Temporary Arterial Shunts To Maintain Limb Perfusion after Arterial Injury

Abstract

Shunts provided adequate flow in this model of extremity trauma. Correctly placed shunts stayed patent for 24 hours, without anticoagulation, if shunt placement followed resuscitation.

Tactical Surgical Intervention With Temporary Shunting of Peripheral Vascular Trauma Sustained During Operation Iraqi Freedom: One Unit??s Experience

“…The internal diameter of these shunts is sufficient to maintain distal blood flow at approximately 50% of normal which provides adequate oxygenation given compensatory local increases in oxygen extraction. 15 This diameter is not, however, sufficient to produce palpable pedal pulses in most instances. Nonetheless, at least biphasic distal flow through arterial shunts should be detectable by hand-held Doppler.…”

“…These benefits of deep shunt insertion must be considered in light of the potential for iatrogenic injury and thrombosis if side branches are entered or the end of the shunt comes to lie against the vessel wall. 15 This appeared to be the primary factor producing thrombosis of superficial femoral artery and vein shunts placed in a multiply traumatized 14-year-old Iraqi patient (patient 17). The distal portion of the shunt in this case came to lie relatively close to the vascular trifurcation despite the proximal ends lying as far proximal as they could be passed without resistance.…”

“…This was also thought to help decrease the risk of thrombotic complications which compensatory peripheral vasoconstriction in under-resuscitated patients can otherwise predispose to. 15 Before restoration of arterial inflow, attempts were, in most instances, first made to preserve the major venous outflow of the extremity either by repair or shunting of venous injuries. In patients with significant systemic metabolic acidosis or limb ischemia times of more than 60 minutes approximately 200 cc of distal venous blood was removed before restoration of flow into the proximal vein to help minimize reperfusion insult.…”

Transection of Common Iliac Arteries and Veins Bilaterally

“…Heparinization was not used in either report and, in fact, it may not be necessary. A recent animal study in pigs found that 13 of 16 common iliac artery shunts remained patent without heparinization for 24 h [10]. Significantly, seven of eight shunts remained patent for that period in a group of animals in shock, in which the shunt was placed 1 h after induction of limb ischemia [10].…”

Damage control in the abdomen and beyond

“…Although its use is generally recommended if not contraindicated, several authors have described successful outcomes in the absence of systemic anticoagulation 41,48 . It has been shown in an animal model that shunt patency can be maintained for at least 24 h in the absence of anticoagulation if the device is correctly placed technically 49 . When dealing with combined arterial and venous injuries, where the vein is ligated in the setting of the patient in extremis, four-compartment fasciotomy at the initial operation is mandatory to prevent subsequent compartment syndrome and its inherent complications.…”