SPECIAL REPORT Management and Outcomes of Major Extremity Vascular Injuries in Armed Conflict: Challenges and Experience from Ukraine

Abstract

Introduction: Extremity vascular injuries constitute the majority of combat vascular trauma and present a complex management challenge due to hemorrhage, ischemia, and associated musculoskeletal destruction.
Methods: This is a retrospective multicenter review of 900 consecutive cases treated at Level II–IV military and civilian referral centers between 2022 and 2024. Major vascular injury was defined as injury to a named extremity vessel causing ischemia, major hemorrhage, or requiring operative vascular intervention.
Results: Femoral–popliteal injuries accounted for 689/900 of the cases (76.6%). Combined arterial–venous injuries were present in 490/900 (54.4%). Complex trauma with bone, nerve, or combined trauma occurred in 711/900 (79.0%). Massive soft-tissue destruction occurred in 776/900 (86.3%). Interventions included vascular reconstructions (15.0%), temporary shunts (5.3%), and fasciotomies (35.8%). Primary amputation rate was 8.3% (75/900) and the secondary rate was 15.6% (140/900), yielding a 23.9% overall amputation rate, primarily driven by massive blast-induced soft-tissue destruction. Mortality was 1.7% (15/900). Chronic arterial insufficiency (17.7%) and thrombosis (13.7%) occurred long term.
Conclusion: Modern combat extremity injuries highlight persistent limb-salvage challenges. Decreasing time to reperfusion is crucial. Key recommendations include: protocolization of damage-control strategies with clear indications for temporary shunts and fasciotomy; preferential use of autologous conduits in contaminated wounds; and early, aggressive soft-tissue management and infection control to reduce secondary amputations.