Venous shunting and limb outcomes in military lower extremity combined arterial and venous injuries

Abstract

Combined arterial and venous lower extremity (LE) injuries present complex management challenges. Temporary arterial shunting is widely accepted, but vein shunting is not well studied. We examined the influence of vein shunting on limb outcomes in military femoropopliteal arterial and venous combined injuries. A retrospective cohort study of Iraq and Afghanistan LE vascular injuries from 2004-2012 was performed and combined arterial and venous femoropopliteal injuries selected. Vein shunted and non-vein shunted groups were identified and pertinent variables compared. Of 135 arteriovenous injuries, 61 (45%) had vein ligation (5 after shunting), leaving 74 injuries undergoing venous repair (37 grafts (3 synthetic), 34 local repairs, 3 patches). The vein was shunted in 16 (22%). The shunt and no shunt cohorts had similar demographics, mechanism (70% blast), and ISS (median 18, IQR 10-26). Tourniquets and fasciotomy were used equally. Venous shunts were used almost exclusively in cases in which the artery was shunted (94% vs 22% no shunt, P<0.001) and more commonly in cases with bilateral LE vascular injuries (25% shunt vs 3.4% no shunt, P=0.01). Shunted veins more frequently underwent grafting (88% vs 40%, P<0.001). Median MESS was 8, IQR 7-9 in shunted vs. 6 (5-7) in unshunted limbs. Outcomes were similar, with amputation in 13% of shunted and 26% (P=0.33) unshunted and arterial repair complications in 44% and 28% (P=0.24). In combat casualties with combined arterial and venous femoropopliteal injury, vein shunting was used primarily in severely injured limbs in conjunction with arterial shunts and in injuries ultimately undergoing autologous grafting. Limb salvage was statistically equivalent with the use of venous shunts, suggesting equipoise in outcomes with and without venous shunting. Temporary venous shunting should be considered but does not appear to be mandatory in severe lower extremity combined arterial and venous injuries.