8. Vascular Shunt

CPT David Crawford
MAJ Joanna Branstetter
 
I. Patient Preparation
            A. Always prep to allow access for proximal vascular control
                        1. upper extremity: subclavian artery
                        2. lower extremity: common femoral artery
            B. Preparation should include access to uninvolved limb in case vein graft is needed to be harvested
            C. Systemic heparinization (50-75 units/kg IV) should be initiated in stable patients with a vascular injury
II. Exposures
            A. Longitudinal incisions over named vascular structures allow for widest exposure
            B. Curvilinear-type incisions made across joints
            C. In contaminated wounds, adequate debridement is essential
            D. If ligation of a major artery is required, distal embolectomy should be performed, followed by administration of heparin to preserve collateral circulation1
III. Stents
            A. Currently there is a limited role for endovascular procedures in penetrating extremity trauma
            B. Endovascular stents may be utilized for blunt trauma or proximal arterial injury where open surgical exposure is difficult (i.e., iliac artery)
IV. Shunts (see figure 1, figure 2, figure 3)
 

Vascular Shunt - Chatt Johnson, MD.

 
            A. Temporary revascularization can be performed with intraluminal shunts
            B. After placement, patency should be confirmed with intraoperative continuous wave Doppler
            C. Shunts may remain patent for 24 hours without systemic heparinization2
            D. Shunts have been reported to maintain limb perfusion up to 48 hours during military operations3
V. Bypass Graft (see figure 4)
            A. Greater saphenous vein is a common conduit utilized for lower extremity trauma
            B. Veins should be harvested from the uninvolved limb and be reversed to allow directional flow
            C. Bypass grafting should usually be performed at a combat support hospital level
            D. Grafting or repair in a grossly contaminated wound should be delayed4
            E. Prophylactic fasciotomy should be considered after any revascularization procedure
 
References
 
1. Gorman JF. Combat arterial trauma. Analysis of 106 limb-threatening injuries. Arch Surg. 1969;123:534-579.
 
2. Dawson D, Putnam T, Light J. Temporary arterial shunts to maintain limb perfusion after arterial injury: an animal study. J Trauma. 1999;47:64-71.
 
3. Brounts LR, Wickel D, Arrington ED, Place RJ, Rush RM. The use of a temporary intraluminal shunt to restore lower limb perfusion over a 4,000 mile air evacuation in a special operations military setting: a case report. Clin Med Trauma. 2008;1:5-9.

4. Fox CJ, Gillespie DL, O’Donnell SD, et al. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41:638–644.

The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense or the U.S. Government.

Materials and support for The Disaster Preparedness Toolbox is provided by Lt Col. Ky Kobayashi, MD and Col. Benjamin Kam, MD.
 



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, April 15, 2014 10:55 am