Temporary Intravascular Shunts Research Articles

Risk factors for stroke in penetrating cerebrovascular injuries

ObjectivePenetrating cerebrovascular injuries (PCVI) are associated with a high incidence of mortality and neurological events. The optimal treatment strategy of PCVI, especially when damage control measures are required, remains controversial. The aim of this study was to describe the management of PCVI and patient outcomes at a level 1 trauma center where vascular injuries are managed predominantly by trauma surgeons. MethodsAn institutional trauma registry was queried for patients with PCVI from 2011 to 2021. Patients with common carotid artery (CCA), internal carotid artery (ICA), or vertebral artery injuries were included for analysis. The primary outcome was in-hospital stroke. The secondary outcomes were in-hospital mortality and in-hospital stroke or death. A subgroup analysis was completed of arterial repair (primary repair or interposition graft) vs ligation or embolization vs temporary intravascular shunting at the index procedure. ResultsWe analyzed 54 patients with PCVI. Overall, the in-hospital stroke rate was 17% and in-hospital mortality was 26%. Twenty-one patients (39%) underwent arterial interventions for PCVI. Ten patients underwent arterial repair, six patients underwent ligation or embolization, and five patients underwent intravascular shunting as a damage control strategy with a plan for delayed repair. The rate of in-hospital stroke was 30% after arterial repair, 0% after arterial ligation or embolization, and 80% after temporary intravascular shunting. There was a significant difference in the stroke rate between the three subgroups (P = .015). Of the 32 patients who did not have an intervention to the CCA, ICA, or vertebral artery, 1 patient with ICA occlusion and 1 patient with CCA intimal injury developed in-hospital stroke. The mortality rate was 0% after arterial repair, 50% after ligation or embolization, and 60% after intravascular shunting. The rate of stroke or death was 30% in the arterial repair group, 50% in the ligation or embolization group, and 100% in the temporary intravascular shunting group. ConclusionsHigh rates of stroke and mortality were seen in patients requiring damage control after PCVI. In particular, temporary intravascular shunting was associated with a high incidence of in-hospital stroke and a 100% rate of stroke or death. Further investigation is needed into the factors related to these finding and whether the use of temporary intravascular shunting in PCVI is an advisable strategy.

Temporary intravascular shunts and limb salvage in civilian vascular trauma

Temporary intravascular shunts and limb salvage in civilian vascular trauma

Temporary IntraVascular Shunts in patients undergoing damage control at the Lourenço Jorge Municipal Hospital in Rio do Janeiro: experience over the last 4 years

Temporary IntraVascular Shunts in patients undergoing damage control at the Lourenço Jorge Municipal Hospital in Rio do Janeiro: experience over the last 4 years

Experience of vascular injuries at a military hospital in Korea.

Vascular injuries require immediate surgical treatment with standard vascular techniques. We aimed to identify pitfalls in vascular surgery for trauma team optimization and to suggest recommendations for trauma and vascular surgeons. We reviewed 28 victims and analyzed the patterns of injuries, methods of repair, and outcomes. Ten patients had torso injuries, among whom three thoracic aorta injuries were repaired with thoracic endovascular aortic repair, one left hepatic artery pseudoaneurysm with embolization, and two inferior vena cava with venorrhaphy, three iliac arteries with patch angioplasty or embolization, and three common femoral arteries with bypass surgery or arterioplasty. Four patients had upper extremity injuries, among whom one brachial artery and vein was repaired with bypass surgery after temporary intravascular shunt perfusion, two radial arteries were repaired with anastomoses, and one ulnar artery was repaired with ligation. One radial artery under tension was occluded. Fourteen patients had lower extremity injuries, among whom one superficial femoral artery and vein was repaired with bypass and concomitant ligation of the deep femoral artery and vein, three superficial femoral arteries were repaired with bypass (two concomitant femoral veins with bypass or anastomosis), one deep femoral artery with embolization, two popliteal arteries with bypass or anastomosis, four infrapopliteal transected arteries, one arteriovenous fistula with ligation, and one pseudoaneurysm with bypass. However, one superficial femoral artery and all femoral veins were occluded. One leg replantation failed. There are potential complications of vascular access during resuscitative endovascular balloon occlusion of the aorta procedures. Vascular repair should be performed without tension or spasm. Preservation of the harvested vein in papaverine solution and blood while using a temporary intravascular shunt is a method of eliminating spasms.

Twenty-minute harvesting of flow-through type vastus lateralis muscle flap significantly reduces the need for a temporary intravascular shunt in the treatment of severe upper extremity trauma in civilian patients.

For the reconstruction of severe upper extremity trauma involving arterial injury in civilian patients, it is generally recommended that the revascularization time be shortened using a temporary intravascular shunt (TIVS). However, if a flow-through type vastus lateralis muscle (VLm) flap can be harvested in 20 minutes and bypassed at the obstructed ischemic zone within 30 minutes, blood flow can be restored as quickly or more quickly than when using a TIVS, eliminating the need for a TIVS. This procedure was applied in the reconstruction of 3 cases of severe extremity trauma with vascular injury. The mean age was 69.7 years. Surgery was started an average of 2.93 hours from the onset. The average flap harvest time was 0.33 hours. The average time to revascularization from flap harvest was 1.33 hours, the average total operation time was 6.43 hours, and all upper extremities were salvaged. No cases showed ischemia-reperfusion injury or severe muscle contracture. The flow-through-type VLm flap can be applicable as a bypass graft for a 20 cm defect at any region distal to the elbow. In addition, harvesting the flap attached to blood-rich muscle not only controls the infection of contaminated wounds through the filling of dead space, but also has the potential to replace damaged muscle or tendon tissue. Even though TIVS placement is currently used extensively in this field of treatment, its role could be significantly reduced if a flow-through-type VLm flap can be harvested within 20 minutes.

Temporary intravascular shunting at the stages of medical evacuation in case of combat injury of the arteries

Temporary intravascular shunting at the stages of medical evacuation in case of combat injury of the arteries

Temporary arterial shunting following a complete transection of femoral artery in a resource-limited setting

The aim of a surgeon managing vascular trauma in an extremity is to save the life, limb, and function of the patient. The use of temporary intravascular shunting has been shown to be a successful damage control strategy in patients who present with hemodynamic instability. We present the first reported case of a penetrating arterial injury of the lower limb causing a large defect that was successfully treated with temporary intravascular shunting before definitive repair in the country of Liberia. In a low-resource setting such as ours, the surgeon often opts to amputate limbs with vascular injuries that are not believed to be candidates for primary repair. Using a pediatric feeding tube with good postoperative results, we demonstrated that temporary arterial shunting in damage control situations before definitive repair was not only feasible but also cost-effective and ultimately resulted in the preservation of the patient’s limb.

Extra-anatomic temporary intravascular shunting to assist with replantation of an amputated hand with prolonged ischemic time.

Although temporary intravascular shunting has been reported to assist with hand revascularization and replantation after traumatic amputation, most reports have described using ipsilateral upper limb inflow. We present a case of a traumatic hand amputation in a patient who had presented with 4 to 5 hours of warm ischemic time. Because the replantation team believed that extra-anatomic revascularization would be necessary, we performed a novel type of temporary intravascular shunting by connecting two arterial sheaths placed in the ulnar and superficial femoral arteries. This permitted the hand to be successfully replanted away from the inflow source and resulted in a good long-term functional outcome.

A swine model of reproducible timed induction of peripheral arterial shunt failure: Developing warning signs of imminent shunt failure

Temporary intravascular shunts are used to maintain perfusion in injured vessels, although failure can be unpredictable and lead to significant morbidity. The aim of the present study was to develop a dose- and timing-controlled swine model of intrinsic shunt failure to facilitate the development of a warning system for impending failure. Ten Yorkshire swine (weight, 56.6 ± 4.2 kg) underwent bilateral Argyle shunt (Cardinal Health, Dublin, OH) placement in the external iliac arteries, with proximal cannulation of the circumflex iliac arteries for infusion of thrombin. The thrombin infusion was randomized to the left or right side for 5000 vs 10,000 U/h. The 5000-U/h group required 2.1 times as long as the 10,000-U/h group to reach failure (mean, 21.8 minutes vs 46.4 minutes; P < .0001), as shown by a Kaplan-Meier survival analysis (log-rank P < .0001). However, the 5000-U/h group required the same total amount of thrombin (mean, 3752 ± 856 U; P = .57). Thus, time- and/or thrombin dose-controlled induction of shunt failure is technically feasible. Furthermore, in the final 15 minutes before failure, the flow was similar between the two groups (P > .05), and the slope of the flow curve became more negative the closer the model was to failure. Overall, this model could be used to develop an alert system to predict for impending shunt failure or the need for intervention.

Systematic review of temporary intravascular shunt use in military and civilian extremity trauma.

The use of temporary intravascular shunts (TIVS) in the setting of military and civilian trauma has grown in recent years, predominantly because of the mounting evidence of improved limb outcomes. We sought to characterize the use and outcomes of TIVS in trauma through a systematic review of military and civilian literature. The MEDLINE, EBSCO, EMBASE, and Cochrane databases were searched for studies on TIVS use in military and civilian trauma settings published between January 2000 and March 2021. Reports lacking systematic data collection along with those with insufficient TIVS descriptive and outcome data were excluded. Data regarding the characteristics and outcomes of TIVS were assessed and collective syntheses of military and civilian data performed. Twenty-one reports were included, 14 from civilian trauma centers or databases and 7 from military field data or databases (total of 1,380 shunts in 1,280 patients). Sixteen were retrospective cohort studies, and four were prospective. Five studies had an unshunted comparison group. Shunts were predominantly used in the lower extremity and most commonly for damage control indications. Dwell times were infrequently reported and were not consistently linked to shunt thrombosis or other complications. Anticoagulation during shunting was sparsely reported and inconsistently applied. Shunted limbs had higher injury severity than unshunted limbs but similar salvage rates. Temporary intravascular shunts are effective for expeditious restoration of perfusion in severely injured limbs and likely contribute to limb salvage. There is a paucity of comparative TIVS data in the literature and no consistently applied reporting standards, so controversies regarding TIVS use remain. Systematic Review, level IV.

Application of a new temporary intravascular shunt device in limb injury of dogs

To explore the effectiveness and safety of a new temporary intravascular shunt (TIVS) device for limb injury in dogs. Eighteen adult beagle dogs, male or female, weighing (20±2) kg, were taken for experiment. A semi-amputated limb model was made by circular amputating the knee joint of one hindlimb, which retained only skin, femoral artery, femoral vein, femoral nerve, and femur. Then the femoral artery was clamped for 2 hours in all animals, resulting in the ischemic environment of the distal limbs. The animals were randomly divided into 3 groups ( n=6). In group A, the bypass was started by using a new TIVS device and replenishing saline through the infusion port; In group B, after intravenous injection of heparin sodium solution, the bypass was started by using a new TIVS device and replenishing 3% heparin sodium solution through the infusion port; In group C, the bypass was started by using the self-made bypass tube. The bypass was end after 12 hours. The general vital signs (body temperature, heart rate, blood pressure) before and after bypass were measured, and the time required for the insertion of the bypass tube, the patency during the bypass, shedding, and thrombosis were recorded. Routine blood test and blood coagulation indicators [white blood cell (WBC), red blood cell (RBC), platelet (PLT), hemoglobin (HGB), activated partial thromboplastin time (APTT), fibrinogen (Fib)] and biochemical indicators [lactic dehydrogenase (LDH) and creatine kinase (CK)] were recorded before bypass and after 3, 6, 9, and 12 hours of bypass, respectively. The gastrocnemius muscles on the surgical side before and after bypass were harvested and the muscle necrosis, the wet-to-dry weight ratio, and the content of malondialdehyde (MDA) and myeloperoxidase (MPO) were measured. In addition, the gastrocnemius muscle and femoral artery were observed after bypass by HE staining. There was no significant difference in body temperature, heart rate, and blood pressure between groups before and after bypass ( P>0.05). Compared with groups A and B, the time required for the insertion of the bypass tube in group C was significantly longer ( P<0.05), and the number of thrombus in the bypass tube, the blockage time significantly increased ( P<0.05). Shedding and sliding of bypass tube occurred in 3 cases of group C, but no shedding or sliding of bypass tube occurred in groups A and B; there was no significant difference in the incidence of shedding between groups ( P=1.000). There was no significant difference ( P>0.05) in routine blood test, blood coagulation indicators, LDH, CK, MPO, MDA, and wet-to-dry weight ratio between groups before bypass. After bypass, the routine blood test and blood coagulation indicators of the 3 groups did not change significantly, and the differences between groups was not significant ( P>0.05); LDH and CK gradually increased ( P<0.05), and group C significantly higher than groups A and B at 12 hours ( P<0.05). After bypass, thrombosis was seen in the bypass tube, the distal gastrocnemius muscle necrosis occurred in group C, and the femoral artery injury was slightly heavier than that in groups A and B. The new TIVS device is safe and effective and has the advantages of convenient implantation, lower thrombosis rate, and less limb ischemia-reperfusion injury.

Extracorporeal sheath shunt technique in trauma: A different vascular shunt in civilian trauma.

Temporary intravascular shunts are widely used in military surgery, representing a bridging until definitive vascular reconstruction. In civilian practice, shunts are mainly used as damage control and as a temporary measure until orthopaedic fixation. The objective of this report is to illustrate a new approach to the temporary restoration of perfusion during open management of extremity arterial injury. The authors present a technique that uses sheaths introducers, instead of commercial or purpose-built shunts, which can be used through surgical or percutaneous approaches. Three clinical cases are presented where this technique was performed.Results/Conclusion: In the presented cases, this technique reduced time of shunt construction by avoiding artery surgical approach. This technique can facilitate the creation of an intravascular shunt among other than vascular surgeons.

Temporary intravascular shunts after civilian arterial injury: A prospective multicenter Eastern Association for the Surgery of Trauma study.

We sought to determine the impact of the indication for shunt placement on shunt-related outcomes after major arterial injuries. We hypothesized that a shunt placed for damage control indications would be associated with an increase in shunt-related complications including shunt dislodgement, thrombosis, or distal ischemia. A prospective, multicenter study (eleven level one US trauma centers) of all adult trauma patients undergoing temporary intravascular shunts (TIVS) after arterial injury was undertaken (January 2017-May 2019). Exclusion criteria included age <15years, shunt placement distal to popliteal/brachial arteries, isolated venous shunts, and death before shunt removal. Clinical variables were compared by indication and shunt-related complications. The primary endpoint was TIVS complications (thrombosis, migration, distal ischemia). The 66 patients who underwent TIVS were primarily young (30years [IQR 22-36]) men (85%), severely injured (ISS 17 [10-25]) by penetrating mechanisms (59%), and had their shunts placed for damage control (41%). After a median SDT of 198min [89-622], 9% experienced shunt-related complications. Compared by shunt placement indication (damage control shunts [n=27] compared to non-damage control shunts [n=39]), there were no differences in gender, mechanism, extremity AIS, MESS score, fractures, or surgeon specialty between the two groups (all p>0.05). Patients with shunts placed for damage control indications had more severe injuries (ISS 23.5 compared to 13; SBP 100 compared to 129; GCS 11 compared to 15; lactate 11.5 compared to 3.6; all p<0.05), and had more frequent shunt complication predictors, but damage control shunts did not have significantly more TIVS complications (11.1% compared to 7.7%, p=0.658). Shunt complication patients were discharged home less often (33% vs 65%; p<0.05) but all survived. Shunts placed for damage control indications were not associated with shunt complications in this prospective, multicenter study.

Temporary intravascular shunt use improves early limb salvage after extremity vascular injury

ObjectiveThe use of temporary intravascular shunts (TIVSs) allow for restoration of distal perfusion and reduce ischemic time in the setting of arterial injury. As a damage control method, adjunct shunts restore perfusion during treatment of life-threatening injuries, or when patients require evacuation to a higher level of care. Single-center reports and case series have demonstrate that TIVS use can extend the opportunity for limb salvage. However, few multi-institutional studies on the topic have been reported. The objective of the present study was to characterize TIVS use through a multi-institutional registry and define its effects on early limb salvage. MethodsData from the Prospective Observation Vascular Injury Treatment registry was analyzed. Civilian patients aged ≥18 years who had sustained an extremity vascular injury from September 2012 to November 2018 were included. Patients who had a TIVS used in the management of vascular injury were included in the TIVS group and those who had received treatment without a TIVS served as the control group. An unadjusted comparison of the groups was conducted to evaluate the differences in the baseline and outcome characteristics. Double robust estimation combining logistic regression with propensity score matching was used to evaluate the effect of TIVS usage on the primary end point of limb salvage. ResultsTIVS use was identified in 78 patients from 24 trauma centers. The control group included 613 patients. Unmatched analysis demonstrated that the TIVS group was more severely injured (mean ± standard deviation injury severity score, 18.83 ± 11.76 for TIVS vs 14.93 ± 10.46 for control; P = .002) and had more severely mangled extremities (mean ± standard deviation abbreviated injury scale, extremity, score 3.23 ± 0.80 for TIVS vs 2.95 ± 0.87 for control; P = .008). Logistic regression demonstrated that propensity-matched control patients had a three times greater likelihood of amputation compared with the TIVS patients (odds ratio, 3.6; 95% confidence interval, 1.2-11.1; P = .026). Concomitant nerve injury and orthopedic fracture were associated with a greater risk of amputation. The median follow-up for the TIVS group was 12 days (interquartile range, 4-25 days) compared with 9 days (interquartile range, 4-18 days) for the control group. ConclusionsTo the best of our knowledge, the present study is the first multicenter, matched-cohort study to characterize early limb salvage as a function of TIVS use in the setting of extremity vascular injury. Shunts expedite limb perfusion and resulted in lower rates of amputation during the early phase of care. The use of TIVS should be one part of a more aggressive approach to restore perfusion in the most injured patients and ischemic limbs.

Temporary Vascular Shunt Utilization in Civilian Extremity Vascular Injury

Temporary intravascular shunts (TIVSs) provide expedited restoration of distal perfusion and shortened ischemia time in the setting of arterial injury. As a damage control adjunct, shunts restore perfusion while life-threatening injuries are treated or the patient is evacuated to a higher level of care. Published single-center experiences with TIVSs from military and civilian centers demonstrated them to be safe and effective, extending the window of opportunity for limb salvage. The objective of this study was to analyze TIVSs from a multicenter national registry of vascular injury and to characterize the impact of shunt utilization on limb salvage.

膵管チューブを temporary intravascular shunt として用いて救肢しえた，前腕不全切断の治療経験

膵管チューブを temporary intravascular shunt として用いて救肢しえた，前腕不全切断の治療経験

四肢の主幹動脈損傷に対する temporary intravascular shunt を用いた治療戦略

四肢の主幹動脈損傷に対する temporary intravascular shunt を用いた治療戦略

To shunt or not to shunt in combined orthopedic and vascular extremity trauma.

There exists a long established but not validated practice of placing temporary intravascular shunts (TIVS) in cases of combined vascular and orthopedic extremity trauma. Though logical to prioritize blood flow, large-scale data to support this practice is lacking. We hypothesize that the order of repair yields no difference in outcomes in combined vascular and orthopedic extremity trauma and offer a larger-scale analysis than is previously available. A retrospective chart review was conducted at six Level I trauma centers from 2004 to 2015 comparing patients who received a TIVS during their initial surgery versus those who did not. Nonshunted patients were further divided into initial definitive vascular repair versus initial orthopedic fixation groups. Metrics were used to control for sampling bias while revision rate, amputation, hospital length of stay (HLOS), and development of thrombosis and compartment syndrome were used to assess outcomes. Of 291 total patients, 72 had TIVS placement, 97 had initial definitive vascular repair, and 122 had initial orthopedic fixation. The shunted group had a higher Abbreviated Injury Scale (3.0 vs. 2.8 p = 0.04) and Mangled Extremity Severity Score (6.1 vs. 5.7 p = 0.006) and a significantly lower rate of compartment syndrome (15% vs. 34% p = 0.002). Among patients who developed compartment syndrome, those who were shunted were younger (23 vs. 35 yrs, p = 0.03) and were more likely sustain a penetrating injury (p = 0.007). Those receiving initial orthopedic fixation had a longer HLOS (HLOS >15 days in 61% vs. 38%, p = 0.049) and a higher amputation rate (20% vs. 7%, p = 0.006) when compared with those undergoing initial definitive vascular repair. Lack of TIVS was associated with a significant increase in the development of compartment syndrome. Though it seems to have become common practice to proceed directly to vascular repair during the initial surgery, morbidity is improved with the placement of a TIVS. Therapeutic cohort, level III.

Management of Vascular Trauma in Military Conflicts and Terrorist Attacks

In war and terror attacks, up to 12% of all casualties suffer a severe vascular injury. Therefore, management of vascular trauma is closely associated with lessons learned during the wars of the 20th and 21st century. This article discusses military aspects of vascular trauma based on historical developments and introduces current standards in military vascular surgery. Up to Word War II, ligation was the predominant therapy for severe vascular trauma. Beginning in the Korean and Vietnam Wars, arterial reconstruction became more and more feasible. This development - in conjunction with rapid helicopter evacuation - decreased the former amputation rate of almost 50% to less than 15%. Nevertheless, exsanguination still remains the major cause of death among casualties with potentially survivable injuries. Standard application of tourniquets, haemostyptica, and balloon occlusion of the aorta improved survival rate. Meanwhile, damage control principals are essential for Forward Surgical Teams and the use of temporary intravascular shunts is well implemented in combat settings. In many armed forces, sophisticated training programs ensure the necessary competence in vascular surgery for all military surgeons deployed. Military surgery provided ample evidence and experience in the management of major vascular trauma over the last century. Much of this knowledge has been translated to civilian health providers and ongoing developments in the military still influence the management of severe vascular trauma.

An Update on the Use of Temporary Intravascular Shunting in the Era of Balanced Blood Product Resuscitation

An Update on the Use of Temporary Intravascular Shunting in the Era of Balanced Blood Product Resuscitation