Damage Control Surgery for Wartime Carotid Artery Injuries: Interaction Between Role 2 and Role 3 Facilities in Ukraine and a Clinical Case Series Analysis

Introduction: This case report aimed to describe patterns of combat related carotid artery injury in Ukrainian military personnel and to evaluate outcomes of damage control surgery (DCS) at Role2 facilities followed by definitive management at Role 3 facilities. Method: A retrospective, observational analysis was conducted over a 12 month period at military Role 2-3 facilities. Medical records, operation reports, imaging studies, and evacuation data were reviewed for patients with penetrating neck trauma and confirmed extracranial carotid artery injury. All patients received individualised surgical management at Role 2 and Role 3 facilities according to DCS principles, tailored to clinical severity, associated injuries, and available resources. Results: Ten male patients with penetrating carotid artery injuries were identified. Six patients presented at Role 2 facilities with hard signs of vascular injury, including active arterial bleeding in four cases and expanding neck haematoma in two cases. Temporary intravascular shunts were used as a DCS measure at Role 2 facilities in four patients (40%). Definitive management included primary arterial repair in four patients (40%), carotid ligation in two patients (20%), and reconstruction with interposition grafts following shunting or ligation in four patients (40%). Shunt thrombosis occurred in two of four shunted patients, both involving improvised temporary shunts. The overall stroke rate was 30% (three of ten), including one non-disabling stroke and two disabling stroke, one of which was fatal. Peri-operative mortality was 10% (one of ten). Among patients with available follow up, most demonstrated favourable neurological outcomes, particularly after primary repair. Conclusion: Combat related carotid artery injuries are life threatening and require rapid application of DCS principles. Temporary shunting at Role 2 facilities can be lifesaving but carries risks, particularly when improvised shunts are used. Primary repair at Role 3 facilities provides favourable neurological outcomes when feasible. Close coordination between Role 2 and Role 3 facilities is essential to optimise survival and neurological outcomes in modern warfare.