Scientific paper
Prolonged use of intraluminal arterial shunts without systemic anticoagulation

Presented at the 52nd Annual Meeting of the Southwestern Surgical Congress, Colorado Springs, Colorado, April 9–12, 2000.
https://doi.org/10.1016/S0002-9610(00)00508-0Get rights and content

Abstract

Background: Temporary arterial shunts maintain perfusion while surgeons postpone arterial repairs. The common indications are combined orthopedic and vascular injuries and damage control. The duration of patency and the need for systemic anticoagulation remain in question. We examined our experience for answers.

Methods: We searched for patients who had temporary arterial shunts and collected the following: mechanism, artery injured, shunt time, blood loss and transfusions, injury severity score (ISS,) mangled extremity severity score (MESS,) and anticoagulation.

Results: Of 19 patients, 10 had shunts for damage control (group 1,) and 9, for orthopedic/vascular injuries (group 2.) group 1 had significantly higher shunt time, mortality, ISS, and MESS. Shunt time ranged from 47 to 3,130 minutes (52 hours.) Two patients, 1 in each group, required amputations.

Conclusions: Temporary arterial shunts can be use for combined orthopedic and vascular injuries and for damage control. Shunts can stay open for 52 hours without systemic anticoagulation.

Section snippets

Methods

This study complied with the guidelines of the institutional review boards at the Baylor College of Medicine and the Harris County Hospital District. We reviewed the charts of all patients on the Trauma Service from January 1993 to December 1998 who had intraluminal arterial shunts placed. We collected the following data: the type of injury, the injury severity score (ISS), the artery shunted, the operation performed, the duration of shunt time, the use of anticoagulation, intraoperative blood

Results

We identified 21 patients who had shunts placed: 18 men and 3 women between the ages of 16 and 49 years (mean 37.7). Mechanisms of injuries were gunshot wounds in 13 patients, stab wounds in 3, automobile-pedestrian collisions in 3, and motor vehicle collisions in 2. The arteries injured were 8 brachial, 6 popliteal, 3 femoral, 1 iliac, 1 radial, 1 axillary, and 1 subclavian. We identified 10 patients who had temporary arterial shunts as part of a damage control operation (group 1), and 11

Comments

Several studies demonstrate the safety and utility of temporary arterial shunts for combined arterial and orthopedic injuries.5, 6, 7, 8 Our clinical experience is similar. We usually place these shunts without systemic anticoagulation. Figure 1 illustrates the shunt placement in the popliteal artery, a common site in our experience. The shunt can be placed quickly into the lumen of a lacerated or transected artery and secured with rubber vessel loops or umbilical tape. The secured shunt

Conclusions

Temporary arterial shunts can be used without systemic anticoagulation to maintain distal perfusion while awaiting fracture reduction and fixation in combined orthopedic and vascular injuries. The shunts are also useful in the setting of damage control surgery. In select patients, the shunts can remain patent and provide adequate limb perfusion for up to 52 hours.

Discussion

Dr. David V. Feliciano (Atlanta, GA): Our own data on the use of shunts in 17 patients since 1995 is similar to those of the authors. We have, however, used trans-shunt anticoagulation in patients with mangled extremities in our recent experience, as their coagulopathies have reversed in the postoperative period.

I have 5 questions for the authors. One, when you discuss damage control surgery, it is important to describe the factors that trigger your use of the technique versus definitive

Closing

Dr. Thomas S. Granchi: Although most of these patients were in hemorrhagic shock, and we usually record the base deficits in these patients, for the purpose of this study, we did not collect that data.

Regarding the size of the shunts, we placed the best fit. The 10 and 12 seem to be the most commonly used in peripheral arteries. We did not deliberately oversize them. They seemed to provide adequate distal flow. Further studies measuring the flow would be helpful. Regarding the verification of

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