CLINICAL OUTCOMES AND AN ALGORITHM FOR SOFT-TISSUE COVERAGE AFTER ARTERIAL RECONSTRUCTION IN COMBAT-RELATED EXTREMITY VASCULAR INJURIES

Iurii  Sivash; Kostyantyn  Gumeniuk

doi:10.21272/eumj.2026;14(2);574-583

Iurii Sivash National Military Medical Clinical Center “Main Military Clinical Hospital”, Kyiv, Ukraine; Bogomolets National Medical University, Kyiv, Ukraine https://orcid.org/0000-0002-7956-6378
Kostyantyn Gumeniuk National Military Medical Clinical Center “Main Military Clinical Hospital”, Kyiv, Ukraine; Medical Forces Command of the Armed Forces of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0001-8892-4061

DOI: https://doi.org/10.21272/eumj.2026;14(2);574-583

Keywords: combat vascular trauma; negative pressure wound therapy; arterial injury; hemorrhage; soft-tissue defects; war in Ukraine

Abstract

Introduction. Extremity vascular injuries represent one of the most challenging forms of combat trauma due to the combination of acute limb ischemia, extensive soft-tissue destruction, and a high risk of infectious and hemorrhagic complications. Adequate soft-tissue coverage of the arterial reconstruction zone is therefore a critical factor in preventing postoperative complications. However, clear criteria for selecting the optimal reconstructive strategy remain insufficiently defined.

Objective. To evaluate the clinical outcomes of different methods of soft-tissue defect closure in the area of arterial reconstruction after combat vascular trauma and to develop an algorithm for selecting the optimal coverage strategy based on defect size and the risk of postoperative complications.

Methods. A retrospective analysis was performed on 85 servicemen with combat-related injuries to major extremity vessels treated at the Clinic of Vascular Surgery of the National Military Medical Clinical Center “Main Military Clinical Hospital” (Kyiv) in 2022. NPWT was used in 69 patients (81.2%) as a preparatory stage before definitive wound closure. Definitive closure techniques included primary closure, split-thickness skin grafting (STSG), flap coverage, or secondary healing. The incidence of erosive bleeding, reconstruction thrombosis, and secondary amputations was assessed, along with the timing of complications, defect size, and the number of NPWT sessions.

Results. Primary closure was performed in 64 cases (75.3%), STSG in 14 (16.5%), flap coverage in 4 (4.7%), and secondary healing in 3 (3.5%). Erosive bleeding occurred in 9 patients (13.0%) with a median onset of 18 days (range 6–29 days). Two periods of increased risk were identified: days 7–10 (predominantly mechanical factors) and days 18–30 (infection-related tissue necrosis). Thrombosis of vascular reconstruction occurred in 6 patients (8.7%), all following primary closure. Secondary amputations were performed in 2 cases (2.9%). The mean defect size was approximately 15 × 20 cm in patients with erosive bleeding and 8 × 9 cm in those with thrombosis. The maximal linear dimension of the defect was used for stratification of surgical strategy. Among patients treated with NPWT, the number of sessions was higher in those who developed erosive bleeding (6–7 vs 2–3 in patients without bleeding).

Conclusions. The size of the soft-tissue defect in the arterial reconstruction zone is a key determinant of postoperative complications and should guide the choice of definitive wound closure. Large defects (>15 cm) are associated with an increased risk of erosive bleeding, whereas primary closure in smaller defects may predispose to reconstruction thrombosis. Early stable vascularized soft-tissue coverage represents a pathogenetically justified preventive strategy in patients with extensive contaminated wounds. The proposed algorithm may assist in selecting the optimal reconstructive strategy in combat-related extremity vascular injuries

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References

White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg. 2011 Jun;253(6):1184–9. https://doi.org/10.1097/SLA.0b013e31820752e3.

Chandler H, MacLeod K, Penn-Barwell JG, Bennett PM, Fries CA, Kendrew JM, et al. Extremity injuries sustained by the UK military in the Iraq and Afghanistan conflicts: 2003–2014. Injury. 2017 Jul;48(7):1439–43. https://doi.org/10.1016/j.injury.2017.05.022.

Ran Y, Mitchnik I, Gendler S, Avital G, Radomislensky I, Bodas M, et al. Isolated limb fractures – the underestimated injury in the Israeli Defense Forces (IDF). Injury. 2023 Feb;54(2):490–6. https://doi.org/10.1016/j.injury.2022.11.014.

Klausner MJ, McKay JT, Bebarta VS, Naylor JF, Fisher AD, Isherwood KD, et al. Warfighter personal protective equipment and combat wounds. Med J Fort Sam Houst Tex. 2021; PB 8-21-04/05/06:72–7.

Clouse WD, Rasmussen TE, Peck MA, Eliason JL, Cox MW, Bowser AN, et al. In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg. 2007 Apr;204(4):625–32. https://doi.org/10.1016/j.jamcollsurg.2007.01.040.

Brown KV, Ramasamy A, Tai N, MacLeod J, Midwinter M, Clasper JC. Complications of extremity vascular injuries in conflict. J Trauma. 2009 Apr;66(4 Suppl): S145–9. https://doi.org/10.1097/TA.0b013e31819cdd82.

Murray CK, Hsu JR, Solomkin JS, Keeling JJ, Andersen RC, Ficke JR, Calhoun JH. Prevention and management of infections associated with combat-related extremity injuries. J Trauma [Internet]. 2008 Mar [cited 2025 Sep 10];64(Supplement):S239—S251: https://doi.org/10.1097/ta.0b013e318163cd14.

Hinck D, Franke A, Gatzka F. Use of vacuum-assisted closure negative pressure wound therapy in combat-related injuries. Mil Med. 2010 Mar;175(3):173–81. https://doi.org/10.7205/MILMED-D-09-00075.

Maurya S, Bhandari PS. Negative pressure wound therapy in the management of combat wounds: a critical review. Adv Wound Care. 2016 Sep;5(9):379–89. https://doi.org/10.1089/wound.2014.0624.

Huang C, Leavitt T, Bayer LR, Orgill DP. Effect of negative pressure wound therapy on wound healing. Curr Probl Surg. 2014 Jul;51(7):301–31. https://doi.org/10.1067/j.cpsurg.2014.04.001.

Krug E, Berg L, Lee C, Hudson D, Birke-Sorensen H, Depoorter M, et al. Evidence-based recommendations for the use of negative pressure wound therapy in traumatic wounds and reconstructive surgery: steps toward an international consensus. Injury. 2011 Feb;42 Suppl 1:S1–12. https://doi.org/10.1016/S0020-1383(11)00041-6.

Chakfé N, Diener H, Lejay A, Assadian O, Berard X, Caillon J, et al. European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of vascular graft and endograft infections. Eur J Vasc Endovasc Surg. 2020 Mar;59(3):339–84. https://doi.org/10.1016/j.ejvs.2019.10.016.

Dosluoglu HH, Loghmanee C, Lall P, Cherr GS, Harris LM, Dryjski ML. Management of early (<30 day) vascular groin infections using vacuum-assisted closure alone without muscle flap coverage in a consecutive patient series. J Vasc Surg. 2010;51(5):1160-1166. https://doi.org/10.1016/j.jvs.2009.11.053.

Matatov T, Reddy KN, Doucet LD, Zhao CX, Zhang WW. Experience with a new negative pressure incision management system in prevention of groin wound infection in vascular surgery patients. J Vasc Surg. 2013 Mar;57(3):791–5. https://doi.org/10.1016/j.jvs.2012.09.037.

Fox CJ, Gillespie DL, O’Donnell SD, Rasmussen TE, Goff JM, Johnson CA, Galgon RE, Sarac TP, Rich NM. Contemporary management of wartime vascular trauma. J Vasc Surg [Internet]. 2005 Apr [cited 2025 Sep 10];41(4):638-44. https://doi.org/10.1016/j.jvs.2005.01.010.

Tribble DR, Conger NG, Fraser S, Gleeson TD, Wilkins K, Antonille T, et al. Infection-associated clinical outcomes in hospitalized medical evacuees after traumatic injury: Trauma Infectious Disease Outcome Study. J Trauma. 2011 Jul;71(Suppl 1):S33–S42. https://doi.org/10.1097/TA.0b013e318221162e.