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Rich’s Vascular Trauma
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Rich’s Vascular
Trauma
FOURTH EDITION

Todd E. Rasmussen, MD, FACS

Colonel (Ret.) USAF MC
Professor of Surgery and Senior Associate Consultant
Division of Vascular and Endovascular Surgery
Mayo Clinic
Rochester, Minnesota

Nigel R.M. Tai, MB, BS, MS, FRCS

Colonel, Late RAMC
Consultant Trauma & Vascular Surgeon
Royal Centre for Defence Medicine (Research & Clinical Innovation)
HQ Defence Medical Services
Birmingham, United Kingdom;
Vascular Clinical Lead
Barts Health NHS Trust
London, United Kingdom
Elsevier
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RICH’S VASCULAR TRAUMA, FOURTH EDITION ISBN: 978-0-323-69766-8

Copyright © 2022, by Elsevier Inc. All Rights Reserved.

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Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1


Christopher Aylwin, MBBS, MA, FRCS
Consultant Vascular and Trauma Surgeon
Major Trauma Centre
Imperial College Healthcare NHS Trust
London, United Kingdom
List o­f C­on­tributors
Ravi Chauhan, FRCA, FCAI, MBChB, Dip IMC, RCSEd
Intensive Care and Anaesthesia Consultant
Intensive Care
Royal Centre of Defence Medicine
Birmingham, United Kingdom

Ed B.G. Barnard, BM, BS, BMedSci(Hons), PhD, FRCEM, Kenneth J. Cherry, MD

FIMC, RCSEd Edwin P. Lehman Professor of Surgery
Senior Lecturer Emeritus University of Virginia Medical Center
Academic Department of Military Emergency Medicine Charlottesville, Virginia;
Royal Centre for Defence Medicine (Research & Clinical Consultant, Sentara Vascular Specialists Sentara
Innovation) Norfolk General Hospital Eastern Virginia Medical
Birmingham, United Kingdom; School
Honorary Consultant in Emergency Medicine Norfolk, Virginia
Cambridge University Hospitals NHS Foundation Trust
Cambridge, United Kingdom Kevin K. Chung, MD
Professor and Chair
Andriy I. Batchinsky Department of Medicine
Director, Autonomous Reanimation and Evacuation Uniformed Services University of the Health Sciences
Program Bethesda, Maryland
Brooks City Base
San Antonio, Texas;
Senior Principal Investigator Ian D. Civil, MBChB, FRACS, FACS
Director of Trauma Services
The Geneva Foundation
Auckland City Hospital
Tacoma, Washington;
Auckland, New Zealand
Manager, Extracorporeal Life Support Capability Area
U.S. Army Institute of Surgical Research
Battlefield Health and Trauma Research Institute Jon Clasper, CBE, DSc, DPhil, DM, LLM,
Fort Sam Houston, Texas FRCSEd(Orth)
Professor Emeritus & Consultant Orthopaedic Surgeon
Kenneth Boffard, MB, BCh, FRCS, FRCS(Edin), Visiting Professor in Bioengineering
FRCPS(Glas), FCS(SA), FACS Imperial College London;
Professor Emeritus Clinical Lead
Department of Surgery The Royal British Legion Centre for Blast Injury Studies
University of the Witwatersrand London, United Kingdom
Johannesburg, South Africa;
Professor and Academic Head William Darrin Clouse, MD
Trauma and Critical Care Professor of Surgery
Milpark Academic Trauma Centre Chief, Division of Vascular & Endovascular Surgery
Johannesburg, South Africa University of Virginia
Charlottesville, Virginia
Jeremy W. Cannon, MD
Associate Professor of Surgery Lazar B. Davidovic, MD, PhD, FETCS
Department of Surgery Head of the Clinic
Perelman School of Medicine at the University of Clinic for Vascular and Endovascular Surgery
Pennsylvania Clinical Center of Serbia
Philadelphia, Pennsylvania; Belgrade, Serbia;
Adjunct Associate Professor of Surgery Full Professor of Vascular Surgery
Department of Surgery Faculty of Medicine
Uniformed Services University of the Health Sciences University of Belgrade
Bethesda, Maryland Belgrade, Serbia

v
vi List o­f C­on­tributors

David L. Dawson, MD Elon Glassberg, MD, MHA, MBA

Clinical Professor Medical Corps Israeli Defense Forces
Texas A&M University Bar-Ilan University Faculty of Medicine
Temple, Texas; Safed
Vascular Surgeon Israel
Baylor Scott & White Health The Uniformed Services University of the Health
Temple, Texas Sciences
Bethesda, Maryland
Demetrios Demetriades, MD, PhD, FACS
Professor of Surgery Peter Gogalniceanu, MEd, FRCS
University of Southern California Senior Surgical Registrar
Los Angeles, California Departments of Trauma and Vascular Surgery
The Royal London Hospital
London, United Kingdom
Joseph J. Dubose, MD, Col, MC, USAF
Professor of Surgery Matthew A. Goldshore
University of Maryland School of Medicine Department of Surgery
Baltimore, Maryland; Perelman School of Medicine at the University of
Director, C-STARS Pennsylvania
R Adams Cowley Shock Trauma Center
Philadelphia, Pennsylvania
University of Maryland Medical Center
Baltimore, Maryland
Eitan Heldenberg, MD
Head Department of Vascular Surgery
Philip M. Edmundson, MD Hillel Yaffe Medical Center
Division of Trauma and Emergency Surgery Hadera, Israel
UT Health San Antonio
San Antonio, Texas Joseph A. Herrold, MD, MPH
Assistant Professor
Timothy Fabian, MD R Adams Cowley Shock Trauma Center
Professor Emeritus Baltimore, Maryland
University of Tennessee Health Science Center
Memphis, Tennessee Shehan Hettiaratchy, MA, DM,
FRCS(Plast)
David V. Feliciano, MD Lead Surgeon
Clinical Professor Imperial College Healthcare NHS Trust
Department of Surgery St Mary’s Hospital
University of Maryland School of Medicine London, United Kingdom
Baltimore, Maryland;
Attending Surgeon Tal M. Hörer, MD, PhD
Shock Trauma Center Associate Professor Surgery
University of Maryland Medical Center Department of Cardiothoracic and Vascular
Baltimore, Maryland Surgery
Örebro University Hospital and Univeristy
Faculty of Life Sceince
Charles James Fox, MD Örebro, Sweden
Associate Professor of Surgery
Baltimore Shock Trauma Center Division of Vascular Kenji Inaba, MD, FACS
Surgery Professor of Surgery
University of Maryland School of Medicine University of Southern California
Baltimore, Maryland Los Angeles, California

Michaela Gaffley, MD Robert H. James, BSc, FRCEM, FIMC, RCSEd, RAF

General Surgery Resident Consultant in Emergency Medicine & Pre-hospital
Wake Forest University School of Medicine Emergency Medicine
Winston-Salem, NC, United States JHG(SW), University Hospitals Plymouth & Devon Air
Ambulance;
Shaun M. Gifford, MD, MS, RPVI Honorary Lecturer in Military Emergency Medicine and
Chief, Vascular Surgery Pre-hospital
David Grant Medical Center Retrieval and Transfer Medicine
Travis Air Force Base Royal Centre for Defence Medicine & University of Plymouth
California Devon, United Kingdom
 List o­f C­on­tributors vii

Jan O. Jansen, MBBS, PhD Clinic for Vascular and Endovascular

Center for Injury Sciences, Department of Surgery Surgery
University of Alabama at Birmingham Clinical Center of Serbia
Birmingham, Alabama Belgrade, Serbia

Donald H. Jenkins, MD Ernest E. Moore, MD

Professor of Surgery, Division of Trauma and Emergency Distinguished Professor and Vice Chair
Surgery for Research
UT Health San Antonio University of Colorado Denver
San Antonio, Texas; Denver, Colorado;
Betty and Bob Kelso Distinguished Chair in Burn and Director of Research
Trauma Surgery Surgery
Division of Trauma and Emergency Surgery Ernest E Moore Trauma Shock Center
Associate Deputy Director, Military Health Institute Denver, Colorado
Division of Trauma and Emergency Surgery
UT Health San Antonio Laura J. Moore, MD
San Antonio, Texas Professor of Surgery & Chief of Surgical
Critical Care
Michael Jenkins, BSc, MS, FRCS, FRCS, FEBVS The University of Texas McGovern
Consultant Vascular Surgeon Medical School
Regional Vascular Unit Houston, Texas;
Imperial College Medical Director
Healthcare NHS Trust Shock Trauma Intensive Care Unit
London, United Kingdom The Red Duke Trauma Institute
Memorial Hermann Hospital—Texas Medical
David S. Kauvar, MD, MPH Center
Vascular Surgery Service Houston, Texas
Brooke Army Medical Center
Fort Sam Houston, Texas;
Associate Professor Jonathan J. Morrison, PhD, FRCS, FEBVS, FACS
Department of Surgery Assistant Professor and Chief of Endovascular
Uniformed Services University of the Health Sciences Surgery
Bethesda, Maryland R Adams Cowley Shock Trauma
University of Maryland
Alexander Kersey, MD Baltimore, Maryland
General Surgery Resident
Walter Reed National Military Medical Center Sanjeewa Heman Munasinghe, RWP, RSP,VSV, USP,
Bethesda, Maryland MBBS, MD, FSLCR
Secretary to the Ministry of Health and Indigenous
Alexis Lauria, MD Medical Services
General Surgery Resident Colombo, Sri Lanka;
Walter Reed National Military Medical Center Consultant Radiologist
Bethesda, Maryland Army Hospital
Colombo, Sri Lanka
Gregory A. Magee, MD, MSc
Assistant Professor of Surgery Rossi Murilo, superior, mestrado
Department of Surgery Professor of Surgery
University of Southern California University of Valença School of Medicine
Los Angeles, California Valença–UNIFAA
Rio de Janeiro, Brazil;
Director Executive of FES
James E. Manning, MD State Health Foundation
Professor of Emergency Medicine (Ret.) Rio de Janeiro, Brazil;
Emergency Medicine Master’s
University of North Carolina Vascular Surgery UFRJ (Federal University of Rio de
Chapel Hill, North Carolina Janeiro)
Rio de Janeiro, Brazil
Miroslav Markovic, MD, PhD, FETCS, FIUA
Professor of Surgery David M. Nott
Faculty of Medicine Consultant Vascular and Trauma Surgeon
University of Belgrade Regional Vascular Unit and Major Trauma Centre
Belgrade, Serbia; Imperial Healthcare NHS Trust
Vascular Surgeon London, United Kingdom
viii List o­f C­on­tributors

Carlos A. Ordoñez, MD, FACS Assistant Professor

Chief, Division of Trauma and Acute Care Surgery Department of Polytrauma
Fundación Valle del Lili Dzhanelidze Research Institute of Emergency Medicine
Cali, Colombia; Saint-Petersburg, Russian Federation
Professor of Surgery, Trauma and Critical Care
Trauma and Acute Care Surgery Fellowship Norman Minner Rich, MD, DMCC
Universidad del Valle Professor Emeritus in Surgery
Cali, Colombia USU Walter Reed Surgery
Uniformed Services University of the Health Sciences
Allan Pang, MBChB, FRCA Bethesda, Maryland
Academic Department Military Anaesthesia and Critical
Care Igor M. Samokhvalov, MD, PhD, Prof., Colonel MC (Ret)
Royal Centre for Defence Medicine Deputy Chief Surgeon of the Russian Army
Birmingham, United Kingdom; Ministry of Defense of the Russian Federation
Specialist Anaesthesia Trainee Moscow, Russian Federation;
Anaesthestic Department Professor and Chair
James Cook University Hospital Department and Clinic of War Surgery
Middlesbrough, United Kingdom Kirov Military Medical Academy
Saint-Petersburg, Russian Federation;
Michael W. Parra, MD Senior Scientific Researcher
Trauma Research Director Department of Polytrauma
Trauma-Critical Care Dzhanelidze Research Institute of Emergency Medicine
Broward Health Level I Trauma Center Saint-Petersburg, Russian Federation
Fort Lauderdale, Florida

Douglas M. Pokorny, MD James B. Sampson, MD

Division of Trauma and Emergency Surgery Colonel USAF MC
UT Health San Antonio Air Force Medical Readiness Agency
San Antonio, Texas San Antonio, Texas

Rina Porta, MD, PhD Stephanie Savage, MD, MS

Vascular Interventionist Radiology Professor of Surgery
Vascular Surgery Department of Surgery
Department of Vascular and Endovascular Surgery University of Wisconsin
Clínicas Hospital—School of Medicine University of São Madison, Wisconsin
Paulo—FMUSP
São Paulo, Brazil Thomas M. Scalea, MD, FACS
Francis X. Kelly Professor of Trauma
Brandon W. Propper, MD Surgery, Director of Program in Trauma,
Vascular Surgery Program Director Physician-in-Chief
Walter Reed National Military Medical Center The University of Maryland School of Medicine
Associate Professor of Surgery R Adams Cowley Shock Trauma Center
Uniformed Services University Baltimore, Maryland
Bethesda, Maryland
David Schechtman, MD
Amila Sanjiva Ratnayake, MBBS, MS General Surgery Resident
Consultant General Surgeon Department of General Surgery
Military Hospital Brooke Army Medical Center
Colombo, Sri Lanka; San Antonio, Texas;
Adjunct Associate Professor Teaching Fellow
Uniformed Services University of the Health Sciences Department of Surgery
Bethesda, Maryland Uniformed Services University
Bethesda, Maryland
Viktor A. Reva, MD, PhD
Assistant Professor Daniel J. Scott, MD, RPVI
Department of War Surgery Deputy Chief, Vascular Surgery
Kirov Military Medical Academy San Antonio Military Medical Center
Saint-Petersburg, Russian Federation; Texas
 List o­f C­on­tributors ix

Niten Singh, MD Pirkka Vikatmaa, MD, PhD

Professor of Surgery Section Chief Vascular Emergencies
Division of Vascular Surgery Department of Vascular Surgery
University of Washington Helsinki University Hospital and University of Helsinki
Seattle, Washington Helsinki, Finland

Michael J. Sise, MD , FACS

Senior Trauma and Vascular Surgeon Matthew Vuoncino, MD
Scripps Mercy Hospital Integrated Vascular Surgery Resident
San Diego, California University of California—Davis and Travis Air Force
Base
Jason E. Smith, MBBS, MSc, MD, Sacramento, California
FRCP, FRCEM
Consultant in Emergency Medicine Carl Magnus Wahlgren, MD, PhD
Defence Medical Services Chief, Senior consultant
United Kingdom; Department of Vascular Surgery
Defence Professor of Emergency Medicine Karolinska University Hospital
Academic Department of Military Emergency Adjunct Professor
Medicine Karolinska Institute
Royal Centre for Defence Medicine Stockholm, Sweden
Birmingham, United Kingdom;
Honorary Consultant in Emergency Medicine
Emergency Department Fred A. Weaver, MD, MMM
University Hospitals Plymouth NHS Trust Professor and Chief
Plymouth, United Kingdom Division of Vascular Surgery and Endovascular
Therapy
Ian J. Stewart, MD Keck School of Medicine, University of Southern
Deputy Vice Chair of Research California
Department of Medicine Los Angeles, California
Uniformed Services University of the Health Sciences
Bethesda, Maryland
Joseph M. White, MD, FACS, FSVS
Peep Talving, MD, PhD, FACS Associate Professor of Surgery
Professor of Surgery The Department of Surgery
Institute of Clinical Medicine Uniformed Services University of the Health
University of Tartu Sciences and Walter Reed National Military
Tartu, Estonia; Medical Center
Director Bethesda, Maryland
Division of Acute Care Surgery
North Estonia Medical Center
Tallinn, Estonia Paul W. White, MD
Program Director, Vascular Surgery Fellowship
Sujeewa P.B. Thalgaspitiya, MBBS, MS Walter Reed National Military Medical Center
Head, Senior Lecturer Bethesda, Maryland;
Department of Surgery Associate Professor
Faculty of Medicine and Allied Sciences Uniformed Services University of the Health Sciences
Rajarata University of Sri Lanka Bethesda, Maryland
Anuradhapura, Sri Lanka; Consultant to the Surgeon General for Vascular
Consultant Surgeon Surgery
Teaching Hospital Anuradhapura United States Army
Anuradhapura, Sri Lanka

Timothy K. Williams, MD
Rebecca Joy Ur, MD Associate Professor
Vascular Surgery Vascular and Endovascular Surgery
Vascular Institute of the Rockies Wake Forest Baptist Health
Denver, Colorado Winston-Salem, NC, United States
x List o­f C­on­tributors

Tom Woolley, MD, FRCA, MBBS Jeniann A. YI, MD, MSCS

Defence Professor Senior Fellow
Anaesthetics and Critical Care Department of Surgery
Academic Department Military Anaesthesia and Critical University of Colorado Anschutz Medical Campus
Care Aurora, Colorado
Royal Centre for Defence Medicine
Birmingham, United Kingdom

One day, this comprehensive, up to date, and carefully
refreshed (see Preface) account of the management of vas-
cular trauma in the second decade of the 21st century will
move from the shelves of volumes that constitute the medi-
cal school curricula around the world to the quieter library
stacks of medical history. The emerging hot topics explored
on its pages will have been resolved and incorporated into
the clinical mainstream. The innovations and new assess-
ments described in each of its chapters will have become
common practice, and the evolving systems will have
been consolidated and implemented as standard. The calls
for new management strategies to fill the gaps in current
capabilities will have been answered. Vascular surgery, the
youngest of the 10 surgical specialties, will have grown into
all its potential.
Rich’s Vascular Trauma, in this current and three pre-
vious editions, provides the textual infrastructure that
has enabled this remarkable disciplinary growth. When,
eventually, it is replaced by successor volumes, its value
will be transformed. Its contents will assume a different
responsibility: that of providing a definitive historical
record of the creation of vascular surgery in the modern
era. Each revised edition contributes to the challenging
task of focused and sustained tracking of an intricate,
highly technical surgical specialty that has developed
at extraordinary speed. Additionally, this fourth edition
contributes a truly international dimension, drawing on
testimony and evidence from vascular specialists with
regional and national specificities in their provision that
has contributed to the global development of the disci-
pline and its community of practice.
* Emily Mayhew is Historian in Residence in the Centre for Blast Injury Studies, Department of Bioengineering at Imperial College London. She is the author of
Wounded: From Battlefield to Blighty, 1914-1918 published by Vintage and The Four Horsemen: War, Pestilence, Famine and Death and the Hope of a New Age,
published by Riverrun.
** Harry Parker is a writer and artist and lives in London. He joined the British Army when he was 23 and served in Iraq in 2007 and Afghanistan in 2009 as a
Captain in 4th Battalion The Rifles. His debut novel, Anatomy of a Soldier is published by Faber and Faber.
Foreword
EMILY MAYHEW*
Imperial College London, 2021
HARRY PARKER**
London, 2021
The features that make this work essential for vascular
specialists also secure its particular interest for medical
historians. It pays respectful attention to the practices of
the past that would eventually coalesce into the discipline
of vascular surgery and the formal management of vascu-
lar injury. The historical review picks up the first signs of
the integration of military and civilian medical practice
in vascular repair to show that it is a fascinating constant
of vascular surgery that alliances forged by military med-
ics in times of war were consolidated in peace. Despite the
unprecedented scale and pace of military casualty, lessons
from field surgery were learned, transmitted, and applied
consistently in civilian practice. Within the medical sector,
it is rare to see progress maintained and stabilized across
periods of transition. A key consequence of this extraor-
dinary success is that both clinician and patient expecta-
tions of survivability were revised significantly, and remain
undiminished. This work provides evidence and exemplar
of disciplinary progress and good historical practice, as well
as a crucial reminder that there are responsibilities to be
respected when the stakes of survival are renegotiated.
One element will never change no matter the century
or the mechanism of vascular injury. Survivors, whether
unexpected or anticipated, will seek to understand the
process by which their lives were secured. This is a useful
dimension of the work that we suggest might receive addi-
tional consideration. Rich’s Vascular Trauma is a resource
that enables professional development, historical reflection,
and, above all, answers to that most important and compli-
cated question asked by the patient from their life beyond
survival: “what happened to me?”
xi
Preface to the Fourth Edition of
Rich’s Vascular Trauma
NORMAN M. RICH and KENNETH J. CHERRY
The first two decades of the 21st century saw the military
surgical communities of the United States of America, the
United Kingdom, and other allied counties respond with
determination and innovation to the challenges faced by
those caring for patients with life-and-limb threatening
vascular trauma. Air superiority during the Afghanistan
and Iraq Wars, combined with sophisticated field and en-
route treatment protocols, allowed rapid evacuation of
the injured to definitive surgical centers within the the-
ater of war. Stabilized patients were repatriated rapidly to
military hospitals back home, half-way around the world
from their original point of injury. Deployed teams cared
for patients who, in previous conflicts, may never have
reached surgical care alive. Killed-in-action and case-
fatality rates decreased as clinical experience and new
systems of care and innovative approaches and products
were applied.
Implementing a process that the National Academy of
Medicine referred to as focused empiricism, military surgeons
managed a once-in-a-generation burden of vascular injury
within a new and evolving global trauma system.1 Newly
designed tourniquets, balanced transfusion of blood prod-
ucts, damage control surgery, including the use of tempo-
rary vascular shunts, and selective venous and tibial artery
repair were among the approaches that became standard
during the wars. For the first time a closed, negative pres-
sure wound dressing technology was used to control soft
tissue injuries associated with vascular trauma and endo-
vascular devices were applied to select injury patterns in
frontline surgical hospitals.
Unable to perform traditional randomized, controlled
research on these approaches, surgeons relied on registry-
based study and international collaboration to develop
real-world evidence that was applied within a system
of data-driven performance improvement. Throughout
this period, military techniques and protocols for vascu-
lar trauma were scrutinized, adjusted based on the best
available evidence, and shared with civilian surgeons, as
part of the constructive exchange of breakthroughs that
accompanies the unearthing of fresh knowledge in either
setting.1
The challenge now is to preserve and sustain the progress
in vascular trauma care made since the beginning of this
century; progress that the Third Edition of Rich’s Vascular
Trauma did much to capture when it was published in
2015, toward the closure of the Iraq and Afghanistan
Wars. Six years on, this carefully refreshed Fourth Edition is
a commendable addition to the toolbox required to address
that ever-urgent task of avoiding the so-called Walker Dip2;
where peacetime or inter-war periods see atrophy of military
xii
surgical readiness, with the cost of that inertia shored up
and eventually born by those injured in wars of the future.
More than ever, we are convinced that the answer to this
conundrum lies in purposeful collaboration and shared
endeavors across all stakeholders charged with the respon-
sibility of surgical care: civilian and military surgical com-
munities, trauma and vascular surgeons, prehospital and
in-hospital specialists, global health, humanitarian and
military providers, and across international borders.
We are delighted to see that, in the Fourth Edition, the
Editors have again assembled contributions from an array
of talented practitioners and leaders who have wedded
state-of-the-art technical insight to hard-won wisdom,
divined from a range of practice settings: an approach
which sees the Fourth Edition endorsed and adopted by
the Society for Vascular Surgery. Todd Rasmussen of the
United States Air Force and Uniformed Service University
has been an effective leader, role model, and respected
mentor in all of this experience, forging an effective part-
nership with his counterpart Nigel Tai of the British Army
and UK Defence Medical Services—a partnership borne
out of the recent wars that has now served two Editions
of this textbook.
These two Editors continue the important work of
forerunners Frank Spencer, Ken Mattox, and Asher
Hirschberg, whose foundational Editorship proved to be
the shoulders upon which subsequent editions rest. The
work of the contributors within these pages consolidates
and continues the themes and perspectives that Michael
E. DeBakey, Carl W. Hughes, and others took from their
respective service in World War II, the Korean Conflict,
and Vietnam, and that Colonels Todd Rasmussen3 and
Nigel Tai took from theirs.
Finally, with the publication of this Fourth Edition we
would like to acknowledge our friend and military surgical
colleague Surgeon Vice-Admiral Alasdair Walker CB OBE
QHS FRCS, who died in 2019. Admiral Walker completed
his surgical research fellowship at the Uniformed Services
University and was a key mentor and contributor to the
Third Edition of this textbook. As Surgeon General to
the UK Armed Forces, Admiral Walker worked tirelessly to
mitigate the insidious effects of the phenomenon that he
defined (The Walker Dip). Admiral Walker was a lion of
military surgery who had immense character and unri-
valed experience in a career spanning the 1982 War in
the South Atlantic to the 2009 fighting season in Hel-
mand Province, Afghanistan. Despite daunting bona fides
and ascension to the highest levels of military leadership,
Admiral Walker was unpretentious in conversation, reas-
suring in mentorship, and ever the advocate for the next
 Preface to the Fourth Edition of Rich’s Vascular Trauma xiii

generation of physician and surgeon. His untimely death References

is a loss to current and future generations of surgeons and
those whom they serve.
The success that we have no doubt will accompany this
latest edition of Rich’s Vascular Trauma was, to a large
degree, set by Admiral Walker’s tireless groundwork in
strengthening and renewing the bonds of surgical kinship
between his country’s military, ours, and that of countless
allies along the way. He leaves us a rich legacy of union and
friendship, upon which this and future Editions of this text-
book will surely capitalize in the pursuit of ever-better out-
comes for our deserving patients.
1. National Academies of Sciences, Engineering, and Medicine. A National
Trauma Care System: Integrating Military and Civilian Trauma Systems to
Achieve Zero Preventable Deaths After Injury. Washington, DC: National
Academies Press; 2016.
2. Expounded on at the 2013 meeting of the Military Health Ser-
vices Research Symposium meeting in Fort Lauderdale, FL using the
example of the Crimean War to illustrate his point. The phenom-
enon can be found in almost all historical antecedents. Military Med.
2014;179:477–482.
3. Rich NM, Carl W, Hughes CW, De Bakey 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.
2007;46(6):1312–1313.

Vice-Admiral Alasdair Walker, CB, OBE, QHS, FRCS, RN

22 June 1956–1 June 2019

Alasdair Walker qualified from the University of Glasgow in 1979. He deployed to the South Atlantic during the Falklands
War in 1982 and led Commando Forward Surgical Goup 2 during the Iraq War in 2003. He was Senior Surgeon in the
Role 3 Hospital at Camp Bastion in 2009. Subsequent appointments included Medical Director (2009), Director of Medical
Policy and Operational Capability for the Surgeon General (2011), Assistant Chief of the Defence Staff for Health (2014),
Medical Director General (Navy), and Surgeon General in 2015. He retired from the Royal Navy in May 2019 as Surgeon
Vice-Admiral.
The portrait above was taken during his time as International Scholar in the Department of Surgery at Uniformed Ser-
vices University of Health Sciences, Bethesda, Maryland, United States in 1992.
Table of Contents
Surgical Trainee’s Perspective, 1
ALEXANDER KERSEY and ALEXIS LAURIA
SECTION 1
Setting the Stage, 11
1 The Vascular Injury Legacy, 12
NORMAN M. RICH and KENNETH J. CHERRY
2 Epidemiology of Vascular Trauma, 23
PETER GOGALNICEANU, TODD E. RASMUSSEN, and NIGEL R.M. TAI
3 Systems of Care in the Management of Vascular
Injury, 34
DONALD H. JENKINS, DOUGLAS M. POKORNY, and PHILIP M.
EDMUNDSON
4 Training Paradigms for Vascular Trauma,
PAUL W. WHITE and JAMES B. SAMPSON
SECTION 2
Immediate Management and Diagnostic
Approaches, 55
5 Prehospital Management of Vascular Injury,
ROBERT H. JAMES and JASON E. SMITH
6 Damage Control and Immediate Resuscitation for
Vascular Trauma, 70
TOM WOOLLEY, RAVI CHAUHAN, and ALLAN PANG
7 Diagnosis of Vascular Injury, 82
MICHAEL J. SISE
8 Imaging for the Evaluation and Treatment of
Vascular Trauma, 91
DAVID L. DAWSON
SECTION 3
Emerging Technologies and New Approaches
to Vascular Trauma and Shock, 107
9 Endovascular Suites and the Emergency Vascular
Service, 108
JOSEPH A. HERROLD, THOMAS M. SCALEA, and JONATHAN J.
MORRISON
10 Stent-Grafts, Coils, and Plugs, 114
DAVID SCHECHTMAN and BRANDON W. PROPPER
11 Resuscitative Endovascular Balloon Occlusion of
the Aorta, 126
JENIANN A. YL, CHARLES JAMES FOX, and ERNEST E. MOORE
xiv
12 Endovascular Variable Aortic Control, 137
MICHAELA GAFFLEY and TIMOTHY K. WILLIAMS
13 Selective Aortic Arch Perfusion, 144
JAMES E. MANNING and ED B.G. BARNARD
14 Endovascular to Extracorporeal Organ Support
for Vascular Trauma and Shock, 158
KEVIN K. CHUNG, ANDRIY I. BATCHINSKY, and IAN J. STEWART
15 Gathering the Evidence: Clinical Study of New
Technologies, 166
LAURA J. MOORE and JAN O. JANSEN
SECTION 4
The Management of Vascular Trauma, 170
42 16 Cardiac, Great Vessel, and Pulmonary
Injuries, 171
DAVID V. FELICIANO and JOSEPH J. DUBOSE
17 Blunt Thoracic Aortic Injury, 199
DEMETRIOS DEMETRIADES, PEEP TALVING, and KENJI INABA
18 Abdominal Aortic Trauma, Iliac and Visceral Vessel
56 Injuries, 212
CHRISTOPHER AYLWIN and MICHAEL JENKINS
19 Inferior Vena Cava, Portal, and Mesenteric Venous
Systems, 226
TIMOTHY FABIAN and STEPHANIE SAVAGE
20 Neck and Thoracic Outlet, 241
GREGORY A. MAGEE and FRED A. WEAVER
21 Upper Extremity and Junctional Zone Injuries, 252
MATTHEW VUONCINO, JOSEPH M. WHITE, and WILLIAM DARRIN
CLOUSE
22 Lower Extremity Vascular Trauma, 273
DAVID S. KAUVAR and BRANDON W. PROPPER
23 Surgical Damage Control and Temporary Vascular
Shunts, 288
DANIEL J. SCOTT and SHAUN M. GIFFORD
24 Considerations for Conduit Repair of Vascular
Injury, 300
NITEN SINGH and REBECCA JOY UR
25 Management of Pediatric Vascular Injury, 312
MATTHEW A. GOLDSHORE and JEREMY W. CANNON
26 Soft-Tissue and Skeletal Wound Management
in the Setting of Vascular Injury, 321
SHEHAN HETTIARATCHY and JON CLASPER
 Table of Contents xv

27 Vascular Surgery in the Austere 32 Russia, 374

Environment, 332 IGOR M. SAMOKHVALOV and VIKTOR A. REVA
DAVID M. NOTT
33 Serbia, 377
LAZAR B. DAVIDOVIC and MIROSLAV MARKOVIC
SECTION 5
Global Perspectives on Vascular Trauma, 352 34 Israel, 388
EITAN HELDENBERG and ELON GLASSBERG
28 Australia and New Zealand, 353
IAN D. CIVIL 35 South Africa, 391
KENNETH BOFFARD
29 Sri Lanka, 357
AMILA SANJIVA RATNAYAKE, SANJEEWA H. MUNASINGHE, and 36 Colombia: Don’t Dread the Popliteal and Axillary
SUJEEWA P.B. THALGASPITIYA Fossa, 396
CARLOS A. ORDOÑEZ and MICHAEL W. PARRA
30 Vascular Trauma in Finland, 365
PIRKKA VIKATMAA 37 Brazil, 401
ROSSI MURILO and RINA PORTA
31 Sweden, 370
TAL M. HÖRER and CARL MAGNUS WAHLGREN Index, 407
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 Surgical Trainee’s Perspective
ALEXANDER KERSEY and ALEXIS LAURIA
Introduction
The aim of this section is to provide a concise, resident-
focused, overview of a select number of chapters in the
textbook. For each of the selected chapters, the topics are
broken down by a general introduction (contextualizing
the subject), ­surgical approach (detailing patient evalu-
ation and prioritization) and tactics (providing helpful
tips – the “Do’s and Don’ts” of safe surgical care) needed to
get the best outcomes.
The section will be most useful for the busy Resident
needing to quickly review the fundamentals of a vascular
trauma topic, priming them for a later and more compre-
hensive review of the relevant chapters when their sched-
ule permits.
Subject: Critical First Steps and
Damage Control Resuscitation
(Chapters 5 and 6)
GENERAL
n Damage control resuscitation (DCR) begins in the pre-
hospital arena and is continued via reception into the
Emergency Department (ED), transfer to surgery or
interventional radiology (IR) suite, and within the Criti-
cal Care Unit.
n DCR prioritizes use of tourniquets, hemostatic dressings,
temporizing procedures (resuscitative endovascular bal-
loon occlusion of the aorta [REBOA]) and balanced trans-
fusion of blood products to mitigate the consequences of
hemorrhage and shock.
n DCR generates surgical options by restoring physiologi-
cal normality.
SURGICAL APPROACH
n Prior preparation in the ED is essential: muster team
members, assign roles, pre rehearse likely scenarios, pre-
pare equipment and drugs, order blood products, don
PPE, forewarn onward destinations (operating room
(OR), IR suite, intensive care unit (ICU), etc.) and antici-
pated consultants.
n Use C-ABC framework to prioritize immediate steps in
management:
n (C) Control of catastrophic bleeding – tourniquet,
hemostatic dressings, REBOA
n (A) Airway management
n (B) Breathing – ensure adequate ventilation
n (C) Circulation – vascular access, hemorrhage con-
trol, restore circulatory volume
n Replace volume with a 1:1:1 ratio of red cells,
plasma and platelets (6U packed red blood cells
(pRBC), 6U fresh frozen plasma (FFP), 1 pack of
platelets [which contains 6U])
n Consider tranexamic acid (TXA) as part of the resuscita-
tion protocol based on local practice.
n Consider broad spectrum antibiotics and tetanus where
indicated.
n Match anesthesia-induction strategy to patient physiol-
ogy (use cardio-stable induction agents to avoid cata-
strophic loss of cardiac output).
n Keep patient warm.
SURGICAL TACTICS IN THE ED
n Do:
n Familiarize yourself with the type of tourniquet and
hemostatic dressings used by your prehospital care
providers – how they are applied and released.
n Understand how long the warm ischemia time has
been and ensure it is recorded.
n Release tourniquets only for specific purpose (e.g.,
immediately prior to diagnostic angiography; to assess
likelihood of arterial injury, etc.). If no gross hemor-
rhage, leave down but be prepared to tighten again if
further hemorrhage occurs.
n Remove dressings if ineffective or if examining wound
will change operative decision-making.
n Re-assess tourniquets/hemostatic dressings after
patient movement to ensure proper function.
n Monitor coagulopathy through early use of thrombo-
elastography (TEG)/rotational thromboelastometry
(ROTEM); monitor physiology through multiple feeds
(trends in hemodynamic variables, lactate, urine out-
put, etc.).
n Refine anticipated management plan as results from
examination and investigations accrue and commu-
nicate accordingly.
n Establish and maintain hierarchy of open, closed-
loop communication and task allocation (i.e., identify
team lead but enable all to have a voice).
n Use checklists and regular, formalized briefing
opportunities (SNAP brief, STACK brief, ‘time outs’)
to review progress and before major interventions
(Chapter 6, p. 68)
n Do Not:
n Lose situational awareness and become task fixated.
n Become distracted by a prominent injury and fail to
appropriately assess whole patient in stepwise fashion.
n Fail to obtain and document a brief but thorough
extremity motor and sensory examination prior to
intubation if safe to do so.
n Fail to consider ethics issues and/or fail to set ceilings
of care for patients where continued medical inter-
vention is likely to be futile.
1
2 • Surgical Trainee’s Perspective
n Fail to consider requirements of associated members of
the attending trauma team (e.g., Orthopedics) and not
integrate these points in to the overall DCR strategy.
Subject: Injury Identification and
Diagnostic Workup (Chapters 7
and 8)
GENERAL
n Early identification of vascular injury is crucial to pre-
venting long-term morbidity, loss of limb, or loss of life
n Chapter 7, Box 7.1 (Checklist for Prompt Recognition
of Vascular Injury)
n Modalities for diagnosis include detailed injury his-
tory, bedside examinations (pulse examination, Doppler
examination, point-of-care ultrasound, Ankle Brachial
Index (ABI)), radiographic imaging (CT angiography
[CTA]) and formal angiography.
n Approach is based on: (1) patient stability, (2) concom­
itant injuries, and (3) availability/feasibility of diagnos-
tic modalities (i.e., contrast allergies).
DIAGNOSTIC APPROACH
n Any exsanguinating hemorrhage should be temporized
per C-ABC with adjuncts (as described previously).
n Hard signs of vascular injury, CTA or angiography posi-
tive for vascular injury→to the OR
n Chapter 7, Fig. 7.5 (Algorithm of the indications for
immediate operation and the role of imaging modalities)
n Hard signs of vascular injury include:
n Pulsatile hemorrhage
n Expanding hematoma
n Bruit or thrill over area of injury
n Absent pulse
n ABI < 0.9
n Soft signs of vascular injury include:
n History of hemorrhage at scene
n Wounds of neck/extremities with unexplained hem-
orrhagic shock
n Neurologic deficit in peripheral nerve in proximity to
vessels
n High risk fracture, dislocation, or penetrating proxim-
ity wound
n Presence of a pulse does not rule out a vascular injury.
Conversely, a normal ABI makes the likelihood of a vas-
cular injury much lower.
n Consider use of checklist adjuncts to “clear” the patient
of vascular injuries in various cavities or prompt further
imaging.
n Chapter 7, Box 7.3 (Clearing Trauma Patients for
Presence of Vascular Injury)
TACTICS
n Do:
n Consider injury mechanism when evaluating for
occult injury.
n Be cognizant of additive use of contrast.
n Discuss injury concerns with radiologist so that vas-
cular workup can be integrated with planned imaging
to avoid multiple trips to the radiology suite.
n Frequently reassess for changes in pulse examination
throughout the resuscitation as hypotension, vaso-
pressors may confound examination.
n Do Not:
n Take an unstable patient to imaging.
n Delay operative intervention for imaging if the imag-
ing will not add to or change decision-making.
n Hesitate to confirm questionable pulse examinations –
either with second provider or Doppler examination.
n Fail to consider the risks associated with each imag-
ing modality (contrast reactions, renal dysfunction,
access site complications, time requirements, risks of
radiation).
Subject: Resuscitative
Endovascular Balloon Occlusion of
the Aorta (REBOA) (Chapter 11)
GENERAL
n Minimally invasive alternative to thoracotomy and aor-
tic clamping for temporization of exsanguinating sub-
diaphragmatic hemorrhage.
n Carries systemic consequences due to lower body and
visceral ischemia but these are probably less than stan-
dard emergency department thoracotomy (EDT) and
cross-clamping. These consequences may be off-set
through the development of partial occlusion or inter-
mittent occlusion techniques.
SURGICAL APPROACH
n The first step is percutaneous femoral artery cannula-
tion, which should be done under ultrasound (US) guid-
ance to maximize chances of success and minimize
complications.
n The artery is accessed via hollow-needle and wire 2 to 3 cm
below the mid-inguinal ligament. Seldinger technique is
used to place a sheath, which is used to position a guide-
wire over which a compliant occlusion balloon can be
placed into zone I or III as required, using predetermined
standard insertion lengths (Chapter 11, Fig. 11.1). The
wireless ER REBOA system (Prytime Medical; Chapter 11,
Fig. 11.2) does not require wire guidance and employs a
7-Fr sheath.
n The aorta is divided into three zones; zone I ((left subcla-
vian to celiac), zone II (celiac to lowest renal artery) and
zone III (infrarenal aorta). Chapter 11, Fig. 11.4).
n The length of catheter insertion needed to reach each
zone can be approximated using anatomic landmarks:
n Zone I: femoral access site to sternal notch
n Zone III: femoral access site to umbilicus
n The occlusion balloon is positioned in zone III for pelvic
hemorrhage and distal zone I for intraabdominal bleeding.
n Position of the balloon may be confirmed with plain x-ray.
n The balloon is inflated with a contrast/saline mix:
n Inflate balloon until recognizable hemodynamic
response (increased central/upper extremity blood

pressure, absent or decreased distal pulses, step-up in
waveform proximal to balloon)
n Tactile feedback during inflation is important in
recognizing aortic wall tension and avoiding injury –
if resistance is met, inflation should stop
n The REBOA is secured to prevent balloon migration and
the patient can be taken to the right place to stop the
hemorrhage (IR suite, OR).
n Balloon time must be assiduously tracked. Zone I aortic
occlusion time must be kept to less than 30 minutes to
reduce the chances of spinal cord or visceral ischemia/
tissue infarction. Longer occlusion times may be toler-
ated for zone III inflation.
SURGICAL TACTICS
n Do:
n Match the need for REBOA to a good understanding of
patient physiology:
n Physiologically stable patients with potential for
sudden deterioration may have a sheath inserted
as a prelude to REBOA deployment if there is
deterioration.
n Unstable patients may have sheath insertion
and balloon inflation to allow safer transfer to
IR/OR.
n Deflate the balloon slowly (consider 1–2 mL every
2–3 minutes) to prevent rapid hemodynamic changes
and catastrophic ischemia-reperfusion injury to
the heart, giving plenty of warning to anesthetic
colleagues.
n Consider adding medications or common rescue needs
(bicarb, blood and/or crystalloid, pressors, manage-
ment of hyperkalemia) in anticipation of reperfusion
injury after balloon deflation.
n Employ REBOA as part of a comprehensive DCR
paradigm.
n Do Not:
n Use REBOA as a “bridge” if the destination is not
determined or the hemorrhage control strategy not
clear – always have a plan as to next steps (including
definitive hemorrhage control).
n Persist at multiple attempts at groin cannulation.
Resort to surgical cutdown early if groin cannulation
is not possible.
n Longitudinal incision extending inferiorly from the
midpoint between the pubic symphysis and ante-
rior superior iliac spine (ASIS).
n Use REBOA for intrathoracic hemorrhage.
n Fail to evaluate the patient for complications, particu-
larly lower limb ischemia due to peri-sheath thrombo-
sis, and have a plan for dealing with them.
Subject: Temporary Vascular
Shunts (Chapter 23)
GENERAL
n Use of shunts is a desirable option to bridge damaged
vessels in the extremities, junctional areas, and trunk to
enable early reperfusion of tissue.
• Surgical Trainee’s Perspective 3
n Consider shunting when definitive repair must be
deferred due to:
n physiological instability (i.e., damage control surgery)
n need to complete other life-saving interventions
n requirement to perform skeletal fixation
n absence of sufficient expertise or materials
n Shunting is applicable to both arteries and veins.
n Shunt dwell times of 2 to 5 hours are typical; however,
some scenarios require longer times. The goal should be
to remove shunts and perform definitive revasculariza-
tion as early as the patient’s status, resources, and tech-
nical expertise allow.
SURGICAL APPROACH
n Shunts should be used as part of a comprehensive vascu-
lar management plan and require a technically experi-
enced team with adequate resources.
SURGICAL TACTICS
n Do:
n Get the preliminaries right: adequate proximal and
distal vascular exposure; injury definition/débride-
ment; assessment of inflow and backflow; Fogarty
sweep; heparinized saline flush.
n Ensure that vascular injury downstream of the shunt
has been ruled out to prevent hemorrhage once flow
restored – consider angiography.
n Choose a shunt and position that is right for the vessel
caliber and injury:
n In-line – short segmental defect or small working
area (Chapter 23, Figs. 23.3 and 23.4)
n Looped – long segment defect, large working area
(Chapter 23, Fig. 23.5).
n Remember standard sequencing: [Shunt]→[Fracture
Reduction and Fixation]→[Definitive Vascular
Repair]→[Fasciotomy].
n Have a plan for definitive management, know when/
where necessary resources are available.
n Be aware of and have a plan for shunt-related com-
plications (dislodgement, luminal injury, thrombosis,
kinking, etc.) and communicate this to other relevant
members of the patient care team.
n Do Not:
n Inadequately secure the shunt.
n Fail to consider collaterals and branch points within
the injury/shunt zone and ligate these as needed.
n Fail to give anesthesia colleagues warning of reperfu-
sion prior to shunt clamp removal.
n Routinely employ systemic anticoagulation.
n Routinely use shunts to bridge defects in small vessels
below the elbow or the knee (increased likelihood of
thrombosis).
Subject: Neck Injury (Chapter 20)
GENERAL
n A unique, compacted and congested anatomical zone
with multiple vital structures.
4 • Surgical Trainee’s Perspective
n Neck trauma is divided into three zones based on ana-
tomic landmarks (Chapter 20, Fig. 20.1):
n Zone I – sternal notch to cricoid cartilage
n Zone II – cricoid cartilage to angle of mandible
n Zone III – angle of mandible to base of skull
n Wide spectrum of presentation from exsanguinating
hemorrhage to subtle clinical or imaging findings that
can lead to delayed stroke.
n Carotid injuries may present with contralateral
extremity weakness, aphasia, or Horner’s syndrome.
n Vertebral injuries are rarely symptomatic on presen-
tation.
n Increased prevalence of CTA has resulted in more blunt
injuries (blunt carotid and vertebral injury – BCVI) being
identified.
n Risk factors for BCVI that should prompt screening
include:
n Head and neck trauma associated with severe neck
hyperextension and rotation or hyperflexion
n Lefort II or III fracture
n Basilar skull fracture involving the carotid canal
n Closed head injury consistent with diffuse axonal
injury presenting with Glasgow coma scale (GCS)
score <6
n• Cervical vertebral body or transverse foramen frac-
ture, subluxation, or ligamentous injury at any level or
any fracture of C1–C3
n A seat-belt or other clothesline-type injury with signif-
icant cervical pain, swelling, or altered mental status
SURGICAL APPROACH
n Physical examination is extremely important with iden-
tification of hard vascular signs an indication for airway
control and operative exploration. For stable patients,
CTA is the next step. It is crucial to pick-up pathologic
neurological signs prior to intervention.
n Repair of penetrating carotid trauma in a patient with
neurological deficit has attracted controversy, but there
are no absolute contraindications. However, a delay of
more than 3 hours from coma onset and large areas of
cerebral infarct seen on initial CT scan are reasons to
consider what reperfusion is likely to achieve.
n Catheter-based angiography and endovascular stenting
is suited to distal carotid (zone III) hemorrhage where
surgical access is difficult. Similarly, very proximal
lesions (zone I) that would otherwise mandate median
sternotomy for proximal control may be managed via
covered stents.
n Operative positioning and draping should take into
account the potential need to open the chest and possible
vein harvest.
n Carotid injuries are exposed via a standard sternal
notch to mastoid process incision, via a plane that lies
medial to the sternocleidomastoid muscle. The inter-
nal jugular vein should be mobilized laterally away
from the carotid; dividing the facial vein facilitates
this. Exposing the upper parts of the internal carotid
(zone III) requires preservation of the XII cranial
nerve, division of the occipital artery, and mobilization
of the posterior belly of the digastric, protecting the IX
and XI cranial nerves.
n Options for carotid repair include:
n Primary repair with monofilament suture (rarely
advisable)
n Patch angioplasty with bovine pericardium or vein
graft
n Interposition graft with saphenous vein preferably
or PTFE (graft generally required for >2-cm length
defects)
n Use of a Fogarty occlusion balloon, carefully inflated, is a
facile means of gaining distal control in zone III injuries.
If possible, repairs of the internal carotid artery (ICA)
should be undertaken using a shunt to maintain pro-
grade flow. If backflow cannot be obtained after gentle
Fogarty thrombectomy, there is little advantage attempt-
ing repair and ligation is advisable.
n Vertebral artery injuries are challenging to repair due
to difficult access; management concentrates on injury
definition (CTA), and control of hemorrhage (ligation,
embolization) where this is significant, accepting the risk
of posterior circulation stroke.
n Injuries to the vertebral artery as it passes through
the transverse processes of the cervical vertebra are
approached by the same route as exposure of the carotid
artery. Hematoma will displace the carotid sheath ante-
riorly; the carotid artery and internal jugular vein must
be displaced to allow access to the injury tract, longus
colli muscle, and injured vertebral artery. Gaining proxi-
mal and distal control requires removal of the anterior
tubercle of the transverse process which is difficult to
accomplish in the midst of hemorrhage.
n Alternatively, tamponading the surgically exposed injury
tract with hemostatic material or the balloon of a Fog-
arty catheter while addressing balanced transfusion and
judicious use of time may be sufficient to allow bleeding
to stop as a prelude to follow-up catheter-based emboli-
zation.
SURGICAL TACTICS
n Do:
n Screen aggressively for BCVI; management is almost
always nonoperative with antithrombotic therapy
and follow-up CTA the mainstay of treatment. Enlarg-
ing pseudoaneurysms that develop during follow-up
can be selectively managed with stenting or coiling.
Grade Description Management
I Intimal injury with <25% Antithrombotic therapy
luminal narrowing
II Dissection or hematoma with Antithrombotic therapy
>25% luminal narrowing
III Pseudoaneurysm Antithrombotic therapy;
consider endovascular
management
IV Occlusion Antithrombotic therapy
V Transection Operative interven-
tion (endovascular if
inaccessible)
n Antithrombotic therapy (either anticoagulation or anti-
platelet) is chosen empirically based on injury pattern,
provider experience, and institutional guidelines.
 • Surgical Trainee’s Perspective 5

n Do Not: n Ligation of the SCA or axillary is unlikely to lead to limb

n Fail to assess penetrating injuries of the neck for pres-
ence of tracheal and esophago-pharyngeal injury,
through rigorous surgical exploration at the time of
vascular repair and combination of rigid esophagos-
copy + esophagography + tracheo-laryngoscopy if
any doubt exists.
n Fail to repeat CTA 7 to 10 days after injury for nonop-
eratively managed patients to assess for resolution or
progression
Subject: Upper Extremity and
Junctional Zone Injuries (Chapter 21)
GENERAL
n Upper limb vascular trauma can lead to life-threatening
hemorrhage and tissue ischemia, neuropathy and isch-
emia reperfusion injury.
n Junctional trauma may require control from within the
chest; is technically challenging to manage and may be
associated with gross shock.
n Where possible, injuries to the subclavian artery (SCA)
can be managed with covered stents.
SURGICAL APPROACH
n Junctional penetrating trauma may present with a com-
bination of upper limb signs (loss or function, reduced
pulse through to obvious ischemia), local signs (pulsatile
periclavicular hemorrhage or expanding hematoma),
chest signs (massive hemothorax).
n A variety of surgical approaches exist for management
of junctional injury:
loss or crippling ischemia due to collaterals but may
result in functional impairment; repair or shunting is
advised if possible. Brachial artery injuries should be
repaired.
n Injuries to single forearm arteries may be ligated if there
is good flow in the intact remaining vessel verified intra-
operatively via Doppler.
SURGICAL TACTICS
n Do:
n Prep widely considering all possible approaches for
proximal and distal control. Include the hand and
forearm to allow for intraoperative Doppler interroga-
tion and possible fasciotomy.
n Be cognizant of critical structures (brachial plexus,
vagus, phrenic nerves).
n Use CTA to confirm site of probable junctional vascu-
lar injury if the patient is stable.
n Make liberal use of shunts for complex injuries,
especially where conjoined orthopedic fixation is
anticipated.
n Remember to perform forearm fasciotomy if compart-
ment syndrome is anticipated (Chapter 21, Box. 21.1
and Fig. 21.15).
n Do Not:
n Use limb viability trauma scoring systems (Chapter 21,
Tables 21.2 and 21.3) as an absolute driver of deci-
sion-making, but instead as a cue/prompting mea-
sure to consider all elements contributing to injury
burden.
n Hesitate to gain the second opinion of a colleague
when considering amputation.
n Cover a dominant vertebral artery when stenting
the SCA, or fail to follow-up on patients with covered
stents (where long-term outcomes are unknown).

Location Approach Adjuncts Subject: Blunt Thoracic Aortic

Right proximal
SCA
Median sternotomy Supraclavicular extension,
resection of clavicular
Injury (Chapter 17)
head
Left proximal Anterolateral Extend with median ster- GENERAL
SCA thoracotomy notomy and supracla-
vicular incision (may be n Blunt thoracic aortic injury (BTAI) typically occurs in the
referred to as trapdoor aorta distal to the origin of the left subclavian artery, and
incision) ranges from intimal tear only (minimal aortic injury) to
Mid-distal SCA, Supraclavicular incision Clavicular resection, pseudoaneurysm and complete transection (with lethal
Proximal (divide sternocleido- ­infraclavicular incision and unconstrained hemorrhage). CTA is the standard
axillary mastoid and anterior diagnostic tool.
scalene)
n Most cases that survive to reach surgical care can be
Distal axillary, Lateral infraclavicular Lateral extension onto arm
Proximal incision (split pec
temporized through vigorous blood pressure control
brachial major, divide pec (beta blockade) and careful monitoring while arrange-
minor) ments are optimized for definitive management or other
Mid-distal Incision over medial more life-threatening injuries addressed.
brachial bicipital groove n In general, goal SBP <120 mm Hg
Ulnar, radial Longitudinal forearm S-shaped extension over n Esmolol drip is most commonly used due to rapid
incision antecubital crease to onset, ease of titration
expose distal brachial n Aortic endovascular stenting (thoracic endovascular
artery
aortic repair (TEVAR); Chapter 17, Figs. 17.9, 17.10)
SCA, Subclavian artery. has become a prevailing mode of treatment, with open
6 • Surgical Trainee’s Perspective
or hybrid repairs reserved for injuries involving the aor-
tic arch or where endovascular resources are limited.
SURGICAL APPROACH
n Open repair is accomplished by the clamp and sew
approach via left posterolateral thoracotomy and distal
perfusion of the aorta to reduce the chance of spinal
cord ischemia (Chapter 17, pp. 5–7, Fig. 17.8).
n Proper sizing of stents is key in preventing TEVAR-related
complications (Chapter 17, Table 17.3 and Figs. 17.11–
17.13). Bird’s neck deformity can be avoided by using
new generation devices that allow for the curvature of
the aorta in young patients.
n Most patients tolerate covering of the origin of the left
subclavian well. Carotid-subclavian bypass can be
undertaken for patients who develop subclavian steal.
SURGICAL TACTICS
n Do:
n Base the timing of definitive management on the
nature and extent of the BTAI lesion, other associated
injuries, and facility expertise.
n Consider conservative management (with early CTA
follow-up) for patients with minor lesions (intimal
tear, small pseudoaneurysm).
n Consider screening for blunt cardiac injury with elec-
trocardiogram (EKG) monitoring.
n Do Not:
n Fail to ensure that all TEVAR patients are submitted to
life-long surveillance programs to ensure stent com-
plications are identified.
Subject: Cardiac, Great Vessel and
Pulmonary Injuries (Chapter 16)
GENERAL
n Surgery is infrequently needed for thoracic injury;
patients with penetrating injuries to the heart and great
vessels usually do not reach the surgeon alive.
n The most common indications for thoracotomy are
hemorrhage from the lung, major arterial injury in the
arch or root-of-neck vessels, or a penetrating cardiac
wound.
SURGICAL APPROACH
n Any penetrating injury between the nipples from
the sternal notch to xiphoid process (known as the
“cardiac box”) or encompassing the left chest, should be
evaluated for potential cardiac injury.
n Site large-bore access venous access sites on the
contralateral side to any injury, and consider using the
common femoral veins.
n Critically shocked patients with evidence of massive
hemothorax (chest x-ray appearance, immediate drain-
age of 1200–1500 mL of blood via tube thoracostomy);
or cardiac tamponade (diagnosed on US); or visible
hemorrhage from the root of the neck should undergo
emergent endotracheal intubation in the ER and transfer
expeditiously to the OR for surgery.
n Where physiology becomes agonal, perform EDT (left
anterolateral thoracotomy or clamshell thoracotomy if
suspected right-sided injury) (Chapter 16, pp. 4–6, Figs.
16.1–16.4) with the aim of:
n Confirming the diagnosis.
n Performing pericardiotomy if tamponade is present.
n Via longitudinal incision in the pericardium above
the left phrenic nerve.
n Controlling hemorrhage from a wound to the heart,
great vessels, or lung.
n Catastrophic lung hemorrhage may be temporized
with use of hilar clamping or lung twist (Chapter
16, p. 25). These require division of the inferior
pulmonary ligament.
n Clamping the descending thoracic aorta to preserve
circulating volume and perfuse the coronary and
carotid arteries.
n The inferior pulmonary ligament can be taken
down to aid in visualization.
n Undertaking internal cardiac massage.
n Less critically disturbed patients whose physiology stabi-
lizes with resuscitation can be more thoroughly worked
up (CT chest, CTA arch vessels) and then moved to criti-
cal care for close observation. Conservative management
should be abandoned if tube thoracostomy output con-
tinues (>200 mL/h over 2–4 hours) or if volume require-
ments become elevated.
SURGICAL TACTICS
n Do:
n Make use of the subxiphoid pericardial window tech-
nique to rule out tamponade during trauma laparot-
omy (Chapter 16, p. 8).
n Match the repair technique to the location of the
heart injury: clamp and suture (permanent monofila-
ment) for atria; unpledgeted repair to right ventricle;
pledgeted repair to left ventricle.
n Consider temporizing cardiac injuries in extremis with
skin staples, Foley balloon, or other adjuncts (Chapter
16, Table 16.2).
n Use partial isolation (Satinsky clamp) to deal with
simple penetrating arch injury.
n Use debranching techniques to manage complex injuries
to the branch vessels (i.e., control the injury→sew proxi-
mal end of prosthetic graft onto arch→sew distal end of
graft to cut distal end of the disrupted arch vessel).
n Use lung-sparing techniques (suture, stapled wedge,
tractotomy) when dealing with pulmonary hemor-
rhage (Chapter 16, pp. 25–26).
n Consider endovascular techniques to manage great
vessel injuries.
n Do Not:
n Undertake futile resuscitative thoracotomy (blunt
mechanism of injury [MOI] with no signs of life in ER,
penetrating MOI with no signs of life in the field).
n Fail to consider packing the chest as a damage control
measure.
n Injure the intercostal arteries arising from the pos-
terior aspect of the thoracic aorta when applying a
cross-clamp.

n Lose sight of location of coronary arteries and inad-
vertently ligate or disrupt coronary arteries while
attempting to repair a cardiac injury.
n Forget to get postop echocardiography to evaluate for
valvular injury post cardiac repair.
Subject: Aortic, Iliac and Visceral
Arterial Injuries (Chapter 18)
GENERAL
n Wide variety of presentation with potential for rapid
deterioration and exsanguination.
n Vascular injuries in the abdomen are categorized accord-
ing to anatomical location, defined within three retro-
peritoneal zones: zone I – midline, zone II – lateral, zone
III – pelvic (Chapter 18, Fig. 18.1).
n CTA is the gold standard investigation for stable casu-
alties; exploratory laparotomy for unstable patients
(i.e., no or short-lived response to initial resuscitation).
SURGICAL APPROACH
n Skin preparation and draping should take account of
the potential need for left anterolateral thoracotomy and
vascular control at the groins.
n Evisceration, four-quadrant packing, and sequential
removal of packs removes blood and allows a methodical
start to challenging surgery.
n Any zone I retroperitoneal hematoma will require explo-
ration as there is a high chance of it involving the aorta
or its branches, or the inferior vena cava (IVC). Left or
right medial visceral rotation respectively for aorta
(hematoma biased to left of midline) and IVC (hematoma
biased to right of midline) are the key maneuvers to
expose the injury, though consideration should be given
to obtaining supraceliac aortic control in very unstable
patients beforehand (Chapter 18, Figs. 18.2–18.4).
n Large zone I hematomas that are present in the supra-
colic compartment may be better controlled through
clamping of the thoracic aorta via left anterolateral
thoracotomy.
n Zone II and zone III hematomas may be managed more
judiciously, with exploration reserved for ongoing bleed-
ing (expanding hematoma or the presence of physiologi-
cal instability). Some also include penetrating trauma as
an indication, particularly for pelvic hematoma where
the iliac vessels may have been injured.
SURGICAL TACTICS
n Do:
n Do consider preplacement of a REBOA catheter
prelaparotomy to enable rapid aortic control should
this be required.
n Branches of the celiac artery can be ligated proxi-
mally with low risk of end-organ ischemia; injury to
the peripancreatic superior mesenteric artery (SMA)
should be repaired or shunted in order to avoid cata-
strophic mid-gut infarction. Approach the celiac via
• Surgical Trainee’s Perspective 7
the lesser sac or left medial visceral rotation; approach
the SMA via the lesser sac (with stapled division of the
pancreas in-extremis), via left medial visceral rotation
or via the root of the small bowel mesentery. The infe-
rior mesenteric artery can be ligated. Injuries to the
renal arteries usually result in ligation and probable
nephrectomy.
n Mobilize the cecum or sigmoid colon to visualize the
common and external iliac vessels, avoiding the ure-
ter, and be prepared to achieve distal control at the
groin if unfavorable pelvic anatomy is present.
n Do Not:
n Fail to consider endovascular treatment of pelvic ves-
sel injury (covered stent) if the situation permits (i.e.,
consider operating in a hybrid room if possible).
n Fail to consider preperitoneal packing as a means to
temporize pelvic bleeding associated with pelvic frac-
tures prior to embolization.
n Fail to consider the likelihood of abdominal compart-
ment syndrome and the advantage of temporary lapar-
ostomy to prevent this and allow assessment of visceral
viability at a subsequent planned relook procedure.
Subject: Inferior Vena Cava, Portal
and Mesenteric Venous Injuries
(Chapter 19)
GENERAL
n As with injury to the aorta and its branches, injuries to
the IVC, portal vein, and mesenteric vessels are highly
lethal.
n CTA is the investigation of choice, with hematomas
around the ascending colon and duodenum fairly spe-
cific for IVC injuries as well as caval filling defect.
n Resuscitative thoracotomy or zone I REBOA are valid
means of controlling aortic inflow in order to manage
the critically deteriorating patient.
n Selected patients, without hemodynamic disturbance,
and where the hematoma is small-to-moderate on CT
scan, may be monitored and observed; assuming there is
no other reason to pursue laparotomy (e.g., blunt injury;
or, if penetrating, no violation of peritoneum or signs of
peritonism).
SURGICAL APPROACH
n Cava:
n Utilize right medial visceral rotation (Chapter 19,
Fig. 19.2), with extensive kocherization of the duo-
denum, for infra- and suprarenal IVC and control.
Use digital pressure or careful application of swabs/
sponges on sticks to occlude the IVC either side of an
injury rather than attempting encirclement with risk
to the lumbar vessels.
n Retrohepatic injuries to the cava, heralded by dark
blood continuously welling up from behind the liver,
should be managed via manual compression of the liver
against the cava and thence appropriate packing and/
or clamping of the portal triad (Pringle maneuver).
8 • Surgical Trainee’s Perspective
n If this fails to control bleeding, the laparotomy inci-
sion should be extended to the right chest via right
anterolateral thoracotomy, with control of the supra-
hepatic IVC from within the pericardium, prior to full
mobilization of the liver, and exposure of the injured
retrohepatic cava. Alternatively, seek to place occlu-
sion balloons in the cava via percutaneous means to
isolate the liver prior to mobilization.
n Portal Vein
n Approach by clamping the portal triad proximal to
the injury, taking down the hepatic flexure of the
colon, and performing a wide Kocher maneuver, then
releasing the clamp to facilitate digital control of the
injury and gentle dissection of the vein away from the
hepatic artery and common bile duct to allow injury
definition and placement of vessel loops.
n Be prepared to divide the neck of the pancreas (to
the left of the SMA/superior mesenteric vein [SMV])
using a linear cutter stapler in order to expose the
most proximal portion of the portal vein if proximal
control is not achievable otherwise.
n Superior Mesenteric Vein
n Injuries are associated with central hematoma at the
base of the small bowel mesentery (at the fusion of
the peritoneum overlying junction of the transverse
colon mesentery).
n Medial visceral rotation from the right with kocher-
ization allows the operator to place a hand behind the
mesentery containing the injured vein. This allows for
application of digital control and dissection of the vessel/
clamping/repair, or ligation prior to hematoma entry.
SURGICAL TACTICS
n Do:
n Consider getting aortic control before opening a large
central hematoma.
n Handle the portal vein and SMV carefully; they are
thin-walled and tear easily.
n Anticipate the splanchnic sequestration effects of
portal vein or SMV ligation and ensure aggressive vol-
ume resuscitation in the postoperative period. Plan for
early relook laparotomy to assess for potential bowel
infarction.
n Do Not:
n Expect to see contrast extravasation on the initial CT
abdomen in venous injury.
n Ligate the suprarenal IVC – this is not tolerated and
will lead to acute renal failure.
n Spend too much time attempting complex repair of
the portal vein – damage control adjuncts such as
ligation or shunting should be considered early to
avoid extensive bleeding.
Subject: Lower Extremity Vascular
Trauma (Chapter 22)
GENERAL
n The lower limb is the most frequent site of arterial injury
in both civilian and military trauma.
n Documenting a complete lower extremity neurovascular
examination prior to intervention assists in determina-
tion of injury pattern as well as evaluation of possible
postoperative complications.
n High energy mechanisms of injury, especially explosions,
result in complex multisegmental injury with disruption
of soft tissue, bone, and skin.
n Limb salvage and vascular reconstruction must only be
considered in the context of the totality of injury and
associated physiological disturbance. Interventions that
save life and restore homeostasis should be prioritized
accordingly.
n The presence of a vascular injury can be discerned from
hemorrhage, ischemia, or signs found on CTA. The
latter, as a preprocedural investigation, is especially
useful in situations where several levels of vascular
damage may be present (shotgun injury, multiple long
bone fracture).
n Warm ischemic time is very important and must be
carefully monitored, driving urgency of revasculariza-
tion. Aim to restore perfusion within 3 hours of injury –
although classic teaching is 6 hours, recent data
indicates this is too long.
n Primary amputation is a difficult decision to undertake –
a second opinion, obtained from an experienced col-
league brought to the OR for this purpose can help in
decision-making.
SURGICAL APPROACH
n Proximal tourniquet for control of ongoing hemorrhage
until proximal control is achieved via exposure of vessels
above the injury zone, with subsequent distal control
and thence entry into the hematoma and evaluation of
the injury. Prep tourniquet into field to allow for intraop-
erative manipulation.
n Injuries at the groin may not be amenable to tourni-
quet control; sponge-stick or digital control of external
hemorrhage should be maintained while a retroperi-
toneal approach is used to effect access to the external
iliac artery (EIA). A curvilinear skin incision, from the
mid-inguinal point superior to the anterior superior
iliac spine, can be employed, dividing aponeurosis of the
external oblique, splitting the underlying fibers of the
internal oblique and transversus abdominis, reaching
the preperitoneal plane, and developing this medially to
reach the EIA.
n In general, standard vascular axial exposures (mid-
inguinal, anteromedial thigh, medial calf; Chapter 22,
pp. 9–13) can be used to deal with injuries to the com-
mon, profunda and superficial femoral arteries, and the
popliteal and posterior tibial vessels. There should be no
hesitation in extending these incisions proximally or dis-
tally as the situation dictates.
n The orthodox preliminaries of injury definition,
evaluation of inflow and backflow, and Fogarty
catheter thrombectomy of upstream and downstream
vessels are required before considering whether the
patient requires a shunt or immediate definitive
repair.
n Ensure adequate healthy tissue coverage over any shunt/
repair after the wound is appropriately débrided.

SURGICAL TACTICS
n Do:
n Consider coil embolization for the treatment of
CTA-identified bleeds emanating from branches of the
profunda.
n Bias toward use of end-to-end interposition with great
saphenous vein for short defects, or formal by-pass for
longer defects. The latter option, combined with vessel
exclusion, is very applicable for popliteal artery injuries
and avoids surgical division of medial knee ligaments.
n Repair the popliteal and common femoral veins, if
possible, in order to avoid the morbidity of ligation.
n Avoid ligation of the external iliac, superficial femoral,
or popliteal artery when possible due to high risk of
limb loss.
n Default to four-quadrant calf fasciotomy unless:
n Ischemia time <2  hours
n Lower limb hourly observations (pain, tissue
laxity, perfusion, pulses) can be assured in the
postoperative period, with concurrently avail-
able surgical capacity for rapid fasciotomy should
compartment syndrome develop. Pain out of pro-
portion to examination and/or pain with passive
motion are commonly first signs of compartment
syndrome.
n Do Not:
n Zealously repair single calf vessel injuries if there is
good evidence of foot perfusion from the uninjured
vessels.
n Fail to verify that all four compartments were opened
during calf fasciotomy.
n anterior/lateral – visualize and palpate septum
between the two compartments ensuring both
opened via H-type incision
n deep posterior – visualization of the posterior tibial
neurovascular bundle
n Injure the superficial peroneal nerve during the lat-
eral incision or the great saphenous vein during the
medial incision.
n Be falsely reassured by a normal compartment
pressure – this can be used as an adjunct in diagnosis
but not unilaterally to rule out compartment
syndrome.
Subject: Soft-Tissue and Skeletal
Wound Management in the Setting
of Vascular Injury (Chapter 26)
GENERAL
n Multidisciplinary input that is timely, coordinated, and
coherent is vital in order to achieve good functional out-
comes in complex limb trauma in both the civilian and
military settings.
n Secondary, or delayed amputation is part of the
spectrum of treatment options.
SURGICAL APPROACH
n Categorize open lower-limb fractures using the Gustilo-
Anderson system (I–III, where III is subcategorized in
• Surgical Trainee’s Perspective 9
to IIIA to IIIC – vascular repair required; Chapter 26,
Table 26.1).
n Options include: primary amputation; defer primary
amputation to a later date once patient has been coun-
selled; or attempt surgical intervention with the aim of
limb salvage (i.e., revascularization, fracture fixation,
soft tissue coverage).
n Tailor decisions to individual patient, overall injury bur-
den, and future functional goals.
n Shunts are a key part of the armamentarium in decision-
making concerning sequencing.
n The viability of the distal soft-tissue envelope defines the
level of the amputation, with preservation of viable soft
tissue a critical goal of initial débridement to preserve
options for later stump closure on re-look surgery 2 to 5
days later.
SURGICAL TACTICS
n Do:
n Save detailed wound evaluation for the OR once it is
clear that surgery is required.
n Appraise skin, muscle, and nerve loss as well as a bony
skeleton assessment during evaluation. Check for
degloving injury.
n Work superficial-to-deep and peripheral-to-central
when performing débridement, extending wounds
along fasciotomy (axial) lines where required. Pre-
serve bony fragments that have a contiguous soft
tissue attachment. Liberally irrigate.
n Utilize viable soft tissue to cover vascular repairs,
mobilizing local flaps if necessary (e.g., Sartorius flap
for common femoral vessels).
n Plan for later definitive orthopedic fixation at the
same time as definitive wound coverage (e.g., the Fix
and Flap approach) to reduce risk of deep infection
and allow for resolution of soft tissue edema.
n Be familiar with the variety of soft tissue coverage
solutions (local and distal fasciocutaneous and mus-
cle flaps, free flaps (Chapter 26, pp. 8–10).
n Do Not:
n Compromise skin perforators when performing calf
fasciotomy.
n Submit patients to complex soft tissue reconstruction
until they are physiological stable.
n Fail to involve the patient in the discussion regarding
reconstruction options, particularly when consider-
ing the place of early amputation.
Subject: Management of Pediatric
Vascular Injury (Chapter 25)
GENERAL
n Pediatric vessel size, propensity for spasm and infre-
quency of presentation combine to make management
challenging; 50% iatrogenic.
n Diagnosis is difficult in the shocked child; continuous
wave Doppler and injury extremity index are useful
adjuncts to clinical diagnosis; CT angiography is a main-
stay of localization if Duplex is not available.
10 • Surgical Trainee’s Perspective
n Abnormal ABI 2 years or younger: < .88, Abnormal
ABI > 2 years: < 0.9 (Chapter 25, p. 2)
SURGICAL APPROACH
n Extremities:
n Standard repair techniques (primary repair, vein
patch angioplasty, interposition grafting with reversed
saphenous vein) should be employed.
n Synthetic grafts are avoided where possible due to
lack of potential for conduit growth and concern for
long-term patency.
n Veins should be repaired to avoid edema, improve
patency of concomitant arterial repairs, and improve
functional outcomes.
n Interrupted sutures permit circumferential anasto-
motic expansion with growth; vessel ends should be
maximally spatulated to the same end.
n Topical papaverine and lidocaine to vessels may
reduce spasm and permit a less technically challeng-
ing repair.
n Trunk and neck:
n Blunt carotid vertebral artery injury (BCVI) rarely
benefit from surgical exploration. Antithrombotic
medications should be considered based on injury
severity. These should be followed up as per adult
practice to ensure complications do not develop.
n Stent graft repair of arch vessel injury or distal extra-
cranial carotid injury is feasible in older children but
long-term outcomes are unknown and open repair is
the default for blunt thoracic aorta injury.
n The use of intraoperative systemic heparin, and short-
term postoperative anticoagulation is permissible to
prevent vessel thrombosis, as is longer-term antiplatelet
therapy.
SURGICAL TACTICS
n Do:
n Respect the propensity of pediatric vessels to
spasm and employ the gentlest of handling tech-
niques; use vessel loops to achieve control; employ
high-magnification loupes and microvascular
instrumentation.
n Remember to employ long-term imaging follow-up
for any stent grafts to assess for device migration as
vasculature enlarges over time.
n Do Not:
n Delay in achieving the best imaging solution that the
child will tolerate; early liaison with anesthetic and
pediatric colleagues and generation of sedation/anal-
gesia options to permit imaging is advisable.
n Delay in intervening where there is evidence of
ischemic compromise to a limb and simple measures
such as fracture reduction have not restored perfusion.
n Forget that fasciotomy is a vital part of the manage-
ment of pediatric extremity vascular injury and use
this liberally.
SECTION 1
Setting the Stage

11
 1 The Vascular Injury Legacy
NORMAN M. RICH and KENNETH J. CHERRY
Although 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 cen-
tury, many if not most of the techniques of modern vascu-
lar surgery had already been explored through extensive
experimental work and early clinical application. In retro-
spect, 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 tech-
nological limitations of their era and had to await the dra-
matic advances in graft materials and imaging seen during
the 1950s and beyond.1,2
Since the days of Ambroise 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-from-ideal conditions. This has been especially true with
vascular injuries.
Although German surgeons accomplished arterial
repairs in the early part of World War I (WWI), it was not
until the Korean War 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 manu-
script by DeBakey and Simeone in 1946, who found only 81
repairs in 2471 arterial injuries among American troops in
Europe in World War II (WWII).3 All but three of the arte-
rial 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 Sir James Learmonth, who said that there was
little place for definitive arterial repair in the combat wound.
Within a few years, however, in the Korean War, the pos-
sibility of successfully repairing arterial injuries was estab-
lished conclusively, stemming especially from the work of
Hughes, Howard, Jahnke, and Spencer. In 1958, Hughes
emphasized the significance of this contribution in a review
of the Korean experience, finding that the overall ampu-
tation rate was lowered to about 13%, compared to the
approximately 49% amputation rate that followed ligation
in WWII.4
During the Vietnam hostilities, more than 500 young
American surgeons, who represented most of the major
surgical training programs in the United States, treated
more than 7500 vascular injuries. In 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
12
servicemen who sustained vascular trauma in Vietnam.5
An interim Registry report that encompassed 1000 major
acute arterial injuries showed little change from the overall
statistics presented in the preliminary report.6 Considering
all major extremity arteries, the amputation rate remained
near 13%. Although 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. Injuries of the popliteal artery,
however, remained an enigma, with an amputation rate
remaining near 30%.
In the past 50 years, civilian experience with vascu-
lar trauma has developed rapidly under conditions much
more favorable than those of warfare. Results are better
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. These methods were described in a his-
torical review by Schwartz in 1958.7 Celsus was the first
to record an accurate account of the use of ligature for
hemostasis in CE 25. During the first three centuries, Galen,
Heliodorus, Rufus of Ephesus, and Archigenes advocated
ligation or compression of a bleeding vessel to control hem-
orrhage.
Ancient methods of hemostasis used by Egyptians about
1600 BCE are described in the Ebers’ papyrus, discovered by
Ebers at Luxor in 1873.7 Styptics prepared from mineral or
vegetable matter were popular, including lead sulfate, anti-
mony, and copper sulfate. Several hundred years later dur-
ing the Middle Ages in Europe, copper sulfate again became
popular and was known as the hemostatic “button.” In
ancient India, compression, cold, elevation, and hot oil
were used to control hemorrhage, while about 1000 BCE,
the Chinese used tight bandaging and styptics.
The writings of Celsus provide most of the knowledge of
methods of hemostasis in the first and second centuries CE.7
When amputation was done for gangrene, the prevailing
surgical practice was to amputate at the line of demarcation
to prevent hemorrhage. In the first century CE, Archigenes
was apparently the first to advocate amputating above the
line of demarcation for tumors and gangrene, using liga-
ture of the artery to control hemorrhage.
Rufus of Ephesus (first century CE) noted that an artery
would continue to bleed when partially severed, but when
completely severed, it would contract and stop bleeding

within a short period of time.7 Galen, the leading physician
of Rome in the second century CE, 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 cessa-
tion 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. If 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 for-
gotten for almost 1200 years in Western medicine. A ten-
sion developed between traditional church teachings and
enlightened thought, perhaps holding back any advance-
ment in Western medicine or surgery. Use of the knife on
living tissue was considered to be wrong; consequently,
amputation was below the line of ischemic demarcation.
Abu al-Qasim al-Zahrawi, a prominent Arab physician from
Moorish Spain (10th century CE), advocated ligation in his
great work Kitab Al-Tasrif almost 600 years before Paré.7
Throughout the Middle Ages, cautery was used almost
exclusively to control hemorrhage. Jerome of Brunswick
(Hieronymus Brunschwig), an Alsatian army surgeon,
actually preceded Paré in describing the use of ligatures as
the best way to stop hemorrhage.7 His recommendations
were recorded in a textbook published in 1497 and provided
a detailed account of the treatment of gunshot wounds.
Ambroise Paré, with wide experience in the surgery of
trauma, especially on the battlefield, firmly established the
use of ligature for control of hemorrhage from open blood
vessels. In 1552, he startled the surgical world by ampu-
tating a leg above the line of demarcation, repeating the
demonstration of Archigenes 1400 years earlier. The ves-
sels 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. 1.1).7
Previously, vessels had been grasped with hooks, tenacu-
lums, or the assistant’s fingers. He designed artificial limbs
and advanced dressing technique. During 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 better outcomes than oil.
In the 17th century, Harvey’s monumental contri-
bution describing circulation of blood greatly aided the
Fig. 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 ves-
sel before ligating it. (From Schwartz AM. The historical development of
methods of hemostasis. Surgery. 1958;44:604.)
1 • The Vascular Injury Legacy 13
understanding of vascular injuries.7 Although Rufus of
Ephesus apparently discussed arteriovenous communi-
cations in the first century CE, it was not until 1757 that
William Hunter first described the arteriovenous fistula as
a pathological entity.8 This was despite the fact that, as early
as the second century CE, Antyllus had described the physi-
cal findings, clinical management (by proximal and distal
ligation), and the significance of collateral circulation.9
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 subse-
quent 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 flow stopped.7
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. In 1873, Freidrich von Esmarch, a
student of Langenbeck, introduced his elastic tourniquet
bandage for first aid use on the battlefield.10 Previously it
was thought that such compression would injure vessels
irreversibly. His discovery permitted surgeons to operate
electively on extremities in a dry, bloodless field.
Ligation was not without its complications, as British
Admiral Horatio Nelson discovered after amputation of his
right arm after the attack at Tenerife, “A nerve had been
taken up in one of the ligatures at the time of the opera-
tion,” causing considerable pain and slowing his recovery.11
Furthermore, the long ligatures meant delayed wound heal-
ing. It was Haire, an assistant surgeon at the Royal Naval
Hospital Haslar, who took the risk of cutting 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.
In 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 attendants. Although John Hunter
demonstrated the value of proximal ligation for control of a
false aneurysm in 1757, failure to control secondary hem-
orrhage resulted in the use of ligature only for secondary
bleeding from the amputation stump.12 Subsequently, Bell
(1801) and Guthrie (1815) performed ligation both proxi-
mal and distal to the arterial wound with better results than
those previously obtained.13,14
Some of the first clear records of ligation of major arter-
ies were written in the 19th century and are of particu-
lar 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 the opera-
tion was performed.15 A servant aboard the HMS Tonnant
attempted 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.
14 SECTION 1 • Setting the Stage
It 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. Approxi-
mately 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, deluged with blood!”15
The dilemma of the surgeon is appreciated by the follow-
ing statement: “In 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 for-
midable, in this case, than in a person not reduced by hem-
orrhage.”15 The wound rapidly healed following ligation of
the carotid artery, and the patient recovered.
Ellis (1845) reported the astonishing experience of suc-
cessful ligation of both carotid arteries in a 21-year-old
patient who sustained a gunshot wound of the neck while
he was setting a trap in the woods in 1844, near Grand
Rapids, Michigan, when he was unfortunately mistaken
for a bear by a companion.16 Approximately 1 week later,
Ellis had to ligate the patient’s left carotid artery because of
hemorrhage. An 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 Dr. Platt and a
student, I ligatured the left carotid artery, below the omo-
hyoideus muscle; an operation attended with a good deal of
difficulty, owing to the swollen state of the parts, the neces-
sity 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 by the blood, and
the necessity of operating by candle light.”16
There was recurrent hemorrhage on the 11th day after
the accident, and right carotid artery pressure helped con-
trol the blood loss. It was, therefore, necessary also to ligate
the right carotid artery 4½ days after the left carotid artery
had been ligated. Ellis remarked: “For convenience, we had
him in the sitting posture during the operation; when we
tightened the ligature, no disagreeable effects followed; no
fainting; no bad feeling about the head; and all the percep-
tible change was a slight paleness, a cessation of pulsation
in both temporal arteries, and of the hemorrhage.”16 The
patient recovered rapidly with good wound healing and
returned to normal daily activity. There was no perceptible
pulsation in either superficial temporal artery.16
The importance of collateral circulation in preserv-
ing viability of the limb after ligation was well understood
for centuries, as identified by Antyllus nearly 2000 years
ago.9 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 the circulation or function of the lower extrem-
ity.17 Asepsis 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 grad-
ually tightened over a period of time.18
Early Vascular Surgery
About two centuries after Paré established the use of the lig-
ature, the first direct repair of an injured artery was accom-
plished. 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 fashion about the pin (Fig. 1.2).19 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.
Unfortunately, others could not duplicate Hallowell’s
successful experience, almost surely because of the mul-
tiple problems of infection and lack of anesthesia. There
was one report by Broca (1762) of a successful suture of a
longitudinal incision in an artery.20 However, according to
Shumacker (1969), an additional 127 years passed follow-
ing the Hallowell-Lambert arterial repair before a second
instance of arterial repair of an artery by lateral suture in
man was reported by Postemski in 1886.20
Figure-of-eight suture
Laceration
Pin
Brachial artery
Fig. 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
1762;2:30–360.)
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: Longmans, Green and Co; 1912.
 1 • The Vascular Injury Legacy 15

With the combined developments of anesthesia and

asepsis, several reports of attempts to repair arteries
appeared in the latter part of the 19th century. The work
of Jassinowsky, who is credited in 1889 for experimentally Femoral artery
proving that arterial wounds could be sutured with preser-
vation of the lumen, was later judged by Murphy in 1897 Femoral vein Posterior
as the best experimental work published at that time.21,22 Anterior
In 1865, Henry Lee of London attempted repair of arterial
lacerations without suture.23 Glück, in 1883, reported 19
experiments with arterial suture, but all experiments failed
because of bleeding from the holes made by the suture nee-
dles.24 He also devised aluminum and ivory clamps to unite Aneurysmal pockets
longitudinal incisions in a vessel, and it was recorded that on the anterior and
the ivory clamps succeeded in one experiment on the femo- posterior surface of
ral artery of a large dog. Von Horoch of Vienna reported B the femoral artery
six experiments, including one end-to-end union, all of
which thrombosed.23 In 1889, Bruci sutured six longitu-
dinal arteriotomies in dogs; the procedure was successful
in four.20 In 1890, Muscatello successfully sutured a par-
tial transection of the abdominal aorta in a dog.20 In 1894, A
Heidenhain closed by catgut suture a 1-cm opening in the
axillary artery made accidentally while removing adherent
carcinomatous glands.25 The patient recovered without any
circulatory disturbance. In 1883, Israel, in a discussion of
a paper by Glück, described closing a laceration in the com-
mon iliac artery created during an operation for perityph-
litic abscess.24,26 The closure was accomplished by five silk
sutures. However, from his personal observations, Murphy
(1897) did not believe it could be possible to have success in
this type of arterial repair.22 In 1896, Sabanyeff successfully
closed small openings in the femoral artery with sutures.20
The classic studies of J.B. Murphy of Chicago (1897) con- C
tributed greatly to the development of arterial repair and
culminated in the first successful end-to-end anastomosis
of an artery in 1896.22 Previously, Murphy had carefully Fig. 1.3 (A–C) The first successful clinical end-to-end anastomosis of
reviewed earlier clinical and experimental studies of arte- an artery was performed in 1896. Sutures were placed in the proximal
rial repair and had evaluated different techniques exten- artery, including only the few outer coats; three sutures were used to
sively in laboratory studies. Murphy attempted to deter- secure the final repair. (From Murphy JB. Resection of arteries and veins
mine experimentally how much artery could be removed injured in continuity—end-to-end suture-experimental clinical research.
and still allow an anastomosis. He found that 1 inch of a Med Record. 1897;51:73.)
calf ’s carotid artery could be removed and the ends still
approximated by invagination suture technique because Hospital in Chicago on September 19, 1896, approximately
of the elasticity of the artery. He concluded that arterial 2 hours after wounding. There was no hemorrhage or
repair could be done with safety when no more than 3/4 increased pulsation noted at the time. Murphy first saw the
inch of an artery had been removed, except in certain patient 15 days later, October 4, 1896, and found a large
locations, such as the popliteal fossa or the axillary space, bruit surrounding the site of injury. Distal pulses were
where the limb could be moved to relieve tension on the barely perceptible. When demonstrating this patient to
repair. He also concluded that when more than half of the students 2 days later, a thrill was also detected. An opera-
artery was destroyed, it was better to perform an end-to- tive repair was decided on. Because of the historical signifi-
end anastomosis by invagination rather than to attempt cance, the operation report is quoted:
repair of the laceration. This repair was done by introduc-
ing sutures into the proximal artery, including only the Operation, October 7, 1896. An incision five inches long was
two outer coats, and using three sutures to invaginate the made from Poupart’s ligament along the course of the femoral
proximal artery into the distal one, reinforcing the closure artery. The artery was readily exposed about one inch above
with an interrupted suture (Fig. 1.3).22 Poupart’s ligament; it was separated from its sheath and a
In 1896, Murphy was unable to find a similar recorded provisional ligature thrown about it but not tied. A careful
case involving the suture of an artery after complete divi- dissection was then made down along the wall of the vessel to
sion, and he consequently reported his experience (1897) the pulsating clot. The artery was exposed to one inch below
and carried out a number of experiments to determine the the point and a ligature thrown around it but not tied: a careful
feasibility of his procedure. Murphy’s patient was a dissection was made upward to the point of the clot. The artery
29-year-old male shot twice with one bullet entering the was then closed above and below with gentle compression
femoral triangle. The patient was admitted to Cook County clamps and was elevated, at which time there was a profuse
16 SECTION 1 • Setting the Stage
hemorrhage from an opening in the vein. A cavity, about the
size of a filbert, was found posterior to the artery communicat-
ing 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 compres-
sion. 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 lacera-
tion 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 surround-
ings. 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 pen-
etrating 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 con-
nective 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 accu-
rately 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 cotton.22
The anatomic location of the injuries, the gross pathol-
ogy involved, and the detailed repair contributed to Mur-
phy’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 circulation during the
reported 3 months of observation.22
Subsequently, Murphy (1897) reviewed the results of
ligature of large arteries before the turn of the century.22
He found that the abdominal aorta had been ligated 10
times, with only 1 patient surviving for 10 days. Lidell
reported only 16 recoveries after ligation of the common
iliac artery 68 times, a mortality of 77%.20 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 by proximal ligation, with a mortality
rate of 35%.
In 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, Schede, Braun,
Schmidt, and others had successfully sutured wounds in
veins.22 He personally had used five silk sutures to close an
opening 3/8-inch long in the common jugular vein.
Several significant accomplishments occurred in vascular
surgery within the next few years. In 1903, Matas described
his endoaneurysmorrhaphy technique, which remained
the standard technique for aneurysms for over 40 years.27
In 1906, Carrel and Guthrie performed classic experimental
studies over a period of time with many significant results.28
These included direct suture repair of arteries, vein trans-
plantation, and transplantation of blood vessels as well as
organs and limbs. In 1912, Guthrie independently pub-
lished his continuing work on vascular surgery.14 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 in 1906.22,29 Work-
ing in Madrid, Goyanes excised a popliteal artery aneurysm
and used the accompanying popliteal vein to restore conti-
nuity (Fig. 1.4).29 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 substi-
tute to restore continuity after excision of an aneurysm of
the axillary artery.29 In his 1969 review, Shumacker com-
mented that within the first few years of the 20th century,
the triangulation stitch of Carrel (1902), the quadrangula-
tion method of Frouin (1908), and the Mourin modification
(1914) had been developed.20
By 1910, Stich had reported more than 100 cases of
arterial reconstruction by lateral suture.30 His review
included 46 repairs, either by end-to-end anastomosis or by
insertion of a vein graft.31 With this promising start, it is
curious that over 30 years elapsed before vascular surgery
was widely employed. A high failure rate, usually by throm-
bosis, attended early attempts at repair, and few surgeons
were convinced that repair of an artery was worthwhile. In
1913, Matas stated that vascular injuries, particularly arte-
riovenous aneurysms, had become conspicuous features of
modern military surgery, and he felt that this class of injury
must command the closest attention of the modern mili-
tary surgeon: “A most timely and valuable contribution to
the surgery of blood vessels resulted from wounds in war.

Artery
A V
g
Fig. 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. 1906;53:561.)
Unusual opportunities for the observation of vascular
wounds inflicted with modern military weapons … based
on material fresh from the field of action, and fully con-
firmed the belief that this last war, waged in close proxim-
ity to well-equipped surgical centers, would also offer an
unusual opportunity for the study of the most advanced
methods of treating injuries of blood vessels.”27
Matas described Soubbotitch’s experience of Serbian
military surgery during the Serbo-Turkish and Serbo-
Bulgarian Wars at the 1913 London International Con-
gress.27 He reported that 77 false aneurysms and arteriove-
nous fistulas were treated. There were 45 ligations, but 32
vessels were repaired, including 19 arteriorrhaphies, 13 ven-
orrhaphies, and 15 end-to-end anastomoses (11 arteries and
4 veins). It is impressive that infection and secondary hemor-
rhage were avoided. In 1915, Matas, in discussing Soubbot-
itch’s report, emphasized that a notable feature was the
suture (circular and lateral repair) of blood vessels, and the
fact that it had been utilized more frequently in the Balkan
conflict than in previous wars.27 He also noted that, judging
by Soubbotitch’s statistics, the success obtained by surgeons
in the Serbian Army 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
During the early part of WWI, with the new techniques
of vascular surgery well established, the German surgeons
1 • The Vascular Injury Legacy 17
attempted repair of acutely injured arteries and were suc-
cessful in more than 100 cases.31 During the first 9 months
of WWI, low-velocity missiles caused arterial trauma of
a limited extent. In 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 impractical.
In 1920, Bernheim went to France with the specific intent
of repairing arterial injuries.32 Despite extensive prior expe-
rience and equipment, however, he concluded that attempts
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. Not
that blood vessels were immune from injury; not that gap-
ing 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 such infections
as were the rule in practically all of the battle wounded.”32
The great frequency of infection with secondary hemor-
rhage virtually precluded arterial repair. In addition, there
were inadequate statistics about the frequency of gangrene
following ligation, and initial reports subsequently proved
to be unduly optimistic. In 1927, Poole, in the United States
Army Medical Department History of WWI, remarked that
if gangrene were a danger following arterial ligation, pri-
mary suture should be performed, and the patient should be
watched very carefully.
Despite the discouragement of managing acute arte-
rial injuries in WWI, fairly frequent repairs of false aneu-
rysms 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. In
1921, Matas recorded that the majority of these repairs
consisted of arteriorrhaphy by lateral or circular suture,
with excision of the sac or endoaneurysmorrhaphy.33
In 1919, Makins, who served in WWI as a British sur-
geon, recommended ligating the concomitant vein when it
was necessary to ligate a major artery.34 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 allowing some collateral development.20,34
World War II Experience
Experiences with vascular surgery in WWII were well
recorded in the classic review by DeBakey and Simeone in
1946, analyzing 2471 arterial injuries.3 Almost all were
treated by ligation, with a subsequent amputation rate near
49%. There were only 81 repairs attempted—78 by lateral
suture and 3 by end-to-end anastomosis—with an amputa-
tion rate of approximately 35%. The use of vein grafts was
18 SECTION 1 • Setting the Stage
even more disappointing: they were attempted in 40 cases
with an amputation rate of nearly 58%. That review cov-
ered the time period ending in December 1944.
More recently, Barr, Cherry, and Rich35 reported on
research analyzing the original records of WWII military
medical units in the Mediterranean and European the-
aters, with emphasis on the treatment of vascular inju-
ries subsequent to December 1944 and going through the
War’s end in May 1945. These authors found that there
was a change in practice from ligation to repair. Whereas
DeBakey and Simeone had reported a 3.3% repair rate,
surgeons in the last half year of the War repaired arter-
ies at an increased rate. The Second Auxiliary Surgical
Group repaired 9% of injured vessels, a threefold increase.
Surgeons in the Third Auxiliary Surgical Group repaired
22% of the injured arteries they encountered, a sevenfold
increase. The amputation rate of the Second Auxiliary was
25%, contrasting with the 50% rate noted with ligation.
The 107 cases of repair reported by the Third Auxiliary
was a greater total than the entirety (81) of the DeBakey
and Simeone report through 1944.
A similar shift to repair was not seen in the Pacific the-
aters.36 Only five reports of attempted repair came from the
War in the Pacific. The surgeons there were aware of the
need for something other than ligation, but the island bat-
tlefields, the vast oceanic distances, the jungle terrain and
climate, the lack of stable supply lines, the lack of estab-
lished nearby evacuation hospitals, and the lack of rapid
methods of evacuation all contributed to the static nature
of surgery for injured vessels there. It simply was not pos-
sible in the Pacific.
The controversial question of ligation of the concomitant
vein remained, though few observers were convinced that
the procedure enhanced circulation. The varying opinions
were summarized by Linton in 1949.37
A refreshing exception to the dismal WWII experience in
regard to ligation and gangrene was the case operated on by
Dr. Allen M. Boyden—an acute arteriovenous fistula of the
femoral vessels repaired shortly after D-Day in Normandy.
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 mili-
tary 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 operation.
Arteriovenous aneurysms isolated near junction with pro-
funda 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 intact
until evacuation.
As this case demonstrated Boyden’s interest in vascu-
lar surgery, the Consulting Surgeon for the First Army
presented him with half of the latter’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 DeBakey and
Simeone in 1946: “It is clear that no procedure other than
ligation is applicable to the majority of vascular injuries
which come under the military surgeons’ observation. It is
not a procedure of choice. It is a procedure of stern neces-
sity, for the basic purpose of controlling hemorrhage, as
well as because of the location, type, size and character of
most battle injuries of the arteries.”3
In retrospect, it should be remembered that the aver-
age time lag between wounding and surgical treatment
was over 10 hours in WWII, virtually precluding success-
ful arterial repair in most patients. Of historical interest is
the nonsuture method of arterial repair used during WWII
(Fig. 1.5).
1
2
Saline Proximal
Rubber shod
Artery clamp
Vein
Kelly clamp
3 Distal end of
4
vein placed into
proximal end of artery
Distal
5
6 7
Fig. 1.5 The various steps of a nonsuture method of bridging arterial
defects designed during World War II. (1) The Vitallium tube with its
two ridges (sometimes grooves). (2) The exposed femoral artery and
vein, with the vein retracted and clamps placed on a branch. (3) The
removed segment of vein is irrigated with saline solution. (4) The vein
has been pushed through the inside of the Vitallium tube, and the two
ends have been everted over the ends of the tube held in place with
one or two ligatures of fine silk. (5) The distal end of the segment of
the vein is placed into the proximal end of the artery and held there
by two ligatures of fine silk. (6) The snug ligature near the end of the
Vitallium tube is tied to provide apposition of the artery and the vein.
(7) The completed operation, showing the bridging of a 2-cm gap in
the femoral artery. (Modified description of the original drawings from
Blakemore AH, Lord JW Jr, Stefko PL. The severed primary artery in war
wounded. Surgery. 1942;12:488.)

Experiences During the Korean
War
In pleasant contrast to the experiences of WWII, the suc-
cessful repairs of arterial injuries in the Korean War were
due to several factors. There had been substantial progress
in the techniques of vascular surgery, accompanied by
improvements in anesthesia, blood transfusion, and antibi-
otics. Perhaps of greatest importance was the rapid evacu-
ation of wounded men, often by helicopter, which often
allowed their transport from time of wounding to surgical
care within 1 to 2 hours. In addition, a thorough under-
standing of the importance of débridement, delayed pri-
mary closure, and antibiotics greatly decreased the hazards
of infection.
Initially in the Korean War, attempts at arterial repair
were disappointing. During one report of experiences at a
surgical hospital for 8 months between September 1951
and April 1952, only 11 of 40 attempted arterial repairs
were thought to be successful, as reported by Hughes in
1959.38 Only 6 of 29 end-to-end anastomoses were con-
sidered initially successful, and all six venous grafts failed.
In another report from a similar period of time, only 4 of
18 attempted repairs were considered successful. In 1952,
Warren emphasized that an aggressive approach was
needed, with the establishment of a research team headed
by a surgeon experienced in vascular grafting.39 Surgical
research teams were established in the army, and there
was improvement in results of vascular repairs by 1952.
Significant reports were published by Jahnke and Seeley in
1953; Hughes in 1955 and 1958; and Inui, Shannon, and
Howard in 1955.4,40–42 Similar work in the navy was done
with the US Marines during 1952 and 1953 by Spencer
and Grewe and reported in 1955.43 These surgeons worked
in specialized research groups under fairly stabilized condi-
tions, considering that they were in a combat zone. Briga-
dier General Sam Seeley, who was chief of the Department
of Surgery at Walter Reed Army Hospital in 1950, had the
foresight to establish Walter Reed Army Hospital as a vas-
cular surgery center, and this made it possible for patients
with vascular injuries to be returned there for later study.
In a total experience with 304 arterial injuries, 269 were
repaired and 35 ligated, as reported by Hughes in 1958.4
The overall amputation rate was 13%, a marked contrast
to that of about 49% in WWII. Because amputation rate is
only one method of determining ultimate success or failure
in arterial repair, it is important to emphasize that Jahnke
revealed in 1958 that, in addition to the lowered rate of
limb loss, limbs functioned normally when arterial repair
was successful.44
EXPERIENCE IN VIETNAM
In Vietnam, the time lag between injury and treatment was
reduced even further by the almost routine evacuation by
helicopter, combined with the widespread availability of
surgeons experienced in vascular surgery. In a 1968 study
by Rich, 95% of 750 patients with missile wounds sus-
tained in Vietnam reached the hospital by helicopter.45 This
promptness of evacuation, however, created an adverse
1 • The Vascular Injury Legacy 19
effect on the overall results, for patients with severe injuries
from high-velocity missiles survived to reach the hospital
but often expired during initial care. These patients would
never have reached the hospital alive in previous military
conflicts.
Between October 1, 1965 and June 30, 1966, there
were 177 known vascular injuries in American casualties,
excluding those with traumatic amputation, as reported by
Heaton and colleagues.46 There were 116 operations per-
formed on 106 patients with 108 injuries. These results
included the personal experience of one of us (NMR) at the
2nd Surgical Hospital. The results reported included a short-
term follow-up of approximately 7 to 10 days in Vietnam. In
Vietnam, amputations were required for only 9 of the 108
vascular injuries—a rate of about 8%. Subsequently, follow-
ing detailed analysis of the Vietnam Vascular Registry by
Rich and colleagues in 1969, and then in 1970, the ampu-
tation rate was found to be approximately 13%—identical
to that of the Korean War.5,6 Almost all amputations were
performed within the first month after wounding.
The Vietnam Vascular Registry was established at Walter
Reed General Hospital in 1966 to document and analyze all
vascular injuries treated in Army Hospitals in Vietnam. A
preliminary report by Rich and Hughes in 1969 involved
the complete follow-up of 500 patients who sustained 718
vascular injuries (Table 1.2).5 Although vascular repairs
on Vietnamese and allied military personnel were not
included, the Registry effort was soon expanded to include
all American service personnel, rather than limiting the
effort to soldiers.
In 1967, Fisher collected 154 acute arterial injuries in
Vietnam covering the 1965–1966 periods.47 There were
108 arterial injuries with significant information for the
initial review from Army hospitals. In 1967, Chandler and
Knapp reported results in managing acute vascular inju-
ries in the US Navy Hospitals in Vietnam.48 These patients
were not included in the initial Vietnam Vascular Registry
report, but, after 1967, an attempt was made to include all
military personnel sustaining vascular trauma in Vietnam.
This included active-duty members of the US Armed Forces
treated at approximately 25 Army hospitals, 6 Navy hospi-
tals, and 1 Air Force hospital.
As with any registry, success of the Vietnam Vascular
Registry has depended on the cooperation of hundreds of
individuals within the military and civilian communities. In
the initial report from the Registry, 20 surgeons who had
done more than five vascular repairs were identified. As can
be seen by the list of more than 500 surgeons within the
front and back covers of the first edition of this textbook,
many surgeons in every training program in the United
States contributed to the generally good results obtained in
Vietnam.5
In addition to the surgeons already cited, hundreds of
individuals have been directly contacted through the Reg-
istry. The cooperative effort that has been obtained has not
only provided long-term follow-up information for the indi-
vidual surgeon, but it has also given the names of additional
patients who have previously been missed, and additional
specific information has been added where needed regard-
ing individual patients. A major success in the Registry
effort was obtained at the American College of Surgeons’
20 SECTION 1 • Setting the Stage

Table 1.2 Management of Arterial Trauma in Vietnam Casualties Preliminary Report from the Vietnam Vascular Registrya
Artery End-to-End Anastomosis Vein Graft Lateral Suture Prosthetic Graft Throm-Bectomy Ligation
Common carotid 2 6 (2) 3 (2) 1
Internal carotid 2 1
Subclavian 1
Axillary 6 (3) 12 (3) 2 (3) (1) (3) (1)
Brachial 57 (8) 32 (10) 2 (1) 1 (9) 1 (2)
Aorta 3 (1)
Renal 1
Iliac 1 1 1 (1) (1) (1)
Common femoral 4 (2) 11 (1) 4 (1) 1 (2) (2) (4)
Superficial femoral 63 (5) 37 (14) 7 (7) (4) 2 (6) (4)
Popliteal 31 (5) 28 (13) 6 (4) (10) 2 (4)
Total 165 (23) 127 (43) 29 (17) 2 (8) 3 (33) 6 (16)
a
Numbers in parenthesis represent additional procedures performed after the initial repair in Vietnam and repair of major arterial injuries not initially treated in
Vietnam.
Modified from Rich NM, Hughes CW. Vietnam vascular registry: a preliminary report. Surgery. 1969;65(1):218–226.

Clinical Congress in Chicago in 1970, where 110 surgeons
who had previously performed arterial repairs in Vietnam
signed in at the Vietnam Vascular Registry exhibit. The
exhibit attempted to represent some of the activities and
presented some of the interim results of the combined effort
of all of the surgeons.
The fact that significant problems continue to confront
the surgeon managing combat vascular injuries is empha-
sized by the report by Cohen and co-workers in 1969, which
evaluated a 6-month period of experience in Vietnam.49
The following list represents some of the major remaining
problems:
1. Arterial injuries associated with massive damage to soft
tissues
2. Major venous obstruction
3. Repeated vascular operations with a viable limb
4. Associated unstable fractures
5. Inadequate tissue débridement
6. Calf wounds with small vessel injury
Through the Vietnam Vascular Registry, identification
cards have been sent to the majority of the patients whose
names and records are included in the long-term follow-
up.1,2,5 The responses from the individual patients through
this media have been extremely encouraging, and the typi-
cal response that is frequently received is that the patients
appreciate the fact that “someone still cares.” Nearly 1500
patients have been evaluated by one of the authors (NMR)
in the Peripheral Vascular Surgery Clinic and Registry at
Walter Reed Army Medical Center over the past 50 years.
Preliminary plans are presently being made to maintain
an extended long-term follow-up. This will be important
in determining the long-term results of the repairs and in
determining the incidence of such problems as the early
development of arteriosclerosis in the repair sites of these
young men. Personal contact has been made through the
Registry with approximately 300 other surgeons who have
performed vascular repairs in Vietnam, and the support of
these surgeons has been solicited in helping with this long-
term follow-up project.
Vietnam via Gulf War 1991 to
Afghanistan and Iraq
Since Vietnam, there have been many minor conflicts
around the world. In the British Falklands campaign of
1982, despite excellent surgical outcomes for those who
reached field hospitals, there was little vascular experi-
ence. The relative paucity of surgical cases during the mul-
tinational Gulf War of 1991 similarly did not influence
advances in military vascular surgery.
The decade and a half of war that followed the events
of September 11, 2001, resulted in a significant bur-
den of injury including vascular trauma. Studies from
White, Stannard, and, more recently, Patel have shown
that the recorded rate of this injury pattern in modern
combat is 7% to 15%, which is considerably higher than
that reported in previous wars.50–52 The reasons behind
the increased rate of vascular trauma are discussed in
Chapter 2, but suffice it to say the recent wartime expe-
rience forms the basis for much of the text that fol-
lows. Providing details on vascular trauma managed in
Afghanistan and Iraq is beyond the scope of this particu-
lar chapter; however, strategies such as topical hemostatic
agents, the reemergence of tourniquets, temporary vascu-
lar shunts, smarter transfusion and resuscitation strategies,
and even catheter-based endovascular techniques will be
highlighted throughout the text. Finally, the vexing injury
pattern from these wars—that is, vascular disruption with
noncompressible torso hemorrhage—will be redefined with
a call for new management strategies.
Civilian Experience
The frequency of arterial injuries in civilian life has
increased greatly in the past decade. This is due to more
automobile accidents, the appalling increase of gunshot
and stab wounds, and the increasing use of therapeutic and
diagnostic techniques involving the cannulation of major
arteries.

As recently as 1950, most general surgeons had little
experience or confidence in techniques of arterial repair.
The experiences in the Korean War, combined with the
widespread teaching of techniques of vascular surgery
in surgical residencies, resulted in a great increase in fre-
quency of arterial repair between 1950 and 1960. This is
well-illustrated in the report by Ferguson and co-authors
in 1961 of experiences with 200 arterial injuries treated in
Atlanta over the 10-year period beginning in 1950.53 The
proportion of patients treated by arterial repair increased
from less than 10% in 1950 to more than 80% in 1959. In
the latter part of the study, ligation was done only for inju-
ries of minor arteries, such as the radial or ulnar, or certain
visceral arteries. The mortality rate was reduced by one-
third and the amputation rate by half when two consecu-
tive 5-year periods were compared. The rate of success of
arterial repair improved from 36% to 90%.
In 1964, Patman and associates reported experiences
with 271 repairs of arterial injuries in Dallas.54 In the
past decade, a series of reports from large urban centers
throughout the United States have appeared, all document-
ing the effectiveness of current techniques of arterial repair.
Reference will be made to these reports in specific discus-
sions in the following chapters. Two large series from the
early 1970s are those of Drapanas and colleagues in 1970
from New Orleans, which included 226 arterial injuries,
and the cumulative report by Perry and associates from Dal-
las in 1971, which included 508 arterial injuries.55,56
In 1974, Smith and co-workers reported a survey of
268 patients in Detroit with 285 penetrating wounds of
the limbs and neck.57 There were 127 peripheral arterial
injuries identified. In 1975, Cheek and coauthors reviewed
200 operative cases of major vascular injuries in Memphis
that included 155 arterial injuries.58 Kelly and Eiseman, in
1975 from Denver, found 116 arterial injuries among 175
injuries to major named vessels in 143 patients.59 Hardy
and associates, in 1975, reviewed 360 arterial injuries in
353 patients in Jackson.60 Bole and colleagues, in 1976,
reported 126 arterial injuries in 122 patients in New York
City during 1968–1973.61
During the Troubles in Belfast in the 1970s and 1980s,
Baros D’Sa combined the skills required of civilian and mili-
tary vascular surgeons in managing vascular injuries and
developed an international reputation for the use of shunts
in terrorist-induced, complex vascular trauma.62,63
Conclusion
Advances in the management of vascular trauma have
been driven by the requirements of warfare. This is no less
true now than it was in medieval times. In the last 50 years,
concomitant technological improvements in resuscitation,
anesthesia, and endovascular technologies within the civil-
ian sector have contributed further. The difficult decisions
of when to repair, how to repair, damage-control vascular
surgery, and when to amputate will be covered in the fol-
lowing chapters of this textbook.
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1 • The Vascular Injury Legacy 21
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34. Makins GH. Gunshot Injuries to the Blood Vessels. Bristol, England: John
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Rasmussen TE. The epidemiology of vascular injury in the wars in
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of arterial injuries. Ann Surg. 1961;153:980–986.
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the neck and limbs. Arch Surg. 1974;109(2):198–205.
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management of major vascular injuries: a review of 200 operative
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507–514.
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Civilian arterial injuries. Ann Surg. 1976;183(1):13–23.
62. Barros D’Sa AAB. Management of vascular injuries of civil strife.
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Grune & Stratton Ltd; 1989.
 2 Epidemiology of Vascular
Trauma
PETER GOGALNICEANU, TODD E. RASMUSSEN, and NIGEL R.M. TAI
Repair the vessel without compromising the lumen
DR. RICHARD LAMBERT (1759)
Lambert’s dictum describes “what” vascular surgeons do.
This has remained constant throughout the centuries.
However, “why” and “how” surgeons do this has changed
drastically from decade to decade. The vascular trauma sub-
specialty in particular has experienced changing practices
with regard to fluid versus blood products resuscitation,
tourniquet use, point-of-care imaging and endovascular
innovations, such as REBOA and the covered stent.
The true purpose of epidemiological study should not
be limited to the listing of injury patterns by mecha-
nism of injury (MOI), anatomical location or geography.
These provide interesting facts but are somewhat artificial
academic exercises that have limited clinical applications.
The real purpose of epidemiology is to understand how
society changes and the mechanisms by which human suf-
fering occurs. Epidemiology serves the surgeon by provid-
ing an understanding of how injury patterns arise from
the patient’s and the surgeon’s broad social and political
context. More importantly, it allows anticipation of how
different infrastructures can serve to mitigate or exacer-
bate this harm. Vascular trauma is both catastrophic and
complex. Studying its origins and patterns provides a more
subtle representation of health-care issues, which have a
far greater reach than the routines of the operating room.
Furthermore, the evolution of the vascular surgeon’s arma-
mentarium, from the cauterizing iron to the endovascular
stent, has itself impacted on the landscape of vascular inju-
ries as the range of iatrogenic injuries has grown.
Contemporary drivers of epidemiological change in vas-
cular injury include:
1. Military conflict.
2. Civilian trauma and urban unrest, including accidental
injury, terrorism, and gang-related civilian violence.
3. Trauma at the extremes of age.
4. Iatrogenic vascular injury as a result of minimally inva-
sive or endovascular procedures.
Principles of Vascular
Epidemiology
Epidemiology (from the Greek: the study of that which befalls
the people) is defined as the study of the distribution and
determinants of health-related states or events in human
populations, and the application of this study to the preven-
tion and control of health problems.1 The global burden
and impact of trauma as an agent of death and disability is
increasingly well characterized (Table 2.1). However, while
the prevalence and incidence of individual vascular injury
patterns have been well depicted in local situations, the
epidemiological study of vascular trauma is a relatively
underexploited field.2 Possible reasons for this include the
heterogeneity of the circumstances in which vascular
injury may be sustained, the protean direct and indirect
consequences of vascular trauma to bodily systems, and the
unsuitability of modern scoring methodologies to capture
the specific effects of vascular injury on patient outcome.
In the first edition of Rich’s Vascular Trauma, Geza de Takats
summarized richness and complexity of traumatic mecha-
nisms of injury as follows:
From time immemorial, hungry or suspicious cavemen,
frustrated and jealous lovers, violent criminals, and, more
recently… machinery and automobiles, have inflicted serious
and often irreparable injury on the human body and soul.
Consequently, understanding the historic and contem-
porary epidemiology of vascular trauma is important.
Box 2.1 lists the generic components of epidemiological
endeavor. With respect to trauma, recognizing the preva-
lent populations underpins the alignment and targeting
of hospital resources, as well as education of health-care
providers. In essence, this informs the design of trauma
and vascular-care systems. More widely, the standard-
ized and open-access description of the incidence, mech-
anisms, and demography of traumatic injury empowers
comparison of properly stratified outcomes from injury.
In turn, these aid not only research, but also clinical gov-
ernance, quality-improvement initiatives, and fair reim-
bursement for treating hospitals. Subsequently, these
provide knowledge of socioeconomic realities and influ-
ence the design and assessment of preventative public
health interventions, thus informing health and social
policy.
If vascular and trauma clinicians are to anticipate
injury patterns, to track changes, and to put into place
effective programs to prevent or to mitigate the effects
of vascular trauma, then the study of injury epidemiol-
ogy is an essential function of practice. The aim of this
chapter is to provide the context to more-detailed illus-
trations of specific anatomical injuries given elsewhere
in the text.
23
24 SECTION 1 • Setting the Stage

Table 2.1 Summary: Deaths (000s) by Cause, in WHO Regions (a), Estimates for 2010 and 2016.
Cause World (2016) World (2010)
Population
(thousands) 7,461,884 6,140,789
000 % total 000 % total Change (000)
Injuries 297,394 11 290,806 10 6589
A. Unintentional 215,158 8 209,494 7 5664
injuries
1. Road injury 82,538 3 69,837 2 12,701
2. Poisonings 6269 0 8341 0 −2073
3. Falls 38,162 1 30,431 1 7731
4. Fire, heat, and hot substances 10,610 0 12,876 0 −2266
5. Drowning 20,134 1 28,715 1 −8581
6. Exposure to mechanical forces 13,225 0 14,057 1 −832
7. Natural disasters 361 0 670 0 −309
8. Other unintentional injuries 43,860 2 44,567 2 −707
B. Intentional 82,236 3 81,311 3 924
injuries
1. Self-harm 37,564 1 39,194 1 −1630
2. Interpersonal violence 31,237 1 32,174 1 −938
3. Collective violence and legal 13,436 1 9943 0 3492
intervention
From the World Health Organization (WHO) Global Health Observatory Data Repository. Accessed May 2019. https://www.who.int/healthinfo/
global_burden_disease/estimates/en/.

different denominators, and inflating or deflating preva-

Box 2.1 Core Purposes of Epidemiological
Programs (1)
Identifying risk factors for disease, injury, and death
Describing the natural history of disease
Identifying individuals and populations at greatest risk for disease
Identifying where the public health problem is the greatest
Monitoring diseases and other health-related events over time
Evaluating the efficacy and effectiveness of prevention and
treatment programs
Providing information that is useful in health planning and
decision making for establishing health programs with
appropriate priorities
Assisting in carrying out public health programs
Context and Categorization of
Vascular Trauma
The epidemiological study of vascular injury is hampered by
the protean nature of trauma and the multiple and interre-
lated factors that determine functional outcome. Examples
include co-injury to critical soft tissue, as well as bony and
neurological structures. This difficulty is made more acute
by the lack of uniformity among authors as to appropriate
injury descriptors, outcome metrics, and follow-up peri-
ods. Most studies in both the military and civilian domains
offer descriptions of cohorts comprising specific vascular
regions (extremities) or anatomical areas (e.g., calf vessels);
this provides detail at the expense of proper epidemiologi-
cal perspective. Rates of vascular trauma are conflicted by
use of different definitions of population-at-risk, invoking
lence accordingly. Outcomes are defined differently and with
varying degrees of accuracy. For instance, mortality rates
may variously be built on definitions such as death while
an inpatient, ignoring those who expire before reaching
the hospital. Epidemiology is dependent on data; countries
with mature trauma systems and mandatory data-collection
infrastructures offer a more fruitful perspective on injury
rates and causes. Similarly, while wartime populations often
have higher vascular injury rates than peacetime cohorts,
the presence of detailed injury data (with accurate descrip-
tion of the denominator populations) is directly related to
whether a trauma systems approach to data collection is
deployed by the medical services of the combatant parties.
It is fair to say that countries without a “trauma systems”
approach to injury management are usually unable to
describe the effect of vascular trauma in populations-at-risk.
Because most developing countries fall into such categories,
it is correct to assume that the global burden of vascular
trauma is unknown.
Vascular trauma may be broadly categorized according to:
1. MOI: e.g., iatrogenic, blunt, penetrating, blast, combina-
tion injuries
2. Anatomical site of injury: e.g., compressible versus
noncompressible hemorrhage
3. Contextual circumstances: e.g., military versus civilian
Each of these domains may be further stratified, with
military injury being subdivided by patient status (combat-
ant vs. noncombatant) and category of conflict (civil war,
counter-insurgency warfare, maneuver warfare). Civilian
injuries may be similarly contextualized by local circum-
stances (e.g., urban trauma vs. rural trauma).

1. MILITARY CONFLICT
Warfare since the 2000s has lost many of the character-
istics that defined previous engagements, such as World
War I (WWI), World War II (WWII), Korea, and Vietnam.
Current conflict is a “war among the people,” where “people
in the streets and houses and fields… are the battlefield. Military
engagements can take place anywhere, with civilians around,
against civilians, in defense of civilians. Civilians are the targets,
objectives to be won, as much as an opposing force.”3 As such,
vascular trauma inflicted by high-energy military ballistic
projectiles and purpose-built or improvised blast weaponry
can affect two populations-at-risk: combatants and non-
combatant (civilians).
Vascular Trauma in Combat Troops
It is important to remember that military combatants repre-
sent a specific demographic group. Compared with civilian
injuries, military arterial injury occurred predominantly
in males in their twenties (25 vs. 32 years and 98.7% vs.
82% males, respectively).4 Furthermore, the predominant
mechanisms of injury to US and UK soldiers (Afghanistan)
are either improvised explosive devices (48%) or gunshot
wounds (29%).5 Contemporary data confirms that exsan-
guination is the major cause of death in fatally wounded
soldiers.6–9 It is also estimated that 80% of arterial injuries
sustained in combat affect the extremities.10 More than
70% of these are associated with blast injuries.
Vascular injury rates seem only to have increased as war-
fare has become more sophisticated: allied surgeons in WWI
noted vascular trauma rates of 0.4% to 1.3%11; DeBakey
characterized the vascular injury burden in WWII as affect-
ing 0.96% of all patients; later, in the Korean and Vietnam
wars, the rate of vascular injury was judged to be higher,
at 2% to 3%.12–16 Coalition militaries engaged in combat
operations in Afghanistan and Iraq have invested substan-
tially in detailed trauma registries in order to capture injury
data. Such databases have been used to characterize miscel-
laneous injury patterns so that force protection (e.g., body
armor or vehicle design) and treatment protocols can be
continually updated and aligned to contemporary trauma
archetypes. Interestingly, present rates of wartime vascular
trauma confirm a much higher prevalence than in previous
campaigns,17–20 with arterial injury rates being reported by
some as high as 7.1%.10
A comparative study of the outcomes of major arterial
injuries in military and civilian populations was under-
taken by Markov et al.4 One-quarter of all military arterial
injuries were not amenable to control by tourniquet appli-
cation or compression (noncompressible arterial injuries
[NCAIs]). Military arterial injuries were shown to have a
lower incidence of NCAIs compared with the civilian pop-
ulations (28% vs. 61%). These differences were attributed
to a higher rate of blunt trauma to the torso in the civilian
setting, as a result of motor vehicle collisions. Blast injuries
were the predominant mechanism of injury in military
settings (69%), while the civilian population was equally
affected by either blunt or penetrating trauma (50% and
50%, respectively). No difference in mortality was found
between matched military and civilian cohorts where com-
pressible arterial injuries were involved (2% military vs.
4.1% civilian). However, their study suggested that NCAIs
2 • Epidemiology of Vascular Trauma 25
carried a lower mortality in the military setting (4.2% vs.
12.16%). This was potentially attributed to the use of body
armor and implementation of combat casualty care strat-
egy. This includes advanced military resuscitative strategies
and the necessary infrastructures that allow rapid evacua-
tion and prehospital care.
A comprehensive study summarizing recent US military
experience (13,076 cases) analyzed vascular injuries from
the United States Joint Theater Trauma Registry (JTTR)
(2002–09).21 It defined battle-related injuries as those suf-
ficiently severe to prevent return to duty into the combat
theater. The specific incidence of vascular injury (“total
incidence injury”) was found to be 12%, while the inci-
dence of injuries requiring surgery (“operative incidence”)
was found to be 9%. The study also identified differences
in vascular injury rates between troops deployed to Iraq
(12.5%) and Afghanistan (9%). Other differences included
causative mechanism, with blast accounting for 74% and
67% of injuries in Iraq and Afghanistan, respectively (with
an overall contribution of 73%). There was no difference
in the anatomical distribution of the injuries, nor the “died
of wounds” (DOW) rate (6.4%) between theaters. Wounds
were principally sustained to the extremities (79%), torso
(12%), and cervical regions (8%). In the torso, the most
commonly injured vessels were the iliac arteries (3.8%), fol-
lowed by the aorta (2.9%), the subclavian arteries (2.3%),
and the inferior vena cava (IVC) (1.4%). In the neck, 109
carotid injuries accounted for 7% of injuries. It was noted
that the vascular injury burden borne by the extremities
was remarkably similar to that noted by DeBakey in WWII.
In contrast, the higher contemporary rate of cervical and
aortic injury was attributed to increased survivability and
far-shortened medivac times.
Overall, the authors concluded that the rate of vascular
injury in these wars was five times that previously reported
from Vietnam and Korea. The early reported incidence of
vascular injury was estimated at around 4.4% to 4.8%,
based on data published from US military hospitals in
Iraq.17,18 However, when this analysis includes nonoperated
cases and vascular injury that was unrecognized on recep-
tion, the prevalence can be as high as 7%.18 This marked
increase in vascular injury rates is striking and not entirely
clear. In addition to increased wound survivability, possible
reasons include:
1. the very high rate of blast-related injury etiology in these
campaigns,
2. overestimation of the population-at-risk in earlier
reports (thus deflating the denominator), or
3. more accurate capture of “minor” nonoperated vascular
wounds (adding to the numerator).
In a similar but smaller British study, Stannard et al.
scrutinized the records of 1203 UK servicemen injured
through enemy action between 2003 and 2008.20 Unlike
the US JTTR, the British JTTR dataset also included patients
who were killed in action (KIA)—that is, who died before
reaching a medical treatment facility22 (an aspect of injury
burden not scrutinized in US accounts). Characterization of
injury was made from clinical data and from postmortem
examinations conducted by the UK Coroner system. It was
determined that 9.1% of this cohort sustained injuries to
26 SECTION 1 • Setting the Stage
named vessels. Blast wounds accounted for 54% torsocer-
vical injuries and 76% of extremity wounds, respectively.
Critically, the study showed that more than half of patients
who sustained an injury to a named vessel died before any
surgical intervention could be undertaken. Injury to named
vessels in the thorax and aorta proved almost universally
fatal. Cervical vascular injuries also proved highly lethal,
with 13 of 17 patients affected eventually succumbing.
Two-thirds of the vascular injuries sustained involved the
extremities. Almost half of these patients survived, albeit
with eventual amputations in a significant proportion. The
limb salvage (primary assisted patency) rate was 84%. This
UK group concluded that while favorable limb-salvage rates
are achievable in casualties able to withstand revasculariza-
tion, torso vascular injury is not usually amenable to suc-
cessful surgical intervention.
The rate of lower limb amputation following vascular
injury to the extremities is important, being a major cause
of disability and avoidable mortality. Lower limb arterial
injuries are thought to be caused predominantly by blast
injuries (70%) or gun-shot wounds (30%). The common-
est affected vessels in penetrating limb injuries include the
superficial femoral artery, the popliteal artery and the pos-
terior tibial arteries, each being affected in around 20% of
cases.10 Perkins et al. studied 579 injured extremities in
US service members from the wars in Iraq and Afghani-
stan.23 Their primary amputation rates were 8.5%, with
salvage attempts occurring in 91% of patients. Tissue loss
and damage control were the principal reasons for primary
amputations. Secondary amputations occurred in 15.5%
of limbs. Early secondary amputations were associated by
nonviable or infected tissue, while late ones with poor limb
function. 57% of amputations were transtibial, while 30%
were transfemoral. It is also important to note that 82.7%
of those undertaking limb salvage were amputation free at
10 years. This highlights the significant threat that military
vascular injuries pose to the lower limbs, but also the value
of attempting limb revascularization within adequately
prepared trauma infrastructures.10,23
Vascular Trauma among Local National Populations
Few studies have examined the burden and impact of vas-
cular trauma in civilians injured in time of war. The regis-
tries of military trauma systems may be biased toward data
collection among their own troops, or in such cases where
information is captured there is usually no data on long-
term outcomes due to lack of follow-up in war-afflicted
societies. In a study by Clouse et al. analyzing vascular
casualties treated at a Level IIIa US facility in Iraq, 30% were
civilians while and 24% were local national combat
forces.17 Extremity vascular injuries were significantly more
prevalent in US forces compared with the local popula-
tion (81% vs. 70%). Vascular injury to the torso was sig-
nificantly less common in US forces (4% vs. 13%), but neck
injuries occurred with similar prevalence (14% vs. 17%).
The authors hypothesized that the lack of protective body
armor might increase the nonextremity vessel injury rate
in the Iraqi population. Interestingly, vascular injuries were
noted to be overrepresented in the local nationals: although
Level III facility is equivalent to a major trauma center (MTC).
a
40% of those admitted to the facility were of Iraqi origin,
they made up to 51% of the vascular injury cohort.
Deployed military hospitals are primarily configured and
resourced for the care of their own nation’s soldiers, so
understanding the additional burden presented with a large
local national population of injured civilians, insurgents,
and military remains important. In a supplementary report
from the Air Force Theater Hospital in Balad, Iraq,24 it was
determined that the incidence of vascular trauma among
4323 locals treated at the facility was 4.4%. The authors
focused on extremity injuries—which affected 70% of vas-
cular casualties—and observed that the median length of
stay from presentation to definitive wound closure was 11
days. Casualties underwent a median of three operations.
Notably, the age range was 4 to 68 years and included 12
pediatric injuries. Mortality was 1.5% with significant com-
plications in 14% but despite this a 95% limb salvage rate
was recorded.
This experience matches earlier reports. Sfeir et al.25
described a population of 366 lower limb–wounded vas-
cular cases, sustained by a mixed population of combatant
and noncombatants during the Lebanese civil war over a
16-year period ending in 1990. Two-thirds of patients had
received gunshot wounds. Patients included 118 who had
popliteal arterial injuries, 252 with femoral injuries and
16 who had tibial vessel injuries. The overall mortality rate
was 2.3% with no mortality in the popliteal and tibial injury
group whereas there were nine deaths in the femoral inju-
ries group. The overall amputation rate was 6% (11.7% for
the popliteal injuries group). Mirroring more contemporary
experience, the authors associated failure of limb salvage
with physiological instability, delay in repair (of more than
6 hours from injury), and presence of long bone fracture.
2. CIVILIAN VASCULAR INJURY
The overall impact of vascular trauma in civilian society is
largely unknown in societies without recourse to large pop-
ulation datasets. Even in the United States, which is served
by the National Trauma Data Bank (NTDB),b large-scale
studies are few. Overall, regional variations in incidence and
MOI of vascular trauma occur based on socioeconomic and
political challenges faced by the populations studied. Vas-
cular trauma in the civilian setting is also seen as a major
consumer of hospital resources,26–28 being associated with
longer hospital stay, greater use of critical care resources,
as well as higher blood transfusion requirements.28 Rapid
access to adequate trauma care facilities is universally
considered to be of major importance in achieving good
outcomes.26,27
In 2010, Demetriades et al. attempted to characterize the
nature of vascular trauma in 22,089 patients—including
children—drawn from a general trauma population of
more than 1.8 million case files recorded on the NTDB
system.29 Accepting the almost inevitable reporting bias
that accompanies analysis of such retrospective data, it was
determined that the overall incidence of vascular injury
during the study period (2002–06) was 1.6%. Four-fifths
of the injured were male, and the average age was 34 years.
NTB: a national trauma registry administered by the American College
b
of Surgeons and receiving data from more than 900 trauma facilities.

It was reported that 51% sustained a penetrating mecha-
nism; the top four mechanisms of injury were motor vehi-
cle collisions, firearm injuries, stab wounds, and falls from
height. Just under one-quarter were shocked on admission,
and over half had an Injury Severity Score of more than 15.
Abdominal injuries and chest injuries accounted for more
than 24.8% and 23.8% of the trauma burden, respectively,
with arm and leg injuries accounting for 26.5% and 18.5%.
Adult mortality was 23.2%; vessels associated with the
highest amputation rates were the axillary artery (upper
limb amputation rate of 6.3%) and popliteal artery (lower
limb amputation rate of 14.6%).29 This impressive dataset
summarized national epidemiological data; but what is of
concern to individual trauma and vascular surgeons is the
local epidemiology of vascular injury among their patients,
because this will determine workload, case mix, and
outcome.
Another American cohort of 5858 patients from NTDB
(2012) analyzed traumatic abdominal and pelvic vascu-
lar injuries. The overall mortality for this group was 25%.
Blunt trauma accounted for 57% of injuries, while 40%
were caused by penetrating trauma. Those with penetrat-
ing injuries were 1.72 more likely to die than those with
blunt trauma. Men had a higher incidence of penetrating
trauma compared with women (48% vs. 17%). This study
highlighted once again the poor outcomes of vascular trun-
cal injuries, especially when associated with penetrating
trauma.30
Data from a major UK trauma center suggested that
vascular injury occurred in 4.4% of consecutive trauma
admissions between 2005 and 2010.28 Vascular injuries in
this cohort had a 18% death rate, with the highest mortality
being seen in those with blunt injuries to junctional areas.
In this UK-specific cohort, stab wounds were the common-
est cause of vascular injury, being five times more com-
mon than gun-shot wounds. However, patients with blunt
injuries were more severely injured. Arterial injuries repre-
sented 87% of the vascular trauma, while 13% were venous
in nature. 47% of injuries were central in nature, with 35%
affecting the extremities and 20% junctional areas.
Civilian trauma has also been changed by the fact that ter-
rorism is now no longer an isolated phenomenon associated
with the developing world. An estimated eightfold increase
in terrorist attacks was noted between 2000 and 2014.31
Recent attacks, including the Boston Marathon bomb-
ing,32 the Paris attacks,c,33 as well as the recent UK terrorist
attacks,d,34 have provided an evolving picture of terror-
related vascular injuries in civilian populations. Many of
these have been associated with a multitude (and often com-
bined) mechanism of injuries, including improvised explo-
sive devices (IED), stabbing, and motor vehicle-induced
injuries. Injury patterns in this population are different
from those seen in military circumstances, as civilians lack
ballistic-proof equipment and communities may not be pre-
pared for these attacks. Different studies of civilian trauma
in Israel (2000–2005) showed that vascular trauma was
more common in terrorist-related compared with non–
terrorist-related scenarios (10% vs. 1%).26 Specifically,
c
Paris terror attacks (2015): Charlie Hebdo and Bataclan.
d
UK terror attacks (2017): Manchester Arena bombing, London Bridge
attack, and Westminster Bridge attack.
2 • Epidemiology of Vascular Trauma 27
vascular trauma occurred in 8.6% of explosion casualties
and was associated predominantly with penetrating inju-
ries.27 Individuals with vascular trauma also had a higher
injury severity score and a mortality rate five times greater
than those with nonvascular trauma (22.9% vs. 4.9%,
respectively). The lower-extremities and head/neck areas
were the most common anatomic regions to suffer vas-
cular trauma (37% and 25%, respectively). Data from the
Boston Marathon bombing also showed that 66% of
patients admitted to hospital had suffered lower extremity
injuries, with 22% undergoing amputation.32
These studies concluded that vascular trauma is associ-
ated with poorer outcomes in the civilian population26,27
and that the higher incidence of vascular injuries in terror-
related scenarios requires integration of a vascular surgeon
as part of the trauma team.
Urban Populations
Inner-city populations in countries such as the United
States and South Africa experience high rates of interper-
sonal violence, often mediated by low-energy handgun or
bladed weaponry. South Africa has an intentional homicide
rate of 32 per 100,000. In the United States this is 4.8 per
100,000, while in the UK it is considerably less, at 1.7 per
10,000.35–37 However, there is significant regional variation
in violence rates even within societies where violent injury
is common. For instance, in South Africa, Limpopo expe-
rienced 762 murders in 2009–10, while Gauteng experi-
enced 3444 murders over the same time frame.35 Similarly,
the murder rate in non-suburban US cities is approximately
twice that of suburban areas.36 Of course, the relationship
between urban concentration and population homicide
rates is not universal. Australia has an overall murder rate
of 1.2 per 100,000, yet the homicide rate in the sparsely
populated Northern Territories is 3.96 per 100,000, com-
pared with 0.8 in Victoria State.38 The degree to which
national and urban murder statistics translate to violent
vascular injury is difficult to quantify, but it is unsurpris-
ing to note that the majority of classical reports detailing
the burden, type, and outcomes from vascular trauma
come from urban institutions serving inner-city and poorer
populations. As described earlier, population-wide data
garnered from the National Trauma Data Bank suggests
the contemporary overall prevalence of vascular injury in
patients is 1.6%21 whereas that presenting for treatment in
urban areas has been quoted as 2.3% in a New York Level I
trauma center39 and 3.4% in a Level II center in El Paso,
Texas.40 These reports typify the perceived demographic as
almost always male and usually young. Mortality is approx-
imately twice that of nonvascular patients39 and penetrat-
ing trauma is overrepresented in vascular patients, with the
El Paso authors recording a 40% penetrating injury mecha-
nism in vascular patients against a rate of 10% in the gen-
eral trauma population.
The largest US single center study of vascular trauma to
date was published in 1988 and emanated from Houston.41
It typifies the experience of many large inner-city urban
trauma facilities and was undertaken with the aim of deriv-
ing epidemiological conclusions that would guide trauma-
center and health logisticians. The study encompassed a
30-year period, describing 5760 cardiovascular injuries
in 4459 patients. The authors set themselves the task of
Another random document with
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dying. I must go to him. Surely you wouldn’t have the heart to keep me
away? He is the only relative I have in the world! How can I act, and sing,
and laugh, when there is a weight like lead at my heart?”
The stage-manager eyed her pityingly. “I know it’s very hard,” he said,
in a softened voice. “But just consider a moment. You cannot get a train to
Durlston to-night, for the last one went at about six o’clock; so you would
have to wait till morning in any case. Now, suppose you go back to St.
John’s Wood, what will you do? Simply sit still and make yourself ill with
fretting, most probably. Whereas, if you remain here, your mind will, at
least temporarily, be diverted into other channels. Miss Franks, I am sure
you are a brave young lady. Won’t you try?”
“Oh, it’s cruel, Mr. Calhoun——” Grace Haviland began, but her brother
would not allow her to finish the sentence.
Celia was well-nigh distracted. Although loth to cause the stage-manager
so much inconvenience and bother, it would be too terrible to think of
Herbert, perhaps dying, with none of his own kin near him, whilst she was
playing on the hateful stage. Calhoun pulled out his watch, for the precious
minutes were speeding away. All three looked at her in eager expectation.
What would her answer be?
After what seemed an eternity, although it was in reality only about fifty
seconds, she heaved a deep sigh.
“All right, I’ll go through with it,” she said with an effort. “Or at least
I’ll do my best. But please—leave me alone—just for a few minutes.”
“That’s a brave girl!” exclaimed Haviland, with gratification. “I knew
she wouldn’t put us in such a fix.”
“In seven minutes the call-boy will be here,” said the stage-manager; and
then with a word of encouragement the two men withdrew.
Celia sat down at the table and buried her face in her hands. She tried to
think, even to pray, but her senses seemed quite dulled. Fortunately the
possibility of her stumbling or breaking down never entered her mind. She
had promised to go through with it; and she meant to fulfil her promise.
There might be tears and pain at heart, but there would be the usual stage-
smile on her face. When she raised her head, there was an expression of
almost fierce determination on her countenance. She would not, must not,
fail!
 Mrs. Jackson readjusted the details of her costume, whilst Grace tried to
utter words of commiseration and encouragement. Then the former
produced a small spirit-flask and glass, and bade Celia drink.
“There’s nothing like a drop of brandy neat, for putting life into a body,”
she said cheerfully. “Come now, drink it, missie; it will do you good.”
But the girl demurred. “No thanks, I would rather not,” she replied. “I
am all right now;” and then the patter of flying feet heralded the coming of
the call-boy.
For years after Celia remembered that night, and declared she could
never have gone through it again. Calhoun said she had never acted so well.
In the third act, in which she was the central figure all through, she
surpassed herself, and as the curtain fell, evoked a veritable tumult of
applause. And not one out of that light-hearted, pleasure-loving audience
had the slightest idea how it hurt her to give that merry ringing laugh at the
end of the first scene; or that when, later on, she had to say, “Where is my
beloved?... My beloved lays a-dying!” the tears in her voice were
unfeigned.
But her nerves were stretched to their utmost limit of endurance, and the
reaction was bound to follow. She returned to the dressing-room in a state
bordering on exhaustion, scarcely heeding Mr. Calhoun’s “Well done!”
Fortunately, however, the worst was over, for the remaining act entailed but
slight exertion. She begged Grace Haviland to read the account of the
assault at Durlston whilst she was changing her costume; and, occasionally
interrupted by sundry comments from Mrs. Jackson, Grace complied with
her request.
The gist of the matter was this:—
Jacob Strelitzki, a former heeler at Messrs. Mendel and Co.’s boot
factory at Durlston, had, after an absence of two months, returned and run
amok at the factory, attempting to wound three men with a large clasp-
knife. Being of the opinion that he was either the victim of delirium
tremens, or else had lost his reason, the factory people made every effort to
detain him, but he cleverly managed to slip through their fingers and made
his escape. Nothing more was heard of him until that very morning, when
he had forced his way into the studio at the Towers, and, without any
warning, attacked Mr. Karne—who was at work upon a picture—with the
same clasp-knife he had used on the former occasion. Mr. Karne’s servants
had come to the rescue, and managed to subdue the man, who was
undoubtedly a raving lunatic, but not before he had been able to inflict
serious injury to the unfortunate artist. No adequate motive for the crime
was assigned, except that for some time Strelitzki had cherished a senseless
grudge against Herbert Karne, and had so worked upon his comrades at the
factory, that at his instigation they had even set fire to the artist’s house.
Recently, however, a complete reconciliation between Herbert Karne and
the factory people had taken place; and the latter were shocked and
horrified in the extreme at the dastardly action of their former colleague.
Meanwhile, Mr. Karne lay in a critical condition, having been wounded in
the thorax and right lung.
Celia’s face blanched as she listened, whilst a sickening anxiety tore at
her heart. Oh, if only Higgins had despatched the telegram a little earlier,
she would have been well on her way to Durlston by now. As it was, she
would have to wait till morning. Would morning ever come?
Mrs. Jackson thought the girl was going to faint, and insisted on forcing
some brandy down her throat. She was very sympathetic, almost
obtrusively so; for it was that tactless sympathy which is worse than none at
all.
“Keep your heart up, miss,” she said cheerily, noticing that Celia’s tears
were making havoc with her make-up. “You can’t rely on some of them
ha’penny papers, you know. I don’t suppose it’s really so bad as they put it
there. Not but what you’ve not cause to be anxious, for all that. I remember
when my poor daughter—her that was on the trapeze business at the ’alls—
fell right down from the roof to the floor without so much as a net to catch
her, they sent for me—I was dresser to Mrs. Potter Wemyss at the
Haymarket then—and I arrived at the ’all just in time to find the poor gel
stiffening. They told me at first it was only a slight accident; but she was
stretched out dead when I got there, miss, and looking as calm as calm can
be. Them accidents are nasty things, I reckon. I do hope as you won’t find
your poor brother laid out ready——”
“Oh, for goodness’ sake, stop!” called out Grace, imperatively. “Can’t
you see that you are frightening Miss Franks?”
She felt ready to throw the hand-glass or any other convenient missile at
the woman for her arrant thoughtlessness.
 Poor Celia was pale and trembling, whilst visions of her brother lying
dead flashed before her mind’s eye. How she managed to get through that
last act she never knew. The dim faces of the audience looming out of the
semi-darkness seemed to her like rows of grisly skeletons mocking her with
sardonic mirth. The sweep of the violins in the orchestra sounded like a
funeral dirge. Two or three times she was almost overcome with dizziness;
but at length all was over, and, for the last time, the curtain fell.
“You did splendidly, Cely,” Guy Haviland said to her on the way home.
“You are what I have a great admiration for: a brave girl—a girl with
‘grit.’ ”
But Celia felt brave no longer. She leant back in the brougham with her
head against Grace’s shoulder, and cried quietly all the way. She was utterly
worn out.

CHAPTER XVIII

“NEITHER JEW NOR GREEK”—ONE GOD OVER ALL

An unmistakable air of gloom hung over the factory club at Durlston. The
members, instead of playing cards or chess as usual, gathered round the fire
and smoked their pipes in silence; whilst one of them sat over in the corner,
and with his velvet cap carelessly donned, droned prayers to himself out of
a well-thumbed Hebrew book. They were all anxiously awaiting the result
of the medical consultation concerning their benefactor, Herbert Karne; and
could settle to nothing until their suspense had been relieved. Now that they
had relinquished their enmity towards him, they went to the other extreme,
and exalted him into a kind of demi-god. If he lived they would do all in
their power to make amends for their past ingratitude; if he died they would
lament him as a martyr, for it was by one of themselves that he had been
struck down.
Presently the door swung open to admit the foreman, Emil Blatz; and at
his appearance the men looked up with expectancy plainly written on their
faces.
“Well, what news?” said one, as though half afraid to ask the question.
The new-comer closed the door and came forward. “The Manchester
physician has just gone back,” he answered. “Strelitzki has been sent to the
Prestwich asylum.”
“And the doctors’ verdict?”
“Mr. Karne will live.”
“Gott sei dank!” ejaculated the man in the corner. He had wanted
Herbert Karne to change his name, so that the Angel of Death would be
deceived, and pass on without claiming his prey.
There was not a man in the room who was not intensely relieved by the
news. Each clamoured for further particulars, and went to the Towers to
read the bulletin for himself. Once more they were able to enter into their
various pastimes and pursuits without feeling that to laugh or chat would be
to exhibit callousness or bad taste. A load had been lifted from their hearts.
Mr. Karne would live.
For nine days he had hovered ’twixt life and death—a time of
heartrending anxiety to his sister, who attended him with untiring devotion,
and scarcely ate or slept until the crisis had been overcome. On the tenth
day Lady Marjorie arrived; and by a coincidence it was on the tenth day
that he began to mend.
“He will get better quickly now that you are here,” Celia said
optimistically; and her prophecy was, happily, fulfilled. Herbert had so
much to live for now, that he was determined to make a good fight for life
and health. He recovered quickly and thoroughly, quite astonishing Dr.
Forrest by his unusual obedience to his orders.
Lady Marjorie looked thin and pale; and quite unlike the vivacious little
woman of a few months ago. During her stay abroad she had suffered both
mentally and physically, the sorrow on her mind having greatly retarded her
recovery from the fever. But as her lover grew stronger, she also picked up
health. The roses returned to her cheeks, and the sparkle to her eyes; until
by degrees she regained the sprightliness which had been hers of old.
“It was a good thing Strelitzki did not quite finish me off just as our
happiness was on the horizon,” Herbert said to her half playfully one day.
“Just imagine if you had come back to find a nice little urn awaiting you,
labelled ‘Concentrated essence of Herbert Karne.’ I am an advocate of
cremation, you know!”
But Marjorie’s eyes filled at the very thought. “Oh, darling, I can’t bear
to hear you jest about it,” she rejoined seriously. “If that wretched lunatic
had killed you, I should have died too.”
 And her lover, although he persisted in making light of the whole affair,
knew that her words were no vain exaggeration. He began to wonder what
Marjorie could see in him, that she should love him so. He considered
himself quite the luckiest man in the world.
A fortnight before Christmas the good people at Durlston were
somewhat surprised to hear that Durlston House was about to change hands,
the new owner being a Mrs. Thornton, of Sydney. One or two of them went
to Lady Marjorie expressing their regret; and asked her if she were leaving
the town for good.
“Oh no, not for good,” she answered with a merry twinkle in her blue
eyes. “Only for about six weeks.” And more she would not divulge.
But somehow the news leaked out, and there was quite a crowd of well-
wishers outside the registrar’s office on the following Monday morning.
They were mostly the tradespeople who attended at Durlston House and the
Towers, probably drawn thither by the fascination which always seems to
hover round a bridal couple, whatever their degree.
It was a dreadfully plebeian way of getting married, they said to each
other; in fact, it was hardly respectable. “No banns, no church, no wedding-
bells, no cake, no free drinks, no nothing.”
“And it’s not as if they couldn’t afford it, neither,” said Mrs. Smith, who
kept the chandler’s shop in the High Street; “she being a hearl’s daughter
and all.”
“Perhaps it’s because she were a widder,” hazarded Mrs. Jones.
“Widders ain’t so pertikler as spinsters, seeing as it’s their second try.”
At the station, however, Mr. Karne somewhat redeemed his character in
their eyes. The factory people, despite the fact that he was marrying out of
the faith, had sent a deputation to wish the bridal pair good luck and a
pleasant journey. In replying to their congratulations, Herbert said that on
account of the state of his health, he had been obliged to have the marriage
as quiet as possible; but when, in the course of a few weeks, he brought his
bride home to the Towers, he hoped to be well enough to organize all the
festivities generally associated with a happy wedding.
His little speech elicited general satisfaction, and after some
consideration it was unanimously agreed throughout the town that he could
not very well have had a “big” wedding, when he had so recently lain at
death’s door.
 “Although it do seem to me that a bride and bridegroom hev no more
right to put off their wedding breakfast than a dead Irishman has to
postpone his wake,” remarked Mrs. Jones to Mrs. Smith. “Seeing as one
follows the other quite natural-like, as you may say. Still, if them Jews at
Mendel’s is satisfied, it’s nowt to do with you and me.”
And there the matter rested.
Celia drove back from the station with Lord Bexley and Mr. Harry
Barnard, who had been the witnesses of the marriage. She could not help
looking a little bit woe-begone in spite of Mr. Barnard’s jocularity.
Although not begrudging Herbert and Marjorie their happiness—on the
contrary, she was deeply thankful for it—she felt that Marjorie was the most
enviable woman in the world, for she had gained her heart’s desire: she had
married the man she loved.
At lunch Mr. Barnard suddenly bethought him of a letter which had
arrived for Herbert that morning.
“It was a black-bordered envelope, so I advised Higgins not to deliver it,
in case Bert should take it as a bad omen, coming on his wedding-day,” he
said in explanation. “What the dickens did I do with it, though? Ah, here it
is!” extracting it from the depths of one of his numerous pockets. “I
suppose we had better forward it, Miss Franks?”
Celia examined the envelope. “I can open it,” she replied, with a sigh. “I
know where it comes from. Poor Mrs. Neville Williams——”
“Do you mean to say she is——” asked Lord Bexley, in a tone of awe.
The girl nodded. “Yes, she is dead,” she rejoined solemnly, as she read
the letter. “I am glad that you did not give this to my brother, Mr. Barnard.”
“But I saw Dr. Milnes last week,” pursued Bexley, as though he could
scarcely believe it. “He told me that the operation was quite a success.”
“Yes, so it was, according to the nurse’s account also,” answered Celia.
“She says: ‘The operation in itself was entirely successful, but the
unfortunate lady succumbed to weakness following a relapse.’ Poor Mrs.
Neville Williams! I am sorry she is dead!”
“She was a slap-bang and a dash kind of woman, if ever there was one,”
remarked Harry Barnard, unfeelingly. “Never happy unless she was up to
some sort of a lark. Great Scott, the tricks she used to get up to when Bert
and I were in Paris! As flighty as a two-year-old she was, but as cunning as
they make ’em. She would have made up to you if you had given her half a
chance, wouldn’t she, my lord?”
Bexley looked over at Celia and felt uncomfortable. “Mrs. Neville
Williams is dead,” he said with quiet emphasis. “Requiescat in pace.”
And then Celia, who considered Mr. Barnard’s remarks in somewhat bad
taste, tactfully changed the subject.
The “Voice of the Charmer” had but another week to run, for the theatre
was wanted for the Christmas pantomime. Celia had promised to return to
the cast for the final performances; and accompanied by the two gentlemen,
caught the afternoon train to London.
Haviland and Calhoun were glad to see her back, for the play without
her in it had been like Hamlet without the Prince of Denmark, even though
Miss Graham had done her best to imitate the original Mallida’s
interpretation of the part.
Celia was not sorry when the last night arrived, although she was bound
to admit that all her co-workers had been exceedingly kind to her, from the
manager down to the call-boy. But when Mr. Calhoun asked her if she
would continue in the part if they resumed the run of the play in the new
year, she quietly but firmly declined; and neither he nor Haviland could
persuade her to alter her mind.
After Christmas, which she spent very enjoyably at Woodruffe, Herbert
and Marjorie wrote for her to come and join them in Bournemouth, both
assuring her that she need have no scruples about trespassing on the
seclusion of their honeymoon, for there were two or three people they knew
staying at the same hotel. The Wiltons, however, would not hear of her
taking her departure until after their annual Christmas party, which was, to
them, the great event of the winter season.
“Your brother ought to be able to spare you a little longer, now that he
has a wife to keep him company,” said Enid, with authority; and to this all
the other members of the family agreed.
But at length, after her sister-in-law had despatched three or four more
letters of invitation, Celia bade farewell to them all and went. She found
both her brother and his wife greatly improved in health; and the cordial
welcome they gave her quite dispelled the fear she had had that her visit
might be an intrusion. Their fellow-visitors at the hotel organized various
forms of social enjoyment; and as the weather was genial—although it was
January—they went about a good deal.
“There is somebody you know staying at Cliff Terrace,” Marjorie
informed her whilst she unpacked. “He came to Bournemouth because he
knew we were here. We scarcely expected you until Monday, and I told him
so; but I should not be surprised if he came round to-morrow.”
“Who is it?” asked the girl with curiosity, but Lady Marjorie only smiled
at her in a tantalizing manner, and refused to say.
The next day was Sunday. Celia expected the mysterious somebody all
day, but he did not arrive. She wondered if it were Lord Bexley, and hoped
he had not been trying to get his sister to intercede in his favour. She
scarcely thought he would do such a thing, for he had appeared to take her
decision as final, when she had rejected his proposal at the Havilands.
In the evening she expressed her intention of going to church; and as
Marjorie was not allowed to inhale the night air, she went alone, her brother
promising to meet her at the conclusion of the service. He did not scruple to
allow her to go unaccompanied, for ever since she had passed out of the
hands of her governess, she had been used to go about by herself.
The church was of modern build, fitted with electric light and numerous
creature comforts unthought of in the days of our fathers. Celia nestled back
in the corner of her pew, allowing the solemn stillness of the sanctuary to
pervade her spirit. Evensong always had the effect of making her feel happy
and restful; it was like a soothing lullaby after a busy day. She loved
especially the jubilant Magnificat and the solemnly sweet Nunc Dimittis, for
they were of peculiarly Jewish interest, and made her glory in her Hebrew
descent.
After the service was over, and the bulk of the congregation filed out,
she still remained in her seat, dreamily listening to the exquisite organ
melody. It was one of Chopin’s most beautiful Nocturnes, sweetly mournful
and pathetic in parts, but occasionally displaying the fervour of its
restrained passion. Celia knew it well, but she had never heard it played
amidst such surroundings before. The building was now in semi-darkness,
the glare of the electric light having been replaced by the softening shadows
of night. At the altar a surpliced choir-boy was extinguishing the six
candles, one by one. He performed the action with care and reverence; and
then quietly withdrew.
 And still the music played on, rising and falling like the throbbing of a
heart; and still, with her face turned towards the east—where the sacred
symbol stood out in bold relief—Celia listened. At last, recollecting that her
brother might be waiting, she passed on tip-toe down the aisle and through
the porch. But he was not there; so, knowing that he would not like her to
wait about alone, she began to make her way towards the hotel.
It was a fine night, frosty and dry. There was no moon, but the stars
shone with dazzling splendour. Celia crossed over to the esplanade, and
stood contemplating the prospect for a moment, whilst the salt breeze
brushed against her cheek. As she gazed at the vast expanse of sky and
ocean, and listened to the dull roar of the waves, some lines she had once
sung in the “Golden Legend” recurred to her memory:
 “The night is calm and cloudless,
And still as still can be,
The stars come forth to listen
To the music of the sea.”

She loved all the sounds of Nature, but especially that “music of the
sea.” Its chords were deep and resonant; and full of meaning to those who
had ears to listen to its ever-changing harmonies. All around was mystery;
mystery in the impenetrable height of the starry heavens; mystery in the
great depth of the moving waters. What was beyond and below?—she
wondered with reverential awe; and realizing—if ever so slightly—the
majestic grandeur of the great Creator’s handiwork, an overpowering sense
of her own littleness overcame her, until, with a sudden longing for human
companionship, she turned to continue her walk.
“ ‘In maiden meditation, fancy free,’ ” quoted a familiar voice close
behind her. “Star-gazing is a pleasant occupation for two, but rather
lonesome for one in solitude. May I join you, Celia dear?”
It was nearly four years since she had last seen him, but even in the
darkness, she recognized his stalwart form.
“Geoffrey!” she exclaimed. “At last!” And try as she would, she could
not keep the joy out of her voice.
There was nobody about, and he took possession of her arm as if it were
the most natural thing in the world. And the funny part about it was that she
did not feel the least surprise that he should do so. How he came to be there
she had not the faintest idea; she did not even wonder about it. She only
knew that his coming filled her with a delicious sense of happiness, and that
the song of the sea sounded sweeter than it had done before.
“I arrived at your hotel just after you had gone,” Geoffrey explained. “So
Herbert sent me on to meet you. I was in church, quite near you, all the
time; but you looked so absorbed that I didn’t like to bring you down from
heaven to earth until it was absolutely necessary. Celia, has Lady Marjorie
said anything to you about me lately?”
“She told me that somebody I knew was staying at Cliff Terrace and
intended coming to see me; but she did not say it was you. I was expecting
the somebody all day.”
 “Were you? Oh, if I had only known that you were here, I would have
come round early this morning. Lady Marjorie has been very good to me;
she has made me see what a timid ass I’ve been. It was not entirely my
fault, though. Stannard would have it that you were engaged to Lord
Bexley; and I was so busy looking after my poor aunt and Miss Thornton
that——”
“Miss Thornton!” interpolated the girl, suddenly shrinking away from
him. “I had forgotten Miss Thornton.”
Her sky was overcast again.
“You don’t know her, do you?” asked Geoffrey, wonderingly. “She is
Stannard’s fiancée.”
Celia drew a deep sigh. Stannard’s fiancée! That made all the difference.
But how foolish she had been to have made such a mistake!
“She used to be subject to fits,” her lover went on to explain. “But
fortunately I have been able to effect a complete cure. She has been under
my supervision for some months.”
“And she is going to marry Dick Stannard?” Celia asked, anxious to hear
a corroboration of the statement.
“Yes, she is going to marry Dick,” he replied with satisfaction. “But I
don’t want to speak about Miss Thornton just now. Oh, you dear, sweet girl,
how nice it is to be talking to you like this after such a long time!” This
with an affecting pressure of her hand. “You do love me just a wee bit,
don’t you, dear?”
“I love you more than a wee bit, Geoffrey,” she answered, in the tone of
one who makes a great confession. “I have loved you ever since that night
when——”
“When I kissed you under the mistletoe? I remember. I’ve been living on
that kiss for four years. I am just aching and hungering for another one. I
am going to have it here and now.”
“Geoffrey!” she protested. “In the open street!”
“I don’t care,” he answered with determination. “There is nobody to see
except Nature, and Nature keeps her secrets well. Ah”—as he put his desire
into execution—“that was beautiful. But tell me, darling, if you really loved
me all that time ago, why did you become engaged to another fellow?”
“Because you—you—didn’t——”
 “Because I didn’t come forward and claim you?” he suggested, finishing
the sentence for her. “But your brother made me promise not to speak: he
thought it might hinder your career. He told me he did not approve of mixed
marriages either, although he has not practised what he preached. Lady
Marjorie is a Christian.”
“Herbert says now that love is more powerful than race and creed,” the
girl said softly. “Love breaks all barriers down.”
“Yes, he is right,” her lover rejoined with deepening earnestness. “But
there is no barrier of creed ’twixt you and me, now, darling; no barrier of
any kind. Did you notice the text of the sermon, to-night, Celia: ‘Neither
Jew nor Greek’? Oh, it seemed to me as if the clergyman must have chosen
it because he knew we were in the church. ‘Neither Jew nor Greek’ ...
united, made one in Christ. No difference between the Jew and the Gentile,
for the same God is God of both!”
They had arrived at the hotel, and Herbert Karne was looking out for
them in the vestibule. Geoffrey’s buoyant manner and Celia’s happy face
told him, before he asked, that their meeting had been a satisfactory one.
Lady Marjorie looked up from her book with a softened expression in
her blue eyes, when they made their appearance at the door of the private
drawing-room.
“So your visitor has come at last, girlie,” she said, as Celia bent down
and kissed her. “I told him that I thought you would give him a hearty
welcome. Was I right, Dr. Geoff?”
“Yes, quite right,” the young doctor replied, as he gripped her hand. “I
can never be sufficiently grateful to you for your kindness, Lady Marjorie.”
“You really were the silliest pair of lovers I ever came across,” Marjorie
said, as she glanced at them and thought what a well-matched couple they
made. “I knew that each of you was just longing for the other; and yet you
both held aloof, although there was no cause or just impediment why you
should not have come together long ago. So I determined to intervene and
make you happy. And, judging by the looks of you both, I think I have
succeeded.”
“You have, indeed!” rejoined Geoffrey, as he drew his sweetheart closer
to him; and Celia, whose heart was too full for words, expressed by her
shining eyes, the great happiness which was hers at last.
* * * * *
 On the deck of a channel-steamer bound for Calais stood a young girl,
shading her eyes with her hand. She was watching the land as it receded
from view, yet with no feeling of regret, for she was making the journey
with the one she loved best in the world.
Less than twenty-four hours ago she had stood beside him at the altar,
and made her marriage vows. The “Voice that breathed o’er Eden” was still
ringing in her ears; the crashing chords of the Wedding March seemed
interwoven with the throbbing of the ship’s engines; the very air seemed
full of the far-off sound of wedding-bells.
It was a bright spring morning, a day fit for the renewing of energy and
hope. All around was sunlight: on the shimmering waters, the polished
deck, and on the girl’s bright hair. It seemed to her like a happy omen,
symbolizing the sunshine on the sea of life. With a deep sigh of happiness
she turned away; and, looking up, encountered the fond gaze of her lover-
husband.
“Why such a sigh, sweet?” he asked, tenderly placing her hand within
his own. “Of what were you thinking, my little wife?”
“Many things, Geoffrey,” she answered softly, her face lit up with a
radiant smile. And then, as they both continued to gaze landwards, she
added: “But—chiefly—that life is full of joy;—and God is good!”

THE END

PRINTED BY WILLIAM CLOWES AND SONS, LIMITED, LONDON AND BECCLES.

FOOTNOTES:
[1] Bridegrooms.
[2] Gentile.
[3] Ritually clean.
[4] Jewish holydays.
[5] Pertaining to Judaism.
[6] Confirmation.
[7] Day of Atonement.
[8] Festive.
[9] Congratulation.
[10] Bridegroom.
[11] Sabbath.
[12] Money.
[13] Jews.
[14] Smart wit.
[15] Mourning.
[16] Converted Jewess.
[17] Sabbath.
[18] Holy-days.
[19] Converse with familiarity.
[20] Bridegroom.

Typographical errors corrected by

the etext transcriber:
whether whether they be Jews or
Gentiles=> whether they be Jews or
Gentiles {pg 84}
Jacob Strelitkzi=> Jacob Strelitzki
{pg 107}
Is was so quiet=> It was so quiet
{pg 128}
mental note or=> mental note of
{pg 220}
*** END OF THE PROJECT GUTENBERG EBOOK NEITHER JEW
NOR GREEK ***

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