Scandinavian Journal of Surgery 95: 49–54, 2006

SEVERE VASCULAR GUNSHOT INJURIES OF THE EXTREMITIES:

A TEN-YEAR NATION-WIDE ANALYSIS FROM FINLAND

I. Mäkitie1, V. M. Mattila1, H. Pihlajamäki1,2

1 Research Institute of Military Medicine, National Military Hospital, Helsinki, Finland
2 Department of Surgery, National Military Hospital, Helsinki, Finland

ABSTRACT

Background and Aims: Gunshot wounds affecting the main vessels of the extremities
mostly threaten limb salvage. The purpose of this study was to analyse the nature and
severity of civilian vascular gunshot injuries of the extremities using a nation-wide da-
tabase.
Material and Methods: Retrospective analysis of the Finnish Hospital Discharge Reg-
ister, hospital records and death certificates over a 10-year period from January 1, 1990 to
December 31, 1999.
Results: Thirty-two individuals with the mean age of 33 years (17–68) sustained 43
severe vascular injuries to the extremities caused by gunshots. The incidence was 6.0
(95% CI: 4.1–8.5) per 10,000,000 person-years and did not change significantly during the
period. Four of the injured died. The most common anatomical locations of vascular
injuries were the femoral artery (6 lesions), popliteal artery (6) and superficial femoral
artery (5). Use of alcohol was detected in ten cases (32% of patients) and of illegal drugs
in seven cases (22%). Five patients (18% of non-fatal injuries) required vascular re-op-
eration caused by post-operative problems. Five amputations were performed as pri-
mary treatment.
Conclusions: Severe vascular gunshot injuries of the extremities are not common in
Finland. The need for primary amputation or vascular re-operations is noteworthy.
Key words: Wounds and injuries; gunshot; epidemiology; vascular

INTRODUCTION In the United States, gunshots constituted the etio-

In most cases, traumas involving the major vessels of
the extremities require limb salvage and they might
even be life-threatening. However, continued im-
provements in limb salvage after vascular injuries in
the lower as well as in the upper extremities is an is-
sue characteristic of many studies (1, 2, 3).
Correspondence:
Harri Pihlajamäki, M.D.
Research Institute of Military Medicine
P.O. BOX 50
FIN - 00301 Helsinki, Finland
Email: harri.pihlajamaki@helsinki.fi
logical factor in 21% of vascular traumas of the ex-
tremities in a civilian series of 5760 cardiovascular
injuries (4). Further, in a series of 320 gunshot injuries
of the extremities treated at an urban trauma centre,
21% presented with a vascular injury (2). Another
report from the United States described nineteen out
of 100 patients who had sustained isolated below-
knee gunshot wounds and exhibited vascular injuries
(3). In the United Kingdom, in a series of 23 shotgun
wounds of the limbs, there were six patients with
severe vessel injuries (5). A more recent British study
reports a four-fold increase in civilian gunshot inju-
ries to the extremities, but vessel injuries were limited
to one case only (6). An earlier report from South
Africa described a two-year follow-up from a univer-
50 I. Mäkitie, V. M. Mattila, H. Pihlajamäki
sity hospital with 173 major arterial injuries in about
4000 patients with gunshot injuries to the extremities
(7).
The annual incidence of gunshot-related injuries in
Finland has been reported to be 3.5 per 100,000 per-
son-years without undergoing a significant change
since the 1980s (8, 9). Fatal gunshot injuries have like-
wise remained on the same level and have required
only minimal hospital resources (10). A large propor-
tion of patients with truncal gunshot wounds have
been treated non-operatively with very good overall
outcomes (11). Despite such favourable results some
complications in gunshot fractures of the extremities
might have been avoided if the principles of war sur-
gery had been more closely observed (12).
The aim of the present study was to analyse the
incidence, nature and severity of vascular gunshot
injuries of the extremities in Finland as well as to
observe their outcome.
MATERIAL AND METHODS
STUDy DESIgN AND SETTINg
Information on all severe non-fatal vascular gunshot injury
hospitalisations were identified from the Finnish Hospital
Discharge Register (FHDR) in Finland. Information on
deaths caused by vascular gunshot injuries was obtained
from the official Cause-of-Death Register (CDR) of Finland,
an extensive medical-legal investigation system for cause-
of-death in Finland.
The diagnosis and cause of injury were coded using the
Ninth (1990–1995), the Tenth (first edition) (1996–1998) and
the Tenth (second edition) (1999) revisions of the Interna-
tional Classification of Diseases (ICD) (13). Based on hos-
pital records and death certificates, our study covered the
period from January 1, 1990 to December 31, 1999.
IDENTIFICATION OF INJURIES
For the purpose of this study, a gunshot-related injury was
defined as an acute, physical injury caused by gunshots.
The corresponding ICD-9 and ICD-10 codes are presented
in table 1. Only hospital admissions with the primary diag-
nosis of an acute injury were included in our analysis.
Copies of the original hospital records of patients with
above selected diagnosis were ordered from the hospitals
and reviewed. Seventeen hospitalisations for vascular in-
juries of the extremities caused by gunshots were found.
The identification of severe vascular gunshot injuries of the extremities.
External causes
Codes of severe vascular injury of the extremity
Codes of fractures and amputations (which might have
included an un-coded associated vascular trauma)
Moreover, 222 hospitalisations for gunshot fractures were
identified. In a critical analysis of these hospital records, six
patients were pinpointed with an un-coded major vascu-
lar lesion concurrent with the gunshot fracture. Finally, 37
patients had been treated for gunshot related amputations,
but, in closer examination, only five of these patients could
be considered to have had a dominant vascular trauma to
the extremity. The majority of gunshot injuries were iden-
tified as minor amputations of fingers and toes without
problems involving vascular surgery. Shock on arrival was
defined as systolic blood pressure recording of less than
90 mm Hg.
Fatal cases were identified by obtaining all non-suicidal
gunshot-related death certificates with above selected di-
agnosis from the Cause-of-Death Statistics. The reviewed
death certificates indicated that there were only four cases
where a major haemorrhage in an extremity was mentioned
as the primary cause of death on scene or during transpor-
tation. To sum up for further detailed analysis, a total of
32 patients were identified with severe vascular gunshot-
related injuries of the extremities.
The type of causative weapon was divided into three cat-
egories when information was available: shotguns, high-ve-
locity (hunting, assault and military rifles) and low-velocity
(mainly pistols, including air-rifle) gunshots.
The incidence rates (per 10,000,000 person-years) were
calculated by dividing the number of persons with se-
vere vascular gunshot injury of the extremities during the
10-year period by the sum of the mid-year populations
(50,986,570) between 1990 and 1999. The population data
was obtained from Statistics Finland, the official popula-
tion register in Finland. Over the study period, the an-
nual population in Finland varied between 4,998,478 and
5,171,302. Ninety-five percent confidence intervals (95% CI)
were constructed by Poisson’s approximation for incidence
(14).
RESULTS
The material consisted of 25 males and 7 females. The
mean age was 32.8 years (17–68 years). The incidence
was 6.0 (CI: 4.1–8.5) per 10,000,000 person-years and
did not change significantly during the period (Fig 1.).
Patients were treated in 16 central and two district
hospitals of the 21 hospital districts in the country.
The average hospitalisation period of the primary
hospital stay (28 patients) was 13.5 days. In many
cases, the follow-up hospitalisation took place in a
district or a psychiatric hospital. In the few cases
TABLE 1
ICD-9 codes ICD-10 codes, ICD-10 codes,
first edition second edition
E925 W32-W34, W43
E955 X72-X74, X93–X95, X74
E964 y22-y24 X95
E974 y24
903–904 S45, S55, S65, S75, S85, S95, T11.4, T13.4, T14.5
812-814 S42, S52, S62, S72, S82, S48, S58, S68, S78, S88
820-824
885-887
895-897
 Vascular gunshot injuries 51

TABLE 2
Location of 43 vascular lesions in 32 patients. Fatal lesions located
in the femoral and popliteal arteries.

Arteries and Number of

Veins lesions
Femoral artery 6
Popliteal artery 6
Superficial femoral artery 5
Anterior tibial artery 4
Posterior tibial artery 4
Axillary artery 2
Radial artery 1
External iliac artery 1
Deep femoral artery 1
great saphenous vein 5
Femoral vein 2
Superficial femoral vein 2
Popliteal vein 2
Axillary vein 1
Tibial vein 1
Total 43

suffered from a haemodynamic shock (systolic pres-

Fig. 1. Number of cases by year and outcome of severe vascular
gunshot injuries in Finland in 1990–1999.
needing an amputation, the primary hospitalisation
period was 17.4 days.
The shooting was unintentional in 14 cases, vio-
lence-related in 11 cases (including an attempt at self-
damage in two cases and a consequence of legal in-
terference by police in two cases) and unclear in
seven cases. The weapon used was a shotgun in 12, a
pistol in 10, a hunting rifle in three, an assault rifle in
one, an airgun in one, and an unknown hand weapon
in five cases.
Alcohol and substance use were strongly related to
vascular gunshot wounds in this Finnish material,
since altogether 13 victims (41%) were under the in-
fluence of alcohol or drugs. Ten (31%) of them were
under the influence of alcohol at the time of shooting,
but substance use (cannabis, heroin, amphetamine)
was almost equally common and was mentioned in
the records of seven cases (22%).
Altogether, 43 severe vascular lesions were identi-
fied. Anatomically, the injuries mostly affected the
vessels in the lower extremities (38 lesions) while
only five lesions were located in the upper extremi-
ties (Table 2.). Four arterial-venous fistulas were de-
tected with six concurrent gunshot fractures involv-
ing a severe vascular injury. Associated arterial and
venous trauma was evident in ten cases. The most
common combination, found in a total of six cases,
was an injury in the femoral artery and an injury in
the femoral vein or in the great saphenous vein.
The use of a tourniquet during the initial treatment
was mentioned in four cases. Seven of the injured had
sure under 90 mm Hg) during the initial treatment
procedures.
Ten patients (36%) were primarily treated by vas-
cular surgeons. Reviewing the hospital records im-
plied substantial clinical variation. Two synthetic
prostheses and 12 great saphena vein grafts were
used. After primary vascular reconstruction, five pa-
tients (18%) required re-operations to establish ade-
quate permanent distal perfusion. In both cases with
synthetic prothesis used, the synthetic graft failed.
Replacement of the prosthesis was due to a septic
infection in one case and difficulties in closure of the
primary wound in the other case. In the three other
cases, the primary repair needed re-operation due to
varying problems (Table 3). After the re-operations
no further acute problems were encountered.
Five amputations were performed as the primary
surgical treatment. In two cases a reconstruction was
impossible due to extensive vascular and tissue de-
struction, in one case the patient was severely multi-
injured, in one case a coronary disease was compli-
cating the treatment and in one case an amputation
of the thigh was performed as a life-saving procedure
due to unstable hypovolemic shock (Table 4). No late
amputations were performed.
The weapon used did not play any coherent role
when comparing different vascular lesions in this
study.
DISCUSSION
This epidemiological study indicated that the abso-
lute number of severe vascular injuries caused by
gunshots seems to be relatively low in Finland. The
annual incidence of all gunshot injury hospitalisa-
tions in Finland has been 3.5 per 100,000 person-years
(9). Thus, the vascular gunshot injuries of the extrem-
ities represent only approximately two per cent of the
gunshot injury hospitalisations in the country. More-
52 I. Mäkitie, V. M. Mattila, H. Pihlajamäki

TABLE 3

Details of five cases with vascular re-operations. (PTFE = synthetic polytetrafluoroethylene graft, SVG = autogenous saphena vein graft)

Sex and age Weapon Vessels injured Primary reconstruction First re-operation Second re-operation

Male, 36 Shotgun Femoral artery and vein The artery and vein The failed PTFE in The failed SVg in
repaired by PTFEs. artery replaced by SVg. artery repaired by
a new SVg.
Male, 21 Air-rifle Superficial femoral The A-V fistula closed The unclosed A-V
artery and femoral vein by an endoprothesis fistula closed by
stent. ligation.
Male, 18 Shotgun Superficial femoral The artery repaired by The SVg replaced by a
artery and femoral vein SVg and the vein by new SVg due to
ligation. inadequate distal
perfusion.
Male, 42 Pistol Popliteal artery and The artery repaired by Failed PTLE repaired by
vein PTFE and the vein by SVg.
ligation.
Male, 26 Shotgun Popliteal artery and The artery repaired by Re-exploration and
femoral vein SVg and the vein by ligation of the bleeding
ligation. branches of popliteal
artery.

TABLE 4
Details of amputations after civilian gunshot injuries in Finland.

Sex and age Weapon Vessels injured and Main indication for amputation Level of amputation
associated trauma

Male, 18 Unknown External iliac artery Unstable hypovolemic shock. Amputation Thigh
and deformation of done as lifesaving procedure.
thigh.
Male, 68 Shotgun Anterior tibial artery Reconstruction not possible due to Lower leg
and fracture of leg. coronary disease.
A re-amputation and haemostasis was
needed for post-operative bleeding.
Female, 30 Shotgun Anterior tibial artery. Reconstruction not possible and a delay Lower leg
gustilo gradus III c of transportation.
injury.
Female, 42 Shotgun Extensive tissue Reconstruction not possible due to tissue Brachial arm
destruction of forearm loses.
Female, 42 Shotgun Extensive tissue Reconstruction not possible due to tissue Forearm
destruction of forearm loss and other multiple injuries.

over, injuries studied here represent approximately
five per cent of the vascular traumas reported in the
country during the same decade (15). In most cases,
the trauma mechanism of vascular injuries in Finland
has been iatrogenic or penetrating, and stab wounds
have been more common than gunshot wounds
(15).
The actual incidence of vascular trauma in most
European countries is unknown, but according to ex-
isting evaluations it is low (15). To our knowledge,
corresponding focused nation-wide incidence figures
as studied here have not been previously reported.
In 41% of the cases, a very strong association
emerged between the presence of alcohol or sub-
stance use and the incidents of injuries studied. More-
over, while information about the types of gunshots
used could be elicited from most of the hospital re-
cords and death certificates, the precise shooting dis-
tance was usually unidentifiable from these records.
A recent national study reports, however, that divid-
ing gunshots into categories like low and high energy
projectiles has little to do with the reality today (16).
Nevertheless, gunshots can result in severe vascular
damage and threaten limb salvage. A clear connec-
tion between the weapon used and the vessel injury
was not found in this study.
Vessels exposed to the effects of ballistic missiles
behave in a rather unpredictable manner (17). In case
of blood vessels, cavitation may lead to considerable
distortion with little external evidence of injury. The
diagnosis of vascular injuries may be difficult and,
since the haemorrhage and ischemia consequences of
a missed diagnosis may be severe, a constant vigil is
essential at the initial assessment and during follow-
up. The method chosen for the vascular reconstruc-
tion needed depends on the type and site of injury.
In most of the cases examined in this study, injuries
affected the vessels of the lower extremities and re-
 Vascular gunshot injuries
quired on average a two-week primary hospitalisa-
tion. However, injury patterns varied greatly. A vas-
cular re-operation was necessary in nearly one-fifth
of the cases. An amputation had to be performed like-
wise in almost one-fifth of the cases.
The occurrence of re-operations (18%) in our study
may be noteworthy. In a series of 31 patients with
vascular shotgun injuries of extremities from the
United States, five patients (16%) needed re-opera-
tions after primary surgery (18). In a South African
series, twenty one (12%) of 169 injured patients un-
derwent an unsuccessful vascular operation and all,
except one, were re-explored (7). McHenry reported
on 27 patients from the United States treated for frac-
tures with major vascular injuries with no cases of
disruption by any method of revascularization (19).
The decisions on amputation (18%) reported in our
study were made after serious consideration and con-
sulting senior colleagues. The proportion of limb sal-
vage has been reported to approach even 100% in
other series at civilian trauma centres (2, 3, 19). How-
ever, the results of the present nation-wide report
cannot be relevantly compared to referred studies
based on differently selected patients.
One complicating factor in a recent series of vascu-
lar injuries to the lower extremities has been the sig-
nificant number of combined arterial and venous le-
sions or the presence of associated bone fractures (1,
20, 21). In the present study, four patients (14%) were
noted to have an arterial-venous lesion. In a series of
220 consecutive vascular injuries of the lower extrem-
ities from the United States, the proportion of arte-
rial-venous fistulas was 10.5% of all patients (1). Our
study reports associated gunshot fractures in six cases
(21%). A previous study reported that a vascular le-
sion was associated with 28% of gunshot fractures of
the extremities in Finland in the 1980s (12). A recent
study even considers that the most severe traumas of
this kind are vascular extremity injuries with skeletal
fracture and severe soft tissue damage (22)
In this series, the patients with vascular injuries
were managed in university and central hospital
emergency departments by general surgeons in
smaller hospitals and cardiothoracic or vascular sur-
geons in larger hospitals. The severity of wounds and
primary operative approach in management varied.
Injuries studied here were rarities and as such chal-
lenges for surgeons on call. The small population
density and the relatively large geographical area of
Finland do not favour high volume, centralised trau-
ma management systems, which is reflected in the
small material presented here.
All studies based on a hospital discharge register
are limited due to underreporting of the external
causes of an injury, which leads to an underestima-
tion of the true incidence rate. Our study was no ex-
ception. However, because gunshot-related injuries
are uncommon in Finland, we may assume that E-
coding has nevertheless been more frequently used.
The present study had several strengths. First, the
nation-wide registers, the Finnish Hospital Discharge
Register and the Cause-of-Death Register, have
shown to be accurate and complete (23, 24, 25, 26).
Second, due to the personal identification number it
53
was possible to follow the patients during the study
period and thus all personal records from hospitals
were ordered and reviewed for each patient. Third,
the accuracy of the number of Finnish inhabitants
provided by Statistics Finland permitted accurate cal-
culation of the incidence (23). Fourth, also cases with
other than vascular gunshot injuries of the extremi-
ties were explored (fractures and amputations) and
11 cases of vascular gunshot injuries of the extremi-
ties were detected. It is, however, possible that some
additional vascular gunshot injuries of the extremi-
ties have occurred and received treatment during the
study period in Finland, without having been validly
entered into the hospital records.
Previously, some gunshot studies have been pub-
lished in Finland concerning truncal gunshot injuries
as well as gunshot fractures (11, 12). Despite the spe-
cific subject of our study, it complements the informa-
tion on gunshot injuries in the country.
Compared with all civilian gunshot injuries in the
country, severe vascular injuries of the extremities
present a minor problem epidemiologically. The na-
ture of injuries studied varied greatly. The proportion
of re-operations, amputations and remarkable hospi-
talisation stays in cases of severe vascular gunshot
injuries of the extremities is noteworthy and cannot
be considered as a negligible medical problem in Fin-
land.
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