The Use of Prosthetic Grafts in Complex Military Vascular Trauma: A Limb Salvage Strategy for Patients With Severely Limited Autologous Conduit

Abstract

When managing patients with multiple extremity trauma and limited noninjured autogenous venous conduits, emergent use of prosthetic grafts may provide an effective limb salvage strategy. Despite being placed in multisystem trauma patients with large contaminated soft tissue wounds, emergent revascularization with polytetrafluoroethylene allowed patient stabilization, transport to a higher echelon of care, and elective revascularization with remaining limited autologous vein.

A Retrospective Cohort Comparison of Expanded Polytetrafluorethylene to Autologous Vein for Vascular Reconstruction in Modern Combat Casualty Care

“…In 2009, Vertrees et al 15 described the Walter Reed experience managing ePTFE grafts used in the treatment of combat injuries sustained in Afghanistan and Iraq. The present study expands the scope of the 2009 report by Vetrees by examining the usage of ePTFE through a longer period of conflict and in anatomic areas beside the extremity.…”

“…These observations further support the idea proposed by the Walter Reed group that ePTFE may be viewed as a temporary rather than a definitive reconstruction. 15 In this context, ePTFE may be viewed as a longer term vascular ''shunt'' providing a ready option for especially challenging cases in austere conditions. Use of ePTFE to restore extremity perfusion with its anticipated removal days or weeks later may allow the deployed surgeon time to resuscitate and evacuate the patient and to debride and control the evolving soft tissue wound before a more definitive reconstruction with vein.…”

The Surgical Legacies of Hawkeye Pierce

“…Data from this military experience confirm that these conduits stay open during the patient evacuation process. 39,40 Later definitive vascular reconstruction is almost always possible and amputations that are necessary later in the course result from nerve injury or infection and not failure of the vascular reconstruction.…”

Lower Extremity Vascular Trauma

“…Importantly, in this experience there were no short-or midterm prosthetic graft disruptions, amputations, or deaths due to graft failure confirming the utility of this damage control approach (i.e., prosthetic first followed by resection and use of vein later) in select injury patterns. 31 Extraanatomic bypass using synthetic conduit routed remotely from the zone of injury should also be considered in some injury patterns in which in-situ vein interposition graft placement is not possible. 32…”

“…However, use of a synthetic vascular graft is acceptable in certain scenarios in which there is no saphenous vein or in which the available saphenous vein is being saved for a later, more-definitive reconstruction (i.e., interval reconstruction). 31,41 In order to expose the popliteal space, the knee is flexed or bent slightly (i.e., frog leg position); and a soft roll or bump is placed behind the leg, below the knee to elevate or suspend the thigh. This maneuver makes it such that the medial musculature of the thigh pulls freely away from the femur and allows gravity to open up the above-knee popliteal space.…”