), an additional 127 years passed
following the Hallowell-Lambert arterial repair before a second instance of arterial
20repair of an artery by lateral suture in man was reported by Postemski in 1886.
With the combined developments of anesthesia and asepsis, several reports of
a empts to repair arteries appeared in the la er part of the 19th century. The work of
J assinowsky, who is credited in 1889 for experimentally proving that arterial wounds
could be sutured with preservation of the lumen, was later judged by Murphy in 1897
21,22as the best experimental work published at that time. I n 1865 Henry Lee of
23London a empted repair of arterial lacerations without suture. Glück in 1883
reported 19 experiments with arterial suture, but all experiments failed because of
24bleeding from the holes made by the suture needles. He also devised aluminum
and ivory clamps to unite longitudinal incisions in a vessel, and it was recorded that
the ivory clamps succeeded in one experiment on the femoral artery of a large dog.
Von Horoch of Vienna reported six experiments, including one end-to-end union, all
23of which thrombosed. I n 1889 Bruci sutured six longitudinal arteriotomies in dogs;
20the procedure was successful in four. I n 1890 Muscatello successfully sutured a
20partial transection of the abdominal aorta in a dog. I n 1894 Heidenhain closed by
catgut suture a 1-cm opening in the axillary artery made accidentally while removing
25adherent carcinomatous glands. The patient recovered without any circulatory
disturbance. I n 1883 I srael, in a discussion of a paper by Glück, described closing a
laceration in the common iliac artery created during an operation for perityphlitic
24,26abscess. The closure was accomplished by five silk sutures. However, from his
personal observations, Murphy (1897) did not believe it could be possible to have
22success in this type of arterial repair. I n 1896 S abanyeff successfully closed small
20openings in the femoral artery with sutures.
The classic studies of J .B. Murphy of Chicago (1897) contributed greatly to the

development of arterial repair and culminated in the first successful end-to-end
22anastomosis of an artery in 1896. Previously, Murphy had carefully reviewed earlier
clinical and experimental studies of arterial repair and had evaluated different
techniques extensively in laboratory studies. Murphy a empted to determine
experimentally how much artery could be removed and still allow an anastomosis. He
found that 1 inch of a calf's carotid artery could be removed and the ends still
approximated by invagination suture technique because of the elasticity of the artery.
He concluded that arterial repair could be done with safety when no more than 3/4
inch of an artery had been removed, except in certain locations such as the popliteal
fossa or the axillary, space where the limb could be moved to relieve tension on the
repair. He also concluded that when more than half of the artery was destroyed, it was
be er to perform an end-to-end anastomosis by invagination rather than to a empt
repair of the laceration. This repair was done by introducing sutures into the proximal
artery, including only the two outer coats, and using three sutures to invaginate the
proximal artery into the distal one, reinforcing the closure with an interrupted suture
22(Fig. 1-3). I n 1896 Murphy was unable to find a similar recorded case involving the
suture of an artery after complete division, and he consequently reported his
experience (1897) and carried out a number of experiments to determine the
feasibility of his procedure. Murphy's patient was a 29-year-old male shot twice with
one bullet entering the femoral triangle. The patient was admi ed to Cook County
Hospital in Chicago on S eptember 19, 1896, approximately 2 hours after wounding.
There was no hemorrhage or increased pulsation noted at the time. Murphy first saw
the patient 15 days later, October 4, 1896, and found a large bruit surrounding the site
of injury. D istal pulses were barely perceptible. When demonstrating this patient to
students 2 days later, a thrill was also detected. A n operative repair was decided on.
Because of the historical significance, the operation report is quoted:FIGURE 1-3 The first successful clinical end-to-end
anastomosis of an artery was performed in 1896. Sutures were
placed in the proximal artery, including only the few outer coats;
three sutures were used to I. (From Murphy JB: Resection of
arteries and veins injured in continuity—end-to-end
sutureexperimental clinical research. Med Record 51:73, 1897.)
Operation, October 7, 1896. An incision five inches long was made from Poupart's
ligament along the course of the femoral artery. The artery was readily exposed about
one inch above Poupart's ligament; it was separated from its sheath and a provisional
ligature thrown about it but not tied. A careful dissection was then made down along
the wall of the vessel to the pulsating clot. The artery was exposed to one inch belowthe point and a ligature thrown around it but not tied: a careful dissection was made
upward to the point of the clot. The artery was then closed above and below with gentle
compression clamps and was elevated, at which time there was a profuse hemorrhage
from an opening in the vein. A cavity, about the size of a filbert, was found posterior to
the artery communicating with its caliber, the aneurysmal pocket. A small aneurysmal
sac about the same size was found on the anterior surface of the artery over the point
of perforation. The hemorrhage from the vein was very profuse and was controlled by
digital compression. It was found that one-eighth of an inch of the arterial wall on the
outer side of the opening remained, and on the inner side of the perforation only a
band of one-sixteenth of an inch of adventitia was intact. The bullet had passed
through the center of the artery, carried away all of its wall except the strands
described above, and passed downward and backward making a large hole in the vein
in its posterior and external side just above the junction of the vena profunda. Great
difficulty was experienced in controlling the hemorrhage from the vein. After dissecting
the vein above and below the point of laceration and placing a temporary ligature on
the vena profunda, the hemorrhage was controlled so that the vein could be sutured. At
the point of suture the vein was greatly diminished in size, but when the clamps were
removed it dilated about one-third the normal diameter or one-third the diameter of the
vein above and below. There was no bleeding from the vein when the clamps were
removed. Our attention was then turned to the artery. Two inches of it had been
exposed and freed from all surroundings. The opening in the artery was three-eighths
of an inch in length; one-half inch was resected and the proximal was invaginated into
the distal for one-third of an inch with four double needle threads which penetrated all
of the walls of the artery. The adventitia was peeled off the invaginated portion for a
distance of one-third of an inch: a row of sutures was placed around the edge of the
overlapping distal end, the sutures penetrating only the media of the proximal portion;
the adventitia was then brought over the end of the union and sutured. The clamps
were removed. Not a drop of blood escaped at the line of suture. Pulsation was
immediately restored in the artery below the line of approximation and it could be felt
feebly in the posterior tibial and dorsalis pedis pulses. The sheath and connective
tissue around the artery were then approximated at the position of the suture with
catgut, so as to support the wall of the artery. The whole cavity was washed out with a
five percent solution of carbolic acid and the edges of the wound were accurately
approximated with silk worm-gut sutures. No drainage. The time of the operation was
approximately two and one-half hours, most of the time being consumed in suturing
the vein. The artery was easily secured and sutured, and the hemorrhage from it
readily controlled. The patient was placed in bed with the leg elevated and wrapped in
The anatomic location of the injuries, the gross pathology involved, and the
detailed repair contributed to Murphy's historically successful arterial anastomosis.
Murphy mentioned that a pulsation could be felt in the dorsalis pedis artery 4 days
following the operation. The patient had no edema and no disturbance of his
22circulation during the reported 3 months of observation.
S ubsequently, Murphy (1897) reviewed the results of ligature of large arteries
22before the turn of the century. He found that the abdominal aorta had been ligated
10 times with only 1 patient surviving for 10 days. Lidell reported only 16 recoveries
20after ligation of the common iliac artery 68 times, a mortality of 77%. Balance and
Edmunds reported a 40% mortality following ligation of a femoral artery aneurysm in
31 patients. Billroth reported secondary hemorrhage from 50%% of large arteries
ligated in continuity. Wyeth collected 106 cases of carotid artery aneurysms treated byproximal ligation, with a mortality rate of 35%.
I n 1897 Murphy summarized techniques he considered necessary for arterial
suture. They bore a close resemblance to principles generally followed today:
1. Complete asepsis
2. Exposure of the vessel with as little injury as possible
3. Temporary suppression of the blood current
4. Control of the vessel while applying the suture
5. Accurate approximation of the walls
6. Perfect hemostasis by pressure after the clamps are taken off
7. Toilet of the wound
Murphy also reported that Billroth, S chede, Braun, S chmidt, and others had
22successfully sutured wounds in veins. He personally had used five silk sutures to
close an opening 3/8-inch long in the common jugular vein.
S everal significant accomplishments occurred in vascular surgery within the next
few years. I n 1903 Matas described his endoaneurysmorrhaphy technique, which
27remained the standard technique for aneurysms for over 40 years. I n 1906 Carrel
and Guthrie performed classic experimental studies over a period of time with many
28significant results. These included direct suture repair of arteries, vein
transplantation, and transplantation of blood vessels as well as organs and limbs. I n
141912 Guthrie independently published his continuing work on vascular surgery.
Following Murphy's successful case in 1896, the next successful repair of an arterial
defect came 10 years later when Goyanes used a vein graft to bridge an arterial defect
22,29in 1906. Working in Madrid, Goyanes excised a popliteal artery aneurysm and
29used the accompanying popliteal vein to restore continuity (Fig. 1-4). He used the
suture technique developed by Carrel and Guthrie of triangulating the arterial orifice
with three sutures, followed by continuous suture between each of the three areas. A
year later in 1907, Lexer in Germany first used the saphenous vein as an arterial
29substitute to restore continuity after excision of an aneurysm of the axillary artery.
I n his 1969 review, S humacker commented that within the first few years of the 20th
century the triangulation stitch of Carrel (1902), the quadrangulation method of
20Frouin (1908), and the Mourin modification (1914) had been developed.

FIGURE 1-4 The first successful repair of an arterial defect
utilizing a vein graft. Using the triangulation technique of Carrel
with endothelial coaptation, a segment of the adjacent popliteal
vein was used to repair the popliteal artery. A, Artery; V, vein; g,
graft. (From Goyanes DJ: Nuevos trabajos chirugia vascular. El
Siglo Med 53:561, 1906.)
By 1910 S tich had reported more than 100 cases of arterial reconstruction by lateral
30suture. His review included 46 repairs, either by end-to-end anastomosis or by
31insertion of a vein graft. With this promising start, it is curious that over 30 years
elapsed before vascular surgery was widely employed. A high failure rate, usually by
thrombosis, a ended early a empts at repair; and few surgeons were convinced that
repair of an artery was worthwhile. I n 1913 Matas stated that vascular injuries,
particularly arteriovenous aneurysms, had become conspicuous features of modern
military surgery; and he felt that this class of injury must command the closest
a ention of the modern military surgeon: “A most timely and valuable contribution
to the surgery of blood vessels resulted from wounds in war. Unusual opportunities
for the observation of vascular wounds inflicted with modern military weapons . . .
based on material fresh from the field of action, and fully confirmed the belief that
this last war, waged in close proximity to well-equipped surgical centers, would also
offer an unusual opportunity for the study of the most advanced methods of treating
27injuries of blood vessels.”

Matas described S oubbotitch's experience of S erbian military surgery during the
S erbo-Turkish and S erbo-Bulgarian Wars at the 1913 London I nternational
27Congress. He reported that 77 false aneurysms and arteriovenous fistulas were
treated. There were 45 ligations; but 32 vessels were repaired, including 19
arteriorrhaphies, 13 venorrhaphies, and 15 end-to-end anastomoses (11 arteries and 4
veins). I t is impressive that infection and secondary hemorrhage were avoided. I n
1915 Matas, in discussing S oubbotitch's report, emphasized that a notable feature was
the suture (circular and lateral repair) of blood vessels and the fact that it had been
27utilized more frequently in the Balkan conflict than in previous wars. He also noted
that, judging by S oubbotitch's statistics, the success obtained by surgeons in the
S erbian A rmy Hospital in Belgrade far surpassed those obtained by other military
surgeons in previous wars, with the exception perhaps of the remarkably favorable
results in the Japanese Reserve Hospitals reported by Kikuzi.
World War I Experience
D uring the early part of World War I , with the new techniques of vascular surgery
well established, the German surgeons a empted repair of acutely injured arteries
31and were successful in more than 100 cases. D uring the first 9 months of World
War I , low-velocity missiles caused arterial trauma of a limited extent. I n 1915,
however, the widespread use of high explosives and high-velocity bullets, combined
with mass casualties and slow evacuation of the wounded, made arterial repair
I n 1920 Bernheim went to France with the specific intent of repairing arterial
32injuries. D espite extensive prior experience and equipment, however, he concluded
that a empts at vascular repair were unwise. He wrote: “Opportunities for carrying
out the more modern procedures for repair or reconstruction of damaged blood
vessels were conspicuous by their absence during the recent military activities. N ot
that blood vessels were immune from injury; not that gaping arteries and veins and
vicariously united vessels did not cry out for relief by fine suture or anastomosis.
They did, most eloquently, and in great numbers, but he would have been a foolhardy
man who would have essayed sutures of arterial or venous trunks in the presence of
32such infections as were the rule in practically all of the battle wounded.”
The great frequency of infection with secondary hemorrhage virtually precluded
arterial repair. I n addition, there were inadequate statistics about the frequency of
gangrene following ligation, and initial reports subsequently proved to be unduly
optimistic. I n 1927 Poole, in the Medical D epartment History of World War I ,
remarked that if gangrene were a danger following arterial ligation, primary suture
should be performed and the patient should be watched very carefully.
D espite the discouragement of managing acute arterial injuries in World War I ,
fairly frequent repairs of false aneurysms and arteriovenous fistulas were carried out
by many surgeons. These cases were treated after the acute period of injury, when
collateral circulation had developed with the passage of time and assured viability of
extremities. I n 1921 Matas recorded that the majority of these repairs consisted of
arteriorrhaphy by lateral or circular suture, with excision of the sac or
I n 1919 Makins, who served in World War I as a British surgeon, recommended
34ligating the concomitant vein when it was necessary to ligate a major artery. He

thought that this reduced the frequency of gangrene by retaining within the limb for
a longer period the small amount of blood supplied by the collateral circulation. This
hypothesis was debated for more than 20 years before it was finally abandoned.
Payr in 1900, Carrel, and the French surgeon Tuffier described temporary arterial
anastomoses with silver and glass tubes that were inserted with some success by
Makins and other WWI military surgeons, but patency was limited to 4 days merely
20,34allowing some collateral development.
World War II Experience
Experiences with vascular surgery in World War I I are well recorded in the review by
3D eBakey and S imeone in1946, analyzing 2471 arterial injuries. A lmost all were
treated by ligation, with a subsequent amputation rate near 49%. There were only 81
repairs a empted—78 by lateral suture and 3 by end-to-end anastomosis—with an
amputation rate of approximately 35%. The use of vein grafts was even more
disappointing; they were a empted in 40 cases with an amputation rate of nearly
The controversial question of ligation of the concomitant vein remained, though
few observers were convinced that the procedure enhanced circulation. The varying
35opinions were summarized by Linton in 1949.
A refreshing exception to the dismal World War I I experience in regard to ligation
and gangrene was the case operated on by D r. A llen M. Boyden—an acute
arteriovenous fistula of the femoral vessels repaired shortly after D -D ay in
The following comments are taken by Boyden from his own original field notes
(approximately 26 years later in 1970) and emphasize the value of adequate records,
even in military combat:
“High explosive wound left groin, 14 June 1944, at 2200 hours. Acute arteriovenous
aneurysm femoral artery.
Preoperative blood pressure 140-70; pulse 104.
Operation: 16 June 1944, nitrous oxide and oxygen.
Operation: 1910 to 22 hours.
One unit of blood transfused during the opera-tion.
Arteriovenous aneurysms isolated near junction with profunda femoris artery.
Considerable hemorrhage.
Openings in both artery and vein were sutured with fine silk.
Postoperative blood pressure 120-68; pulse 118. Circulation of the extremity remained
until evacuation.”
A s this case demonstrated Boyden's interest in vascular surgery, the Consulting
S urgeon for the First A rmy presented him with half of the la er's supply of vascular
instruments and material. This supply consisted of two sets of Blakemore (Vitallium)
tubes, two bulldog forceps, and a 2-mL ampoule of heparin!
The conclusion that ligation was the treatment of choice for an injured artery was
summarized by D eBakey and S imeone in 1946: “I t is clear that no procedure other
than ligation is applicable to the majority of vascular injuries which come under the
military surgeons' observation. I t is not a procedure of choice. I t is a procedure of
stern necessity, for the basic purpose of controlling hemorrhage, as well as because of
3the location, type, size and character of most battle injuries of the arteries.”
In retrospect it should be remembered that the average time lag between wounding
and surgical treatment was over 10 hours in World War I I , virtually precluding
successful arterial repair in most patients. Of historical interest is the nonsuture
method of arterial repair used during World War II (Fig. 1-5).