In-Theater Management of Vascular Injury: 2 Years of the Balad Vascular Registry LT COL W Darrin Clouse, MD, FACS, LT COL Todd E Rasmussen, MD, FACS, MAJ Michael A Peck, MD, MAJ Jonathan L Eliason, MD, MAJ Mitchell W Cox, MD, MAJ Andrew N Bowser, MD, COL Donald H Jenkins, MD, FACS, COL David L Smith, MD, FACS, COL (RET) Norman M Rich, MD, FACS BACKGROUND: Wartime vascular injury management has traditionally advanced vascular surgery. Despite past military experience, and recent civilian publications, there are no reports detailing current in-theater treatment. The objective of this analysis is to describe the management of vascular injury at the central echelon III surgical facility in Iraq, and to place this experience in perspec- tive with past conflicts. STUDY DESIGN: Vascular injuries evaluated at our facility between September 1, 2004 and August 31, 2006 were prospectively entered into a registry and reviewed. RESULTS: During this 24-month period, 6,801 battle-related casualties were assessed. Three hundred twenty-four (4.8%) were diagnosed with 347 vascular injuries. Extremity injuries accounted for 260 (74.9%). Vascular injuries in the neck (n = 56; 16.1%) and thoracoabdominal domain (n = 31; 8.9%) were less common. US forces accounted for 149 casualties (46%), 97 (30%) were local civilian, and 78 (24%) were Iraqi forces. One hundred seven (33%) patients with vascular injury were evacuated from forward locations after treatment initiation. Fifty-four (50%) of these had temporary shunts placed. Of 43 proximal shunts placed in-field, 37 (86%) were patent at the time of our assessment. Early amputation rate was 6.6% for those extremity injuries treated for limb salvage. Perioperative mortality was 4.3%. CONCLUSIONS: This evaluation represents the first in-theater report of wartime vascular injury since Vietnam. Extremity injuries continue to predominate, although the incidence of vascular injury appears to be somewhat increased. Local forces and civilians now represent a substantial proportion of those injured. The principles of rapid evacuation, temporary shunting, and early reconstruction are effective, with satisfactory early in-theater limb salvage. (J Am Coll Surg 2007;204: 625–632. © 2007 by the American College of Surgeons) Our understanding of vascular injury has been intri- cately related to experience obtained during wartime. The injured military casualty has provided substantial impetus for scientific and clinical advancement because of both the desire to improve outcomes and the unfor- tunate high volume with which this care can become necessary. Consequently, from use of routine ligation and amputation in World War II, through to rapid evac- uation and successful use of in-theater autogenous re- construction during the Korean and Vietnam Wars, these labors have provided models for revascularization and limb salvage in vascular injury. 1-8 Recent missions in support of Operation Iraqi Free- dom (OIF) represent the first expanded US military conflict since Vietnam where reappraisal of established, modern-day vascular practices can occur. Although we have descriptions of definitive care required at Level V Military Treatment Facilities in the US on casualty ar- rival after evacuation, 9 there have been no systematic, Competing Interests Declared: None. This article represents the personal viewpoints of the authors and cannot be construed as a statement of Department of Defense or US Government policy. Presented at the American College of Surgeons 92 nd Annual Clinical Con- gress, Chicago, IL, October 2006. Received October 6, 2006; Revised January 8, 2007; Accepted January 17, 2007. From the 332 nd Expeditionary Medical Group, Air Force Theater Hospital, Balad Air Base, Iraq (Clouse, Rasmussen, Peck, Eliason, Cox, Bowser, Jenkins, Smith); Wilford Hall US Air Force Medical Center, Lackland Air Force Base, TX (Clouse, Rasmussen, Peck, Eliason, Cox, Bowser, Jenkins, Smith); and the Norman M Rich Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD (Clouse, Rasmussen, Peck, Eliason, Cox, Bowser, Jenkins, Smith, Rich). Correspondence address: Lt Col W Darrin Clouse, MD, FACS, Division of Vascular and Endovascular Surgery, Wilford Hall US Air Force Medical Cen- ter, 2200 Bergquist Dr, Ste 1, Lackland AFB, TX 78236-5200. email: william.clouse@lackland.af.mil; william.clouse@blab.centaf.af.mil 625 © 2007 by the American College of Surgeons ISSN 1072-7515/07/$32.00 Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2007.01.040