Effect of temporary shunting on extremity vascular injury: An outcome analysis from the Global War on Terror vascular injury initiative

Abstract

Temporary vascular shunting used as a damage control adjunct in management of wartime extremity vascular injury does not lead to worse outcomes. Benefit from TVS is suggested, but not statistically significant. Injury specific variables of venous ligation, associated fracture, and penetrating blast mechanism are associated with amputation. Amputation-free survival after vascular injury in Operation Iraqi Freedom is 79% at three years. Further studies to statistically define any possible benefits of TVS are needed.

Surgical Damage Control and Temporary Vascular Shunts

“…In their study, the authors used case-controlled methodology to show that the use of temporary vascular shunts had no adverse outcome in the years following vascular repair and likely extended the window for limb salvage, especially in the most severely injured extremities. 25 Finally in a recent and larger 10-year review of the civilian experience from Feliciano's group at Grady Memorial, Subramanian et al confirmed the utility of temporary vascular shunts in certain patterns of vascular injury. This study demonstrated a 95% patency rate of shunts and an overall survival rate of 88% following major vascular injury.…”

“…This determination can often be aided by the use of continuous-wave Doppler. [21][22][23][24][25][26][27][28][29] In cases where there is injury to more than one of the small distal arteries (e.g., both ulnar and radial arteries) resulting in an absence of Doppler signal beyond the injury, use of a vascular shunt is recommended. 33 Those who have extensive experience with placing shunts frequently state that in the setting of penetrating vascular injury, the two ends of the severed vessel must be exposed for ligation anyway.…”

“…These factors explain the high prophylactic fasciotomy rates reported in both military and civilian series, ranging from 60% to 100%. 21,25,26 It is recommended that prophylactic fasciotomy be considered in patients requiring shunt placement and any of the following: severe extremity injuries (Abbreviated Injury Scale [AIS] score of ≥3 or Mangled Extremity Severity Score [MESS] of ≥5), combined arterial and/or venous injury, prolonged ischemia or tourniquet time (>1 to 2 hours), penetrating or crush mechanisms of injury, injury to proximal below-knee or forearm vasculature, associated open fractures or nerve injuries, and significant intraoperative blood loss. [36][37][38][39] …”

Femoral and Above-Knee Popliteal Injuries

“…This trend was greatest in patients with severely injured limbs. The authors concluded that temporary vascular shunting used as a damage control adjunct in management of wartime extremity vascular injury does not lead to worse outcomes [ 16 ]. Analyses from all available publications suggest that temporary vascular shunting is an effective technique to facilitate patient transfer and is preferable to prolonged reconstruction efforts in remote less capable locations.…”

Lessons from the front line

“…14 Lower echelons of care perform any essential immediate amputations, but every eff ort is made to initially preserve limbs when they are perfused or revascularised, often using temporary vascular shunts. 21,22 When performed, traumatic amputations are …”