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Introduction Combat extremity vascular injuries are frequently associated with extensive soft-tissue loss and contamination, increasing the risk of infection, graft thrombosis and erosion-related bleeding (ERB). Negative pressure wound therapy (NPWT) is widely used to manage complex combat wounds, but evidence regarding its use after vascular reconstruction remains limited.Methods We retrospectively analysed 69 patients with combat-related vascular injuries who underwent NPWT at a Role IV (Echelon of Care in the Military Medical System) facility in Ukraine during 2022. NPWT applications were categorised into two predefined groups: an interface group—NPWT applied adjacent to exposed vascular reconstructions using a protective multilayer system (n=28); and a covered group—NPWT applied over established soft-tissue or muscle flap coverage (n=41). Outcomes included ERB, graft thrombosis, infectious complications and limb loss. NPWT was applied as part of staged wound management following debridement and revascularisation.Results ERB occurred exclusively in the interface group (9/28, 32.1%) and was not observed in the covered group (0/41). ERB events were observed only prior to stable soft-tissue or flap coverage. Graft thrombosis (14.3% vs 4.9%), wound infection (10.7% vs 2.4%) and secondary amputations (7.1% vs 0%) were more frequent in the interface group. Overall limb salvage was 97.1%. Two ERB risk windows were observed: postoperative days 7–10 (mechanical) and 18–30 (infection-related).Conclusions NPWT may be incorporated into staged wound management following combat-related extremity vascular reconstruction; however, outcomes differed according to the soft-tissue coverage strategy employed. Application of NPWT near exposed vascular repairs was associated with a higher ERB rate and should be considered a short-term temporising strategy when immediate definitive coverage is not feasible, and only within a controlled Role IV environment. Early definitive soft-tissue or muscle coverage remains the preferred protective strategy whenever feasible.