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The views in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Air Force, Department of Defense, or the United States Government.
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C.D.R. Knipp and M.A.J. Henry are military service members. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.
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As discussed in depth in other chapters in this text, traumatic vascular injuries may be expeditiously repaired with a variety of techniques, depending on the location and extent of injury as well as on pre-existing patient factors such as the availability of suitable autologous conduits and vascular access for endovascular interventions. Postoperative complications, however, can and do occur. Technical issues include intimal flaps, retained thrombus, or anastomotic stenoses, postoperative hemorrhage, or the development of pseudoaneurysms or arteriovenous fistulae. Many of these issues are addressed elsewhere in this text. We focus here on the postoperative medical management and surveillance following vascular reconstruction.
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Postoperative management after major vascular trauma remains poorly defined. Trauma patients by nature have an increased risk of both hemorrhage and thrombosis.1 Anticoagulation may result in life-threatening bleeding complications in the polytrauma patient. Given the broad spectrum of vascular injuries, complexity of various repair types, underlying patient factors, and confounding variables (such as head trauma and intra-abdominal or intrathoracic hemorrhage) that are often present in trauma patients, it is difficult to achieve consensus guidelines. Recommendations, therefore, are generally extrapolated from elective vascular surgery and interventional cardiology procedures.2 In addition, postoperative imaging and follow up can be challenging in this unique and often noncompliant population.
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Medical therapy also poses a controversial issue since well-constructed studies in this population are lacking. The purpose of prophylactic medical therapy has two roles. First to reduce local complications directly related to the vascular repair, and second to reduce systemic complications associated with major trauma and immobilization. The agents commonly used are antiplatelet agents, aspirin, and clopidogrel, these being the most common, and anticoagulants, inclusive of vitamin K antagonists (VKA) such as coumadin, heparins (to include low molecular weight variants), and more recently factor Xa inhibitors and director thrombin inhibitors commonly known as “direct oral anticoagulants” or DOACs.
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Ultimately, no “one size fits all” recommendations can be made, even if injuries are classified by location. Instead, the provider must weigh risks and benefits and possibly change intervals and modalities for monitoring complications accordingly. One of the significant benefits of postoperative surveillance imaging is that medical therapy can be tailored based ...