Beyond damage control: Functional preservation and avoidance of iatrogenic harm in combat vascular injury and fasciotomy.

Abstract

Damage-control interventions are essential in combat vascular trauma, but their benefits must be balanced against iatrogenic injury and long-term functional impairment. Extensive vascular exposure, temporary shunting, vessel ligation, and prophylactic fasciotomy may be lifesaving in selected patients, yet their indiscriminate use can increase operative burden and complicate definitive reconstruction. A focused narrative review of PubMed/MEDLINE and Google Scholar was performed through July 2026 using predefined combinations of terms related to vascular trauma, temporary shunting, ligation, endovascular management, fasciotomy, compartment syndrome, limb ischemia, and damage-control surgery. Civilian and military guidelines, reviews, comparative and observational studies, case series, and technical reports were included, with priority given to combat casualty care and staged evacuation. Owing to heterogeneity and the narrative design, findings were synthesized qualitatively without meta-analysis or formal certainty grading. Vascular injury alone does not invariably mandate immediate extensive exploration. In stable patients, imaging, observation, and endovascular or hybrid techniques may avoid non-therapeutic dissection. Temporary shunts have an established damage-control role in reducing ischemic time during resuscitation, treatment of higher-priority injuries, skeletal stabilization, or evacuation, particularly when definitive vascular expertise is unavailable. Their use nevertheless requires attention to patency, vessel injury, and the implications for later reconstruction. Ligation may be appropriate for selected vessels and exceptional damage-control circumstances, but major named arteries should generally be repaired or shunted when limb or organ perfusion is threatened. Therapeutic fasciotomy is mandatory for established compartment syndrome. Prophylactic fasciotomy is supported in high-risk settings, including prolonged ischemia with reperfusion, combined arterial and venous injury, major venous outflow obstruction, unreliable examination, and prolonged evacuation; lower-risk scenarios require individualized assessment and reliable surveillance. Damage-control interventions should be selected according to physiology, anatomy, ischemic burden, evacuation conditions, available expertise, and their functional consequences. Preservation of life and limb remains the priority, but avoidance of preventable iatrogenic harm should be incorporated into operative decision-making from the initial level of care.