Page 78 - JSOM Fall 2024

Dr. Hughes deployed to Korea in 1952, carrying with him ensured the shortest evacuation times possible, which were in-
a number of rudimentary vascular clamps. In the field, Dr. valuable in salvaging the vessels, and in turn, the limbs of the
Hughes combined his previous experience at Walter Reed with war-wounded.
his inquisitive and technical skills to repair injured vessels
closer to the front lines. The use of the intra-aortic balloon Proximity of Surgical Teams to the
catheter tamponade for the management of intra-abdominal Point-of-injury Results in Better Outcomes
hemorrhage is one of many innovative surgical techniques The introduction of the MASH units brought the first surgical
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used by Dr. Hughes during the Korean War. The credit to Dr. capability closer to the POI than previously possible during
Hughes is that he dared to record and publish his experience WWII, which generally had larger and less mobile surgical
with these vascular repairs that were technically considered field units. The proximity and shortened time to operation
contrary to Medical Corps doctrine at the time. The experience enables the next generation of military surgeons to challenge
of vascular repair was broad and deep, thanks to his deploy- existing dogma and press for a more aggressive approach to
ment to the MASH units. Dr. Hughes also leveraged his senior limb salvage by restoring perfusion with reversed vein grafts
experience to advocate for vascular repair techniques as well and, when possible, arterial repair.
as train younger surgeons in new vascular surgical methods.
Prior to Dr. Hughes’ arrival in Korea in 1952, other U.S. sur-
Dr. Hughes was a prolific medical author. His discussion of the geons, including Drs. Hornberger, Lyday, Apel, and Coleman,
benefits of vascular repair, based on his Korean experience, had were attempting vascular repair. The previously reported re-
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a significant impact on the field of surgery. Among his papers, sults of DeBakey and Simeone suggested that ligation was
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one stands out: “Arterial Repair During the Korean War,” preferrable to reperfusion and was considered the accepted
which discusses the outcomes of patients who underwent at- military standard of care for managing significant major ves-
tempted vascular repair instead of vessel ligation. One can ar- sel injuries. The young Army surgeons deployed to Korea kept
gue that with this paper, followed by another that extrapolated their attempts at revascularization discreet and failed to for-
these findings to civilian hospitals, Dr. Hughes became a leader mally record their efforts. Surgeons performed directed vascu-
in the emerging surgical specialty of vascular surgery. lar repairs “off the record” and undocumented, preferring to
follow up on their own patients by making phone calls to the
Dr. Hughes continued to serve in the U.S. rearward evacuation facilities to inquire on their status. 1
Army through the Vietnam War, holding
various positions including Commander Dr. Hughes’ arrival in theater, as well as his formal review of
of Walter Reed and Chief Surgeon of the the results, objectively validated the technique of vascular re-
U.S. Army Pacific. He retired from the construction as a procedure of merit. In addition, Dr. Hughes
U.S. Army in 1974 as a Major General. significantly improved the instrumentation and clamps nec-
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He continued his service to his nation essary to successfully carry out vascular anastomoses. Dr.
in the Department of Veterans Affairs, Hughes discussed the importance of reducing the time to sur-
culminating in his role as the Assistant gery, stating that the success of vascular repairs was best if per-
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Chief Medical Director for Professional formed within 10 hours of injury. By contrast, according to
Dr. Carl W. Hughes
Services until he retired from the VA in the current standards, most surgeons would hope to have limb
1985. Dr. Hughes continued to teach as a professor of surgery perfusion restored within 4 hours and no later than 6 hours.
at the Uniformed Services University until his death in 2012. 1
Essentials of Vascular Repair Training: Direct Anastomosis
and Grafting for Modern-day Battle Surgeons
Why is This Article Relevant Today?
Currently, training in directed vascular repair is an innovative
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Early Actions by Medics at the Point-of-injury and ever-changing area of education for today’s surgeons. The
Impact Downstream Success of Vascular Repair need for training in anastomotic techniques spans more than
Dr. Hughes discussed the important role that medics at the just the field of vascular surgery and should be understood
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point-of-injury (POI) play in the successful repair of vessels. by all wartime surgical specialties. From his experience and
This emphasis is summarized in the conclusion of this high- research on the Korean War, Dr. Hughes mentions that of the
lighted paper, where he states: “Stress is placed on the impor- 269 cases treated by vascular repair, “145 were treated suc-
tance of resuscitation and evaluation of the patient for priority cessfully by direct anastomosis.” End-to-end or end-to-side
of care of all injuries and for the ability of the patient to with- anastomosis was the preferred method of arterial repair, with
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stand the additional operating time required for vascular sur- only a 9% amputation rate among the 145 patients. Nearly
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gery.” Dr. Hughes reported that the average evacuation time 70 years later, the combat surgeon must be familiar not only
from POI to a hospital for higher triaged patients was 4–6 with directed surgical vascular repairs but also with the ev-
hours. The long prehospital evacuation times are extended er-expanding repertoire of endovascular repair. Although the
by the need for preoperative resuscitation so that the patient austere setting of combat medicine may preclude advanced
might be resuscitated to withstand the rigors of surgery. This endovascular procedures in the early theater setting, ongoing
prolonged evacuation chain to first operation increases the advances in imaging and equipment are expected to provide
risk of ischemia of the wounded limb, which significantly cutting-edge endovascular procedures to the far-forward area.
impedes successful wound salvage. Accordingly, it is remark-
able that the published limb salvage rate of revascularization The second and third most effective methods cited by Dr.
(as opposed to ligation) exceeds 80%. The authors note that Hughes were autogenous venous grafts using the saphenous
ground medics in the Korean War were not as well equipped or cephalic vein and arterial homografts, respectively. A retro-
as medics today to provide resuscitation with whole blood spective analysis of vascular surgeries performed at role 2 and
on the battlefield. However, proper triage by these medics role 3 military treatment facilities from 2002 to 2016 revealed

76 | JSOM Volume 24, Edition 3 / Fall 2024