Scientific paperProlonged use of intraluminal arterial shunts 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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