Experience of treating gunshot wounds of large vessels in Afghanistan.

The problem of treating injuries of large vessels in times of peace has been sufficiently well developed both in theoretical and practical aspects. In times of war, however, due to the large numbers of the wounded, a shortage of expert angiosurgeons, and multiple gunshot wounds, many theoretical tenets lose their academic regularity. The present study is based on the experience of treating 302 patients wounded during the Afghanistan war (1981-1985). Most of the injuries were to the vessels of the extremities. The gunshot wounds were complex. They included extensive destruction of tissue in the damaged segments of the extremities with simultaneous damage of large veins (42.0% of the cases), nerves (45.5%), and bones (47.4%). Multiple-vessel injuries were encountered in 4% of the cases, with combined injuries comprising 17.5%. Most of the wounded (83.7%) were in a state of shock, with 6.4% in a terminal condition. The blood loss amounted to 15% to 65% of the total volume. Ninety percent of the wounded were admitted to hospitals in the first 6 hours. A two-stage method was used to treat 71 of the wounded. The method included temporary bypass of the injured arteries and veins while evacuating the wounded and during surgery. Two hundred ninety-five wounded underwent vessel surgery. Out of the total number of injuries of arteries and veins, vessel sutures were used in 36.9% and 35.9% of the cases, vessel plastics in 41.4% and 7.1% of the cases, and vessel ligation in 21.7% and 60.0% of the cases, respectively. Surgery was completed by fixing the bone fragments externally with the help of special devices using the Ilizarov method. Amputation was performed in 13.9% of the cases. In 7.3% of the cases amputation was performed according to primary indications (no reconstructive surgery attempted on the vessels). In 6.6% of the cases extremities were amputated during the early postoperative period as a result of vessel thrombosis and an increase of tissue ischemia. The mortality rate after vessel surgery was 5.3%. We believe that for patients with gunshot wounds involving vessel injuries, early one-time reconstruction of the destroyed anatomical structures should be performed.