From the Society for Vascular Surgery
Delayed evaluation of combat-related penetrating
Charles J. Fox, MD,a,bDavid L. Gillespie, MD,a,bMichael A. Weber, MD,a,bMitchell W. Cox, MD,a,b
Jason S. Hawksworth, MD,a,bChad M. Cryer, MD,aNorman M. Rich, MD,band Sean D. O’Donnell,
MD,a,bWashington, DC; and Bethesda, MD
Objective: The approach to penetrating trauma of the head and neck has undergone significant evolution and offers unique
challenges during wartime. Military munitions produce complex injury patterns that challenge conventional diagnosis
and management. Mass casualties may not allow for routine exploration of all stable cervical blast injuries. The objective
of this study was to review the delayed evaluation of combat-related penetrating neck trauma in patients after evacuation
to the United States.
Method: From February 2003 through April 2005, a series of patients with military-associated penetrating cervical trauma
were evacuated to a single institution, prospectively entered into a database, and retrospectively reviewed.
Results: Suspected vascular injury from penetrating neck trauma occurred in 63 patients. Injuries were to zone II in 33%,
zone III in 33%, and zone I in 11%. The remaining injuries involved multiple zones, including the lower face or posterior
neck. Explosive devices wounded 50 patients (79%), 13 (21%) had high-velocity gunshot wounds, and 19 (30%) had
associated intracranial or cervical spine injury. Of the 39 patients (62%) who underwent emergent neck exploration in
Iraq or Afghanistan, 21 had 24 injuries requiring ligation (18), vein interposition or primary repair (4), polytetrafluo-
roethylene (PTFE) graft interposition (1), or patch angioplasty (1). Injuries occurred to the carotid, vertebral, or
innominate arteries, or the jugular vein. After evacuation to the United States, all patients underwent radiologic
evaluation of the head and neck vasculature. Computed tomography angiography was performed in 45 patients (71%),
including six zone II injuries without prior exploration. Forty (63%) underwent diagnostic arteriography that detected
pseudoaneurysms (5) or occlusions (8) of the carotid and vertebral arteries. No occult venous injuries were noted.
Delayed evaluation resulted in the detection of 12 additional occult injuries and one graft thrombosis in 11 patients.
Management included observation (5), vein or PTFE graft repair (3), coil embolization (2), or ligation (1).
Conclusions: Penetrating multiple fragment injury to the head and neck is common during wartime. Computed
tomography angiography is useful in the delayed evaluation of stable patients, but retained fragments produce
suboptimal imaging in the zone of injury. Arteriography remains the imaging study of choice to evaluate for cervical
vascular trauma, and its use should be liberalized for combat injuries. Stable injuries may not require immediate neck
exploration; however, the high prevalence of occult injuries discovered in this review underscores the need for a complete
re-evaluation upon return to the United States. (J Vasc Surg 2006;44:86-93.)
Military conflicts have advanced the management of
penetrating vascular injury. Ambroise Paré1 recorded the
first carotid ligation, saving the life of a French soldier
?400 years ago. Although simple ligation became standard
practice for centuries to follow, reports from both World
Wars have documented many cases of irreversible neuro-
logic deficit from this practice. More recently, as shown in
the Korean and Vietnam conflicts, early exploration with
expeditious intervention has reduced mortality. However,
controversy continues about the proper assessment and
management of penetrating cervical vascular injury.
The recent conflicts in Iraq and Afghanistan have pro-
duced a rise in the number of penetrating head and neck
injuries. Mass casualty situations do not allow for routine
exploration of all stable cervical blast injuries. Even with
sophisticated aeromedical transport, injured soldiers often
arrive in the United States more than a week after a pene-
trating cervical injury. The objective of this study was to
review our diagnostic and therapeutic approach to the
delayed evaluation of combat-related penetrating neck
trauma after evacuation to the United States.
MATERIAL AND METHODS
From February 2003 through April 2005, a senior
vascular surgeon evaluated all United States military casu-
alties evacuated to Walter Reed Army Medical Center
(WRAMC) with a military-associated penetrating cervical
injury. These patients were prospectively entered into a
clinical database, and the data were then retrospectively
reviewed. Basic demographic data collected included pa-
tient age, gender, country where injured, date of injury,
From the Department of Surgery, Vascular Surgery Service, Walter Reed
Army Medical Center,aand the Division of Vascular Surgery, Uniformed
University of the Health Sciences.b
Competition of interest: none.
The opinions or assertions contained herein are the private views of the
authors and are not to be construed as official or as reflecting the views of
the Department of the Army or the Department of Defense.
Presented at the 2005 Joint Annual Meeting of the Society for Vascular
Surgery/American Association for Vascular Surgery, Chicago, Ill, June
Reprint requests: Charles J. Fox, MD, Walter Reed Army Medical Center,
Vascular Surgery, Bldg 2, Ward 64, 6900 Georgia Avenue, NW, Wash-
ington, DC 20307 (e-mail: Charles.Fox@na.amedd.army.mil).
Copyright © 2006 by The Society for Vascular Surgery.
date of arrival at WRAMC, and presence of a prior surgical
Specific patterns of injury were documented, noting
the mechanism of vascular injury, cervical zone involved,
type of vessel injured, and the presence of any associated
trauma or neurologic deficit. Vascular injuries were studied
with respect to the specific vessel injured, type of repair
performed, and use of autologous or prosthetic conduit.
The initial outcome was documented, including complica-
tions or the need for reintervention. Patients were carefully
re-examined after evacuation to the United States, and
newly discovered occult injuries were documented.
All patients had radiologic evaluation on arrival to the
United States. The imaging protocol was not predeter-
mined; however, patients with prior neck exploration only
had arteriography when noninvasive images were inconclu-
sive or fragmentation also involved zones I or III. The
findings of imaging modalities used for delayed evaluation,
including computed tomography angiography (CTA),
color-flow duplex scans, and arteriography, were analyzed.
Arteriographic findings were documented, including
based techniques to treat selected vascular injuries. Com-
plications and outcomes were reviewed. These data were
collected with the approval of the institutional review
Demographics. Sixty-three patients (62 men, 1
woman) were transferred to WRAMC with a diagnosis of
penetrating neck trauma. Sixty were injured during Oper-
ation Iraqi Freedom, and the remaining three were injured
average age was 27 years (range, 19 to 58 years).
Twenty-one (33%) of the 63 patients evaluated had
arrived from Iraq with documentation of a recent vascular
repair. The remaining patients were evaluated for a sus-
pected vascular injury, and all patients had careful re-
evaluation on arrival to the United States. The median time
to arrival was 8.5 days (range, 3 to 14 days).
Injury pattern. The cervical vascular injuries were iso-
lated to zone II in 33%, zone III in 33%, and zone I in 11%,
and 23% were diffuse injuries involving multiple zones,
including the lower face or posterior neck. Fifty patients
explosive mortars, and improvised explosive devices. High-
velocity gunshot wounds were associated with vascular
injuries in 13 patients (21%).
Table I summarizes the distribution of vascular injuries
managed in Iraq and Afghanistan. Multiple fragment inju-
ries resulted in severe soft-tissue defects associated with
complex craniofacial injuries that were frequently associ-
ated with a major vascular injury. All but eight patients had
associated injuries, including a tracheoesophageal injury,
facial or cervical spine fracture, globe rupture, or intracra-
nial injury. Nineteen patients (30%) had an associated in-
tracranial or cervical spine injury, and 41% (26/63) had
motor paralysis or a major neurologic deficit. Half of all
patients had facial fractures or complex ocular trauma, and
13 (20%) required tracheostomy for airway management.
Initial management of penetrating cervical injuries.
Thirty-nine patients (30%) underwent immediate neck ex-
ploration in Iraq or Afghanistan, of which 65% (25/39)
were positive for a major injury. Twenty-one patients un-
derwent 24 vascular repairs for 13 arterial and 11 venous
injuries (Table I). The most common vascular injuries were
to the carotid artery in 50% (12/24) and the jugular vein in
Urgent exploration in the combat zone revealed ca-
rotid injury with segmental arterial loss, necessitating inter-
position graft repair in four injuries. Saphenous vein was
used in three and a polytetrafluoroethylene (PTFE) graft in
one. Arterial ligation was used less commonly. Two pa-
tients had emergent ligation of the internal carotid artery,
jugular venous injuries were ligated and well tolerated. Of
the 11 venous injuries included with this report, eight
internal jugular vein injuries and two external jugular vein
injuries were managed by ligation. One superior vena cava
injury was managed by primary repair.
Delayed evaluation with noninvasive imaging. All
patients were carefully re-examined after evacuation to the
ally supplemented with an imaging study. Of the 63 pa-
tients in this series, 51 (81%) had some form of noninvasive
imaging to assess for injury and determine the need for
arteriography. Color flow duplex was performed as an
alternative to arteriography in six patients (10%), to evalu-
ate a previous repair or stable fragmentation injury in three
patients (5%) each. Color flow duplex was often suboptimal
due to mechanical ventilation, large soft-tissue wounds, or
injuries to the patient’s cervical spine. CTA was performed
at WRAMC in 45 patients (71%), including six zone II
injuries without previous exploration, providing detailed
arterial and venous imaging. Metallic fragments, however,
often produced artifact leading to equivocal studies (Fig1),
and contrast arteriography was required in these cases to
further evaluate for an occult injury. Ultimately, CTA
correctly identified only two patients with an occult injury
that was subsequently confirmed by arteriogram.
Arteriography and occult arterial injury. Forty of
the patients (63%) evaluated in this series underwent arte-
Table I. Distribution of cervical vascular injuries
managed in Iraq and Afghanistan
Vessel Repair typeTotal repairs
Superior vena cava
JOURNAL OF VASCULAR SURGERY
Volume 44, Number 1
Fox et al 87
riographic evaluation, of which 26 arteriograms were done
to evaluate a suspected injury, and 14 were performed on
patients with a previous vascular repair. Indications for
arteriography included injury to zone I or III, an indeter-
minant CTA, multiple fragment injury, or an abnormal
Eleven (27.5%) of the 40 patients undergoing arterio-
graphic evaluation had an abnormal finding. Arteriography
detected 12 occult injuries and one graft thrombosis in 11
patients (Table II). Three patients with occult injuries were
among the 39 patients initially managed by exploration and
repair of a vascular injury in Iraq or Afghanistan. Two of
these patients with positive findings had an injury in zone
II. All other occult injuries found were among the 24
patients who were not explored overseas but had a delayed
evaluation in the United States. All abnormal arteriograms
with fragments in the zone of injury had a negative or
equivocal CTA. Of the 11 patients with abnormal arterio-
grams, CTA correctly identified only two with occult in-
jury. Since neither patient had an embedded metallic frag-
ment in the zone of injury, artifact was the usual cause for
an indeterminant study.
Delayed surgical and endovascular therapy. Six of
the 13 occult injuries detected radiographically in the
United States required treatment. All vertebral occlusions
wereasymptomaticand treated nonoperatively.All
pseudoaneurysms and one internal carotid artery occlusion
were surgically repaired or coil embolized.
All pseudoaneurysms were successfully treated without
complication. Catheter-based interventions were applied
for treatment of two patients with pseudoaneurysms arising
from the external carotid artery. Although a pseudoaneu-
rysm of the lingual artery was correctly detected by CTA
(Fig 2), another was masked by embedded metallic frag-
ments and discovered later on the cerebrovascular arterio-
gram. Coil embolization was successful in both cases and
eliminated the need for a lengthy and potentially difficult
Complications. Six (29%) of the 21 patients who un-
derwent emergent major vascular repairs in Iraq and Af-
ghanistan had an associated complication. Two were re-
explored for bleeding, one died of a massive pulmonary
embolism, and one had an early graft occlusion. Postoper-
ative strokes occurred in both patients with ligation of the
internal carotid artery, with one resulting in a permanent
deficit. Injuries to the common carotid artery had the
highest complication rate. No immediate or early compli-
cations were associated with venous ligation. Repair of the
occult injuries discovered during the delayed evaluation
caused no immediate or early complications. Moreover,
there were no access complications from arteriography.
The modern management of penetrating neck trauma
has emerged from the principles applied from previous
military conflicts.2 The current war in Iraq has resulted in
numerous casualties with multiple fragment wounds from
explosive devices.3 Penetrating facial and cervical trauma is
common during wartime. The incidence when reported by
anatomic area is about 5% to 10% of all combat injuries.4
Moreover, a leading cause of death in the wars in Iraq and
Afghanistan is now from injury to the head and neck.
Numerous patients with stable penetrating neck injuries
Fig 1. A, The quality of computed tomography angiography can be easily degraded by metallic artifact (arrow) (B)
as depicted by subsequent sections acquired within the zone of injury. C, A carotid pseudoaneurysm (arrow) was later
discovered on the arteriogram.
Table II. Cervical vascular injuries discovered on delayed
evaluation after evacuation to the United States
Internal carotid artery
External carotid artery
Common carotid artery
JOURNAL OF VASCULAR SURGERY
88 Fox et al
have arrived in our medical center more than a week after
injury, some without prior neck exploration. Many have
severe associated craniofacial, ocular, or cervical spinal
trauma. The complexity of these injuries, coupled with
current management controversies, has prompted a review
of this experience.5– 8
Historic military data report that carotid injuries repre-
sent about 5% of all arterial injuries,9 and our recent find-
ings reflect past experience. For centuries, carotid ligation
was standard practice, but devastating neurologic outcome
has led to more conservative approaches in the contempo-
rary management of carotid injury. In World War I, Makins
reported that one third of 128 cases of carotid artery injury
treated by ligation resulted in irreversible deficit.10 Despite
the poor outcome, there were very few reports of carotid
repairs during World War II and the Korean War.11,12
During the Vietnam War, Rich13 reported on 50 carotid
injuries. With advances in operative technique and diagno-
sis, carotid repair rather than ligation became the accepted
treatment, and the neurologic complications subsequently
Surgical decisions about the timing of treatment were
instrumental in reducing mortality from neck wounds. In
1956, Fogelman and Stewart14 showed a 35% mortality
rate in patients with delayed exploration vs 6% in those
undergoing an immediate operation. Rich and Hughes15
reported that it was customary practice during the Vietnam
War to immediately explore all penetrating neck injuries
and to repair them with a vein patch or interposition vein
graft. Contemporary practice has been to divide the neck
into three anatomic zones as described by Monson et al,16
exploring those in zone II while obtaining further diagnos-
tic information in areas of high or low cervical injury.
Several modern studies now emphasize selective explora-
tion of stable injuries, taking into consideration the ease of
surgical exposure and the probability of injury based on the
Modern advancements in the aeromedical evacuation
system have resulted in patients reaching tertiary stateside
Today, the median time to arrival for a critical care air
the initial injury. This is fivefold faster than the Vietnam
War experience, where patients remained in evacuation
hospitals located in Vietnam for several weeks to months
before arriving in the United States.23 Evacuation time to
the continental United States has further improved since
Operation Desert Storm in 1991.23,24
As a consequence of rapid evacuation, many of these
patients now arrive at WRAMC in critical condition 3 to 7
days after injury. They are often septic, usually on mechan-
ical ventilation, with open abdominal wounds and complex
orthopedic injuries. In this review, one fourth of the pa-
tients required urgent operations upon arrival. Although
surgeons located in the battle area performed repair of
obvious cervical vascular injuries, only 39 of the 63 patients
underwent immediate neck exploration.
Similar to the Vietnam experience, our findings show
that common carotid injury was the most frequent cervical
vessel injured, and repair by vein interposition rather than
ligation was the preferred strategy. Ligation of the internal
carotid artery in this series resulted in a neurologic deficit.
All external carotid and jugular injuries were ligated and
well tolerated. Many casualties arrived at the forward sur-
gical sites en masse, and some combat hospitals that lacked
CT or digital subtraction angiography quickly transferred
stable patients to a higher echelon of care for the definitive
evaluation. In this series, more than one third of the pa-
tients had a penetrating neck injury without immediate
exploration. This required a delayed comprehensive evalu-
Fig 2. A, The lingual artery pseudoaneurysm (arrow) is demonstrated on the initial computed tomography angiog-
raphy. B, The subsequent arteriogram shows the pseudoaneurysm (arrow). C, Arteriogram illustrates the utility of
endovascular coiling to manage an occult injury in a difficult location.
JOURNAL OF VASCULAR SURGERY
Volume 44, Number 1
Fox et al 89
ation of injuries that were more than a week old by the time
facial fractures or ocular trauma, necessitating coordinated
care with multiple services.
All 63 patients were carefully re-examined for occult
injury. Fragment injury was the most common mechanism
of injury. One third had a repair of a cervical vascular injury
before arrival in the United States. Two thirds of the
penetrating neck injuries were in zone II or III. The use of
individual body armor, which has a short neck collar, may
account for the smaller percentage of injuries isolated to
zone I. Blast injuries frequently involved a large surface
area, and 23% had fragment injuries of multiple zones,
including the lower face or posterior neck. Multiple injuries
were common, as 30% had associated traumatic brain or
spinal injury, and 20% required tracheostomy for airway
management. Mechanical ventilation and the use of rigid
cervical collars could obscure wounds, challenge physical
evaluation, and raise the potential for a missed injury.
Proponents of selective management of penetrating
neck injury claim that patients can be spared unnecessary
to mandatory exploration when examined by experienced
surgeons.25,26 Although the application of arteriography is
still debated, there is general agreement that physical exam-
ination and sophisticated imaging techniques can be used
in lieu of mandatory exploration, particularly when the
injury is isolated to zone I or III.26 –29 Immediate neck
explorations in Iraq resulted in positive findings in 25
(65%) of 39 patients. Four patients had isolated injury to
the trachea or esophagus, and the rest had one or more
vascular injuries. In comparison, delayed evaluation of the
24 patients not explored in Iraq identified eight patients
(33%) with an occult injury. Three (7.6%) of 39 patients
immediately explored had an additional occult injury dis-
covered upon re-evaluation at WRAMC, including two
vertebral occlusions and a carotid pseudoaneurysm that
required coil embolization.
This suggests that there is a high risk of vascular injury
with cervical fragmentation, even in patients who are oth-
erwise stable. Furthermore, multiple zone of injury is com-
mon, and injuries to zone III or I need careful and contin-
uous assessment in tertiary centers. This emphasizes the
importance of meticulous and continuous re-evaluation
regardless of the initial management strategy.
Our approach for patients with penetrating neck
trauma incorporated a physical examination and some form
of noninvasive imaging, regardless of how the patient was
initially managed in Iraq. The rare exception may be a
patient with an isolated nonfragment zone II injury, arriv-
ing after a negative exploration, with a normal physical
examination result. Color Doppler ultrasound examination
is well established for trauma.30 In our experience, it was
useful to evaluate previous repairs, but was technically
limited for zone I or III injuries or cervical wounds with
large soft-tissue defects. Moreover, it was often impractical
for the critically ill, especially patients with cervical spine
CTA has been used as a noninvasive alternative to
conventional angiography.31–34 We found this to be an
acceptable method to evaluate a stable injury, particularly if
the neck had been explored previously or a vascular repair
was already done and the results of the patient’s examina-
tion were normal. With a properly sequenced protocol, the
imaging quality can be very good. The potential disadvan-
tages are the administration of a contrast agent and degra-
dation of image quality from the artifact produced by
metallic fragments embedded in the soft tissues.35 For this
reason, we prefer to obtain a plain radiograph (Fig 3) to
examine the neck for metallic fragments before ordering a
Fig 3. Plain radiographs demonstrate that metallic deposits by explosive munitions (long white arrows) or high
velocity weapons (short black arrow) can predict the potential inaccuracy of a computed tomography angiography.
JOURNAL OF VASCULAR SURGERY
90 Fox et al
CTA. If fragments are localized to the zone of injury, (Fig
4) contrast arteriography is recommended.
Cerebrovascular arteriograms were also performed for
injuries to zones I or III, an abnormal or indeterminant
CTA, or if the patient’s examination suggested that a
therapeutic intervention would be necessary after the diag-
nosis. Forty arteriograms detected abnormalities in 11 pa-
tients (27.5%). All of the occult injuries were occlusions or
pseudoaneurysms, and no arteriovenous fistulas were seen.
CTA was performed on eight of these 11 patients and
correctly identified only two patients with an occult injury.
Interestingly, neither of the two patients had embedded
metallic fragments in the zone of injury.
Contrast arteriography is especially useful when an
intervention is required, because it has the potential to
serve as both a diagnostic and therapeutic maneuver. Ex-
cessive contrast administration represents a limitation of
CTA, particularly if additional contrast-enhanced imaging
becomes necessary.35 A CTA is therefore most helpful
when no intervention is anticipated and potential artifacts
are considered before obtaining the study.
The distribution of occult injury was evenly split be-
tween the carotid and vertebral arteries. Six patients (10%)
required a subsequent intervention to repair an occult
injury after the results of arteriogram were abnormal. One
patient required revision of a thrombosed vein patch repair
of the common carotid artery. This case illustrated the high
potential for graft failure when near circumferential injuries
are repaired by patch angioplasty. When a vein patch is
wall is essential to avoid a subsequent stenosis. Fragment
injuries will usually result in segmental loss of the artery and
are best repaired with vein interposition grafts. We con-
tinue to encourage the use of autologous grafts for all
wartime vascular injuries secondary to the size and degree
of contamination that are typical of these cavitary
wounds.36 Therefore, the extremities of all patients who are
returned to the operating room are prepared for potential
Endovascular therapies have been incorporated into
the routine management of traumatic vascular inju-
ries.37– 42 We have previously applied this technology to
ing a potentially complicated and difficult reoperative pro-
cedure. In one case, a lingual artery pseudoaneurysm was
correctly identified on CTA. In the second case, the CTA
was indeterminant because of metallic artifact, and a subse-
quent arteriogram revealed a pseudoaneurysm of the exter-
nal carotid artery. Both carotid pseudoaneurysms were
successfully treated by coil embolization using a low-profile
sheath and catheter system with a series of tornado coils.
Current findings confirm the historical experience that
wartime. Wounding patterns are complex and are usually
associated with multiple injuries that require specialty care.
Because strict mandatory exploration may overburden
available resources, neck exploration is sometimes deferred
for stable cervical injuries. Multiple providers, prolonged
aeromedical evacuation, and delayed evaluation necessitate
that all patients have careful assessment to identify occult
injuries once they are in a tertiary center.
Computed tomography angiography is useful in the
delayed evaluation of stable patients, but retained frag-
ments produce suboptimal imaging in the zone of injury.
Therefore, plain radiographs should first be examined for
fragments to avoid an indeterminant study and additional
contrast administration. Arteriography remains the best
imaging study to evaluate for cervical vascular trauma, and
its use should be liberalized for combat injuries. Arterial
defects are best managed by primary repair or interposition
grafting with autologous conduit. Because of the degree of
Selective exploration and the use of endovascular tech-
niques represent modern changes in the care of wartime
vascular injuries. However, current battlefield medical ca-
Fig 4. Contrast arteriography is recommended when metallic fragments are in the zone of injury, as illustrated by this
combined internal carotid and vertebral artery injury from a cervical gunshot wound.
JOURNAL OF VASCULAR SURGERY
Volume 44, Number 1
Fox et al 91
side tertiary center are probably the major advancements in
the management of neck injury from prior conflicts. Al-
immediate neck exploration, the high prevalence of occult
injuries discovered in this review underscores the need for
complete re-evaluation upon return to the United States.
Conception and design: CJF, DLG, NMR, SDO
Analysis and interpretation: CJF, DLG, NMR, SDO
MWC, JSH, CMC, MAW
Data collection: CJF, DLG, SDO MWC, JSH, CMC,
Writing the article: CJF, DLG
Critical revision of the article: DLG, SDO
Final approval of the article: CJF, DLG
Statistical analysis: CJF
Obtained funding: CJF, DLG
Overall responsibility: CJF
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