Temporary Vascular Shunts Research Articles

Temporary vascular shunts in training programs for general surgeons

Temporary vascular shunts in training programs for general surgeons

Effect of Combination of Temporary Vascular Shunt and Prophylactic Fasciotomy on Limb Salvage after Lower Extremity Arterial Injuries among Yemeni Patients with War-Related Polytrauma

Context and Aim: In cases of severe lower extremity arterial injuries (LEAI), such as those resulting from combatrelated injuries, the preservation of the affected limb is a significant challenge. The combination of a temporary vascular shunt (TVS) and prophylactic fasciotomy (PF) has emerged as a potential approach to improving limb salvage outcomes in these cases. In the context of the war in Yemen, we aimed to assess the effect of combination TVS and PF on limb salvage after LEAI in patients with war-related polytrauma (WRPT). Patients and Methods: A retrospective study was conducted among patients with WRPT at Al Hazm Hospital in Al Jawf Governorate in northeastern Yemen. Cases identified as polytrauma with LEAI in which PF was used comprise the study. These cases were matched to patients, or a control group, injured during the same period having polytrauma with LEAI requiring major vascular intervention but managed without fasciotomy. The primary outcome was surgical amputation. Results: Inclusion criteria were met in 39 cases, 18 (46.2%) had undergone fasciotomy, while the other 21 (53.8%) did not. Both study groups were entirely young (mean age 26.32 ± 5.01 years) males (100%). The overall amputation rate was 17.9% (7 of 39 cases), with 6 (28.57%) cases in the non-fasciotomy group and 1 (5.55%) case in the fasciotomy group. The difference in amputation rate was not statistically significant (p-value, 0.071). Likewise, the mechanism of injury, clinical findings on admission, arterial injuries, and types of surgical procedures were similar in both groups. By contrast, the fasciotomy group had a lower rate of limb infection than their non-fasciotomy counterpart (38.1% vs. 5.6%, respectively). The mortality rate in the hospital was 5.1% (2 of 39 cases), and all of them did not undergo fasciotomies. Conclusion: The combination of TVS and PF was associated with significantly improved limb infection. While statistically unproven, this combination may also enhance limb salvage. Therefore, it should be performed in cases of WRPT.

Damage Control Strategies For Vascular Injuries – A Report From The Amazon

Patients may sustain vascular injuries in rural areas or isolated locations, which are very common in the vast area of the Amazon rainforest. In situations like this, patients may take many hours, or even days, to get access to hospitals capable of dealing with these potentially lethal injuries, arriving in severe conditions that may require damage control strategies. Among the currently available techniques for damage control resuscitation and damage control surgery, the endovascular balloon occlusion of the aorta (REBOA) and temporary vascular shunts play an important role, but appropriate devices are often unavailable; in such scenarios, surgeons’ expertise on how to improvise devices, using more accessible materials, can be lifesaving. This paper presents a case of femoral vessel injury in a patient who required REBOA and vascular shunt improvisation; discussions regarding possible improvisation strategies are provided and technical steps on how to implement them are described.

Cross-Limb Vascular Shunting for Traumatic Popliteal Artery Injury

Popliteal artery injury (PAI) is a challenging trauma that requires prompt and accurate treatment since the probability of lower-limb amputation increases with the ischemic time. Intravascular shunting (IVS) and cross-limb vascular shunting (CLS) are used as temporary vascular shunting (TVS) methods to shorten the ischemic time for limb vascular injury. CLS involves sending blood from an artery in a healthy body part to a peripheral vessel in an injured part to immediately resume blood flow to the injured limb. For closed injuries including PAI, CLS may be performed without exploring and identifying the arterial stumps and it enables early reperfusion to the ischemic limb. We report the cases series of traumatic PAI treated using CLS and verify the usefulness of CLS. All patients with traumatic PAI treated with CLS at our institution between August 2013 and December 2021 were included. Demographic and clinical patient characteristics were extracted from the medical records. Comorbid injuries, severity of acute limb ischemia based on Rutherford grading scale, time from injury to reperfusion by CLS, time from injury to completion of artery, and the use of fasciotomy were investigated. As outcomes, we investigated the presence or absence of lower extremity amputation during the course of treatment. We used CLS for treatment for 5 cases with traumatic PAI. Based on the Rutherford grading scale for acute limb ischemia, there were one limb with grade 2B and four with grade 3. Amputation of the lower extremities was avoided except for one extremity in which arterial reconstruction was not achieved due to unexplained cardiac arrest during surgery. CLS enables early reperfusion of the injured limb and is effective as a TVS method for traumatic PAI with severe ischemia or soft tissue damage.

Application of damage control tactics in combat injuries of limbs at the advanced stages of medical evacuation in modern war settings (literature review)

Relevance. Limb injuries occupy the first place in the structure of modern combat injuries and are one of the main reasons for the decline in fitness for military service and disability. In the conditions of conducting largescale hostilities, the role of the advanced stages of medical evacuation, where surgical care is provided according to the principles of damage control, increases. Features of the tactics of damage control in combat injuries of the extremities determine the need for special training of military surgeons.The objective is to consider the features and effectiveness of the provision of surgical care according to the principles of damage control in combat injuries of the extremities at the advanced stages of medical evacuation in armed conflicts of the last two decades (in the countries of the Middle East and Africa, Afghanistan, Ukraine).Methodology. A search was made for scientific articles in the PubMed database and the Scientific Electronic Library (eLIBRARY.ru), published from 2013 to 2023.Results and Discussion. Modern combat trauma of the extremities is characterized by a high frequency of vascular damage, extensive destruction of soft tissues and bones from the impact of damaging factors of explosive ammunition. Surgical interventions for combat injuries of the extremities (external fixation of bone fractures with rod devices, ligation or temporary vascular shunt of damaged vessels, fasciotomy, amputation) were the most frequent of all operations performed at the advanced stages of medical evacuation during modern military conflicts. The volume of surgical interventions corresponded to the first stage of orthopedics and vascular control of injuries and was determined by the severity of the condition of the wounded, the degree of ischemia and severity of limb injuries, and the medical and tactical situation.Conclusion. Assistance at the advanced stages of medical evacuation according to the principles of orthopedics and vascular damage control can significantly reduce the frequency of amputations and improve the functional results of treatment for combat injuries of the extremities.

Effect of SAM junctional tourniquet on respiration when applied in the axilla: A swine model

PurposeSAM junctional tourniquet (SJT) has been applied to control junctional hemorrhage. However, there is limited information about its safety and efficacy when applied in the axilla. This study aims to investigate the effect of SJT on respiration when used in the axilla in a swine model. MethodsEighteen male Yorkshire swines, aged 6-month-old and weighing 55 – 72 kg, were randomized into 3 groups, with 6 in each. An axillary hemorrhage model was established by cutting a 2 mm transverse incision in the axillary artery. Hemorrhagic shock was induced by exsanguinating through the left carotid artery to achieve a controlled volume reduction of 30% of total blood volume. Vascular blocking bands were used to temporarily control axillary hemorrhage before SJT was applied. In Group I, the swine spontaneously breathed, while SJT was applied for 2 h with a pressure of 210 mmHg. In Group II, the swine were mechanically ventilated, and SJT was applied for the same duration and pressure as Group I. In Group III, the swine spontaneously breathed, but the axillary hemorrhage was controlled using vascular blocking bands without SJT compression. The amount of free blood loss was calculated in the axillary wound during the 2 h of hemostasis by SJT application or vascular blocking bands. After then, a temporary vascular shunt was performed in the 3 groups to achieve resuscitation. Pathophysiologic state of each swine was monitored for 1 h with an infusion of 400 mL of autologous whole blood and 500 mL of lactated ringer solution. Tb and T0 represent the time points before and immediate after the 30% volume-controlled hemorrhagic shock, respectively. T30, T60, T90 and T120, denote 30, 60, 90, and 120 min after T0 (hemostasis period), while T150, and T180 denote 150 and 180 min after T0 (resuscitation period). The mean arterial pressure and heart rate were monitored through the right carotid artery catheter. Blood samples were collected at each time point for the analysis of blood gas, complete cell count, serum chemistry, standard coagulation tests, etc., and thromboelastography was conducted subsequently. Movement of the left hemidiaphragm was measured by ultrasonography at Tb and T0 to assess respiration. Data were presented as mean ± standard deviation and analyzed using repeated measures of two-way analysis of variance with pairwise comparisons adjusted using the Bonferroni method. All statistical analyses were processed using GraphPad Prism software. ResultsCompared to Tb, a statistically significant increase in the left hemidiaphragm movement at T0 was observed in Groups I and II (both p < 0.001). In Group III, the left hemidiaphragm movement remained unchanged (p = 0.660). Compared to Group I, mechanical ventilation in Group II significantly alleviated the effect of SJT application on the left hemidiaphragm movement (p < 0.001). Blood pressure and heart rate rapidly increased at T0 in all three groups. Respiratory arrest suddenly occurred in Group I after T120, which required immediate manual respiratory assistance. PaO2 in Group I decreased significantly at T120, accompanied by an increase in PaCO2 (both p < 0.001 vs. Groups II and III). Other biochemical metabolic changes were similar among groups. However, in all 3 groups, lactate and potassium increased immediately after 1 min of resuscitation concurrent with a drop in pH. The swine in Group I exhibited the most severe hyperkalemia and metabolic acidosis. The coagulation function test did not show statistically significant differences among three groups at any time point. However, D-dimer levels showed a more than 16-fold increase from T120 to T180 in all groups. ConclusionIn the swine model, SJT is effective in controlling axillary hemorrhage during both spontaneous breathing and mechanical ventilation. Mechanical ventilation is found to alleviate the restrictive effect of SJT on thoracic movement without affecting hemostatic efficiency. Therefore, mechanical ventilation could be necessary before SJT removal.

Damage control laparotomy outcomes in a major urban trauma centre

BACKGROUND: Damage control laparotomy (DCL) is associated with high mortality. The purpose of this study was to review the outcomes of DCL. METHODS: All patients undergoing DCL for penetrating trauma from May 2015 to July 2017 were reviewed. Data retrieved were demographics, mechanism of injury, vitals, and biochemical parameters. Injury severity was described by the revised trauma score (RTS), penetrating abdominal trauma index (PATI), injury severity score (ISS) and trauma and injury severity score (TRISS). Indications for DCL, length of ICU stay, number of procedures and primary abdominal closure rates, complications and mortality were recorded. RESULTS: Fifty-one patients underwent DCL and 47 patients sustained gunshot injuries. Indications for laparotomy were haemodynamic instability (n = 27) and peritonism in stable patients (n = 22). The medians for the different severity scores were RTS 7.36, ISS 20, and PATI 30. The organs most commonly injured, in decreasing frequency, were small bowel (33), large bowel (25), abdominal vasculature (22), liver (18), stomach (14), kidney (10), diaphragm (10), spleen (9) and pancreas (8). DCL procedures performed were abdominal packing (36), temporary bowel ligation (30), vascular (5) and ureteric (1) shunting. The median number of laparotomies performed per patient was three, with a primary fascial closure rate of 69%. The mortality rate was 29%. CONCLUSION: DCL in our centre is associated with a 29% mortality rate. Severe acidosis, massive blood transfusion in first 24 hours and median PATI score more than 47 are independent risk factors associated with increased mortality.

Temporary vascular shunt for damage control surgery: case report

Background: Although rare, arterial limb injuries are cause of massive hemorrhage and consequently hypovolemic shock. Temporary vascular shunts have many benefits: not only do they allow for reperfu­sion, but they also afford time to transport a patient to a higher level of care. Methods: Case report Results: The authors present a case report of a 35-year-old man brought to the emergency department one hour after suffering a penetrating injury to the anterior right thigh. In the operative room a complete superficial femoral artery transection was detected so artery shunt was performed. In the immediate post-operative period, the patient was transferred to a specialized center where the final revascularization was accomplished by interposition of the contralateral great saphenous vein in reverse. Patient was discharged after a seven day hospital stay and follow up demonstrated viable and functional limb. Conclusions: Vascular shunt seems a good option in the early approach of arterial injuries in the absence of resources for definitive care, as it allows early revascularizations without compromising subsequent definitive revascularization after transfer to a specialized department.

Stopping extremity hemorrhage: More than just a tourniquet

Major extremity hemorrhage is a surgical emergency, and the physical examination is essential to help dictate appropriate clinical decision making. Hard signs that require immediate surgical intervention include ongoing bleeding, expanding hematoma, ischemic limb, as well as partial/complete amputation. Packing, compression, balloon tamponade, and tourniquets are very helpful to temporize major hemorrhage. Mangled extremities are very challenging to manage and require a multidisciplinary approach. Temporary vascular shunts are excellent tools for vascular/orthopedic damage control and for temporary stabilization prior to transport for definitive care.

Contemporary Management of Axillosubclavian Arterial Injuries Using Data from the AAST PROOVIT Registry

Background: Endovascular repair has emerged as a viable repair option for axillosubclavian arterial injuries in select patients; however, further study of contemporary outcomes is warranted.&#x0D; Methods: The American Association for the Surgery of Trauma (AAST) PROspective Observational Vascular Injury Treatment (PROOVIT) registry was used to identify patients with axillo-subclavian arterial injuries from 2013 – 2019. Demographics and outcomes were compared between patients undergoing endovascular repair versus open repair.&#x0D; Results: 167 patients were identified, with intervention required in 107 (64.1%). Among these, 24 patients underwent open damage control surgery (primary amputation = 3, ligation = 17, temporary vascular shunt = 4). The remaining 83 patients (91.6% male; mean age 26.0 ± 16) underwent either endovascular repair (36, 43.4%) or open repair (47, 56.6%). Patients managed with definitive endovascular or open repair had similar demographics and presentation, with the only exception that endovascular repair was more commonly employed for traumatic pseudoaneurysms (p=0.004). Endovascular repair was associated with lower 24-hour transfusion requirements (p=0.012), but otherwise the two groups were similar with regards to in-hospital outcomes.&#x0D; Conclusion: Endovascular repair is now employed in &gt; 40% of axillo-subclavian arterial injuries undergoing repair at initial operation and is associated with lower 24 hour transfusion requirements, but otherwise outcomes are comparable to open repair.

Performance of a novel temporary arterial shunt in a military-relevant controlled hemorrhage swine model.

In military trauma, temporary vascular shunts restore arterial continuity until delayed vascular reconstruction, often for a period of hours. A novel US Air Force-developed trauma-specific vascular injury shunt (TS-VIS) incorporates an accessible side port for intervention or monitoring, which may improve patency under adverse hemodynamic conditions. Our objective was to evaluate TS-VIS patency in the setting of volume-limited resuscitation from hemorrhagic shock. Female swine (70-90 kg) underwent 30% hemorrhage and occlusion of the left external iliac artery for 30 minutes. Animals were allocated to one of three groups (n = 5 per group) by left external iliac artery treatment: Sundt shunt (SUNDT), TS-VIS with arterial pressure monitoring (TS-VIS), or TS-VIS with heparin infusion (10 μ/kg per hour, TS-VISHep). Animals were resuscitated with up to 3 U of whole blood to maintain a mean arterial pressure (MAP) of >60 mm Hg and were monitored for 6 hours. Bilateral femoral arterial flow was continuously monitored with transonic flow probes, and shunt thrombosis was defined as the absence of flow for greater than 5 minutes. No intergroup differences in MAP or flow were observed at baseline or following hemorrhage. Animals were hypotensive at shunt placement (MAP, 35.5 ± 7.3 mm Hg); resuscitation raised MAP to >60 mm Hg by 26.5 ± 15.5 minutes. Shunt placement required 4.5 ± 1.8 minutes with no difference between groups. Four SUNDT thrombosed (three before 60 minutes). One SUNDT thrombosed at 240 minutes, and two TS-VIS and one TS-VISHep thrombosed between 230 and 282 minutes. Median patency was 21 minutes for SUNDT and 360 minutes for both TS-VIS groups (p = 0.04). While patent, all shunts maintained flow between 60% and 90% of contralateral. The TS-VIS demonstrated sustained patency superior to the Sundt under adverse hemodynamic conditions. No benefit was observed by the addition of localized heparin therapy over arterial pressure monitoring by the TS-VIS side port.

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.

Management and outcomes of wartime cervical carotid artery injury.

Cervical carotid artery injuries entail high morbidity and mortality and are technically challenging to repair. This retrospective study describes the management and outcomes of cervical carotid injuries sustained during the recent wars in Iraq and Afghanistan. The Department of Defense Trauma Registry was queried to identify US military personnel who sustained battle-related cervical carotid injury between January 2002 and December 2015. Retrospective chart reviews of the military Electronic Health Record were performed on patients identified. Demographics, injury characteristics, surgical management, and outcomes were reviewed. Statistical analysis was performed to identify associations between injury and management factors, as well as stroke and mortality. In total, 67 patients (100% male; age, 25 ± 7 years) were identified with cervical carotid artery injuries. Fifty-six patients (84%) sustained a common carotid artery (CCA) or internal carotid artery (ICA) injury, and 11 patients (16%) had an isolated external carotid artery (ECA) injury. The anatomic distribution of injury was as follows: CCA, 26 (38.8%); ICA, 24 (35.8%); CCA and ICA 2 (3%); ICA and ECA 3 (4.5%); and CCA, ICA, and ECA 1 (1.5%). Of the 56 CCA or ICA injuries, 39 underwent vascular repair, 9 (16%) were managed with ligation, 1 was treated with a temporary vascular shunt but succumbed to injuries before vascular repair, and 7 (13%) were treated nonoperatively. Seven (23%) of 30 ICA injuries were ligated compared with 2 (7.7%) of 26 injuries isolated to the CCA (p = 0.02). Compared with repair, ligation of the CCA/ICA was associated with a higher rate of stroke (89% vs. 33%, p = 0.003) and increased mortality without statistical significance (22% vs. 10%, p = 0.3). Every patient who underwent ICA ligation had a stroke (7/7). There was no difference in Injury Severity Score between the ligation and repair groups (23.8 ± 10.6 vs. 24.7 ± 13.4, p = 0.9). At a mean follow-up of 34.5 months, 10 of 17 stroke survivors had permanent neurologic deficits. In modern combat, penetrating injuries involving the cervical carotid arteries are relatively infrequent. In this experience, isolated ICA injuries were three times more likely to be ligated than those involving the CCA. As a surgical maneuver, ICA ligation resulted in stroke in all cases. Retrospective cohort analysis, level III.

A temporary bypass used in end-to-end anastomosis of major vessels without stopping blood flow in the segment under repair

The authors developed an original set of tools and a method of carrying out end-to-end anastomosis on major vessels, without stopping blood circulation in the vascular segment being repaired. The proposed set of tools includes 10 tubes (temporary vascular grafts) made of medical silicone with external diameters from 8 to 26 mm. The length of each tube is not less than 10 cm, and the wall thickness is 1.2 mm. A spiral notch with a step of 1.2 mm is made on the outer surface of the tubes, to a depth of 1 mm. The set of tools also includes a set of metal hollow half cylinders with a through hole made in the middle, designed to extract the temporary shunt of the appropriate diameter. Before the formation of a vascular anastomosis, a silicone tube is selected, the outer diameter of which corresponds to the inner diameter of the damaged vessel. It is necessary to cut off a length of the tube, so that 23 cm of it could be introduced into the lumen of the proximal and distal segments of the damaged vessel. A stay-suture is laid in the center of the temporary bypass, on a site of its wall between two neighboring spiral notches. The ends of the temporary bypass, pre-filled with saline solution, are introduced into the distal and proximal ends of the divided vessel and are firmly fixed in the lumen of the vessel with two elastic bands. After placing the temporary bypass in the lumen of the damaged vessel, the blood flow is restored. Using the intraluminar temporary shunt as a scaffold, the edges of the vessel are approximated and stitched to its entire circumference, tying the first and last stitches of this seam. The last additional suture is placed in the area of the stay-suture overlying the wall of the temporary vascular shunt and is not tightened. A half-cylinder is placed above the untightened vascular suture and a stay-suture is placed at its opening. After that, tightly pressing the metal hollow half-cylinder to the vascular wall, and applying traction to the ends of the stay-suture the mechanical destruction of the silicone tube along the line of the spiral incision ensues. As a result, the tube is transformed into a double silicone rod, which is pulled through a through hole in the metal half-cylinder floor. After the extraction of the tube, the anastomosis is completed by tying a knot on the provisional suture. To simulate the proposed method, 10 operations were performed using a closed experimental circuit that completely simulates the real situation of restoring a damaged major vessel. The time of the operation, the technical features of the intervention, as well as the volume of blood loss, which was estimated by reducing the volume of blood circulating in the experimental circuit, were evaluated. Experimental testing with the use of a model simulating the situation of restoring a damaged major vessel, demonstrated the effectiveness of the developed method of applying a vascular end-to-end anastomosis with the use of a destructible temporary bypass; the average time of the operation was 10 minutes, and the volume of blood loss did not exceed 5 ml. The proposed set of tools and method can be effectively used in case of major vessels injury. The technique completely excludes the need for interrupting blood flow through the sutured vessel; it allows to reduce the volume of blood loss in vascular trauma, minimizes the time of ischemia in the area of blood supply to the damaged artery or venous stagnation of the drained segment (when suturing a vein), as well as to facilitate the imposition of a vascular suture to surgeons who do not have sufficient qualification in vascular surgery.

Epidemiology of Upper Extremity Vascular Injury in Contemporary Combat

The incidence of wartime upper-extremity vascular injury (UEVI) has been stable for the past century. The objective of this study is to provide a contemporary review of wartime UEVI, including epidemiologic characterization and description of early limb loss. The Department of Defense Trauma Registry (DoDTR) was queried to identify US service members who sustained a battle-related UEVI in Afghanistan between January 2009 and December 2015. Anatomic distribution of injury, mechanism of injury (MOI), associated injuries, early management, and early limb loss were analyzed. Analysis identified 247 casualties who sustained 308 UEVIs. The most common injury was to the vessels distal to the brachial bifurcation (63.3%, n=195), followed by the brachial vessels (27.3%, n=84) and the axillary vessels (9.4%, n=29). The predominant MOIs were penetrating explosive fragments (74.1%, n=183) and gunshot wounds (25.9%, n=64). Associated fractures were identified in 151 (61.1%) casualties and nerve injuries in 133 (53.8%). Angiography was performed in 91 (36.8%) casualties, and endovascular treatment was performed 10 (4%) times. Temporary vascular shunts were placed in 39 (15.8%) casualties. Data on surgical management were available for 171 injuries and included repair (48%, n=82) and ligation (52%, n=89). The early limb loss rate was 12.1% (n=30). For all casualties sustaining early limb loss, the MOI was penetrating fragments from an explosion; the average injury severity score (ISS) was 32.3, and the mortality was 6.7% (n=2). In those without amputation, the ISS and mortality were low at 20 and 4.6% (n=10), respectively. Overall mortality was 4.9% (n=12). The early limb loss rate was increased compared with initial descriptions from Operation Iraqi Freedom. Amputations are associated with a higher ISS. Improved data capture and fidelity, or differing MOIs, may account for this trend. Proficiency with open and endovascular therapy remains a critical focus for combat casualty care.

Development of a Puncture Technique for Implanting Temporary Vascular Shunts in a Porcine Model

Temporary vascular shunts (TVSs) are an effective tool for rapidly restoring blood flow to a limb or organ that has experienced vascular injury and ischemia and for which revascularization isnot an immediate option. Usually, through an opening in the skin, the TVS is positioned within the proximal and distal stumps of the injured vessel, restoring perfusion and stopping the ischemia. The aim of this study is to compare standard TVS technique and a developed puncture technique for implanting TVS and to evaluate the utility and feasibility of this protocol after arterial lesions, in pigs. Vascular injuries were inflicted in both hind limbs of 30 pigs, and vascular interventions were performed, using standard and puncture TVS. Because each pig was implanted with both types of TVSs, it was possible to simultaneously monitor, analyze, and compare parameters such as, the mean arterial pressure (MAP, in mm Hg), blood flow (mL/min), and insertion times, in the same animal. It was observed that the MAP in the limbs recovered and approached systemic MAP, in 100% of the experiments, in both groups. Analysis of the blood flow data showed that this parameter was significantly reduced in the puncture TVS group (110.36±9.99mL/min vs. 153.20±18.57mL/min, P=0.001). On the other hand, the insertion time for the standard TVS was significantly greater than that of the puncture shunt (15.32±3.08min vs. 10.37±1.7min, P=0.001). Furthermore, it was found that the primary and secondary patency and complication rates were similar for both TVS types. Thus, given the adequate MAP recovery and reduction in implantation time observed in this experimental and in an animal model study, the use of the puncture TVS technique is effective and feasible.

Vascular Trauma—Open or Endovascular

This review discusses the trends in management of vascular trauma comparing open management with endovascular strategies. Endovascular vascular approaches to vascular trauma has evolved significantly in the past several decades, providing an option for reduced morbidity and mortality in the carefully selected trauma patient. While open surgery is a critical skill to maintain, there are strategies more than ever before that can be applied to a hemorrhaging trauma patient which include stent-graft placement, the use of temporary vascular shunts, and vascular balloon occlusion. Vascular trauma management has evolved over the last several decades, introducing promising endovascular treatment strategies, particularly in junctional and torso hemorrhage.

Management and outcome of 597 wartime penetrating lower extremity arterial injuries from an international military cohort

ObjectiveVascular injury is a leading cause of death and disability in military and civilian settings. Most wartime and an increasing amount of civilian vascular trauma arises from penetrating mechanisms of injury due to gunshot or explosion. The objective of this study was to provide a comprehensive examination of penetrating lower extremity arterial injury and to characterize long-term limb salvage and differences related to mechanisms of injury. MethodsThe military trauma registries of the United States and the United Kingdom were analyzed to identify service members who sustained penetrating lower limb arterial injury (2001-2014). Treatment and limb salvage data were studied and comparisons made of patients whose penetrating vascular trauma arose from explosion (group 1) vs gunshot (group 2). Standardized statistical testing was used, with Bonferroni corrections for multiple comparisons. ResultsThe cohort consisted of 568 combat casualties (mean age, 25.2 years) with 597 injuries (explosion, n = 416; gunshot, n = 181). Group 1 had higher Injury Severity Score (P < .05) and Mangled Extremity Severity Score (P < .0001), required more blood transfusion (P < .05), and had more tibial (P < .01) and popliteal (P < .05) arterial injuries; group 2 had more profunda femoris injuries (P < .05). Initial surgical management for the whole cohort included vein interposition graft (33%), ligation (31%), primary repair with or without patch angioplasty (16%), temporary vascular shunting (15%), and primary amputation (6%). No difference in patency of arterial reconstruction was found between group 1 and group 2, although group 1 had a higher incidence of primary (13% vs 2%; P < .05) and secondary (19% vs 9%; P < .05) amputation. Similarly, longer term freedom from amputation was lower for group 1 than for group 2 (68% vs 89% at 5.5 years; Cox hazard ratio, 0.30; P < .0001), as was physical functioning (36-Item Short Form Health Survey data; mean, 39.80 vs 43.20; P < .05). ConclusionsThe majority of wartime lower extremity arterial injuries result from an explosive mechanism that preferentially affects the tibial vasculature and results in poorer long-term limb salvage compared with those injured with firearms. The mortality associated with immediate limb salvage attempts is low, and delayed amputations occur weeks later, affording the patient involvement in the decision-making and rehabilitation planning. We recommend assertive attempts at vascular repair and limb salvage for service members injured by explosive and gunshot mechanisms.

Application of the temporary arterial sound at the footwears of the lower hideship vessels (review and methods of temporary succession)

Damage to the vessels remains an urgent and complicated issue of angio-surgery, both in the curative and organizational terms. In the course of the anti-terrorist operation in eastern Ukraine in 2014 — 2018, damage to major vessels requiring reconstructive interventions occurred in 2 % of the victims. In 90 % of the wounded, trauma to the vessels of the lower extremities was noted. In order to prevent the development of irreversible limb ischemia and its amputation in the trauma of major vessels in the conditions of the implementation of the surgical tactic «Damage control», the method of temporary shunting of the trunk vessels of the extremity deserves attention, which allows to restore blood flow through damaged major arteries in the short term, to prevent the development of irreversible ischemia and save the limb. Temporary bypass must be the initial stage of reconstructive surgery on the damaged major artery of the limb.The article describes the main historical stages of the inventions and improvements of temporal vascular shunts. The classification of temporal vascular shunts is given, their characteristics and detailed method of application are given. Temporary vascular shunts are effective; the possibility of their application should be considered when treating wounds of the vessels of the limbs of practically all types, in particular proximal veins. The main advantage of such shunts is to ensure early recovery of blood flow and to reduce the negative effects of arterial ischemia and venous hypertension. Unlike ligation, temporal bypass surgery is an element of multi-stage surgical treatment or damage control surgery. Despite the desire to maximize the implementation of primary reconstructive techniques at the stages of medical evacuation, for various reasons (delayed evacuation, intense combat and medical conditions) the frequency of the use of temporary prosthesis will not decrease. Therefore, in order to improve the results of treatment of injuries with damage to the main vessels, experimental and clinical testing of the use of the temporary prosthesis method in the implementation of the surgical tactic «damage control» is required.

Use of a Temporary Vascular Shunt Across the Knee Joint for Proximal Arterial Injury of the Extremity

Use of a Temporary Vascular Shunt Across the Knee Joint for Proximal Arterial Injury of the Extremity