Temporary intravascular shunts for peripheral vascular trauma.
AK Husain, JM Khandeparkar, AG Tendolkar, RA Magotra, GB Parulkar
Dept. of Cardiovascular and Thoracic Surgery, KEM Hospital, Parel, Bombay, India., India
A K Husain
Dept. of Cardiovascular and Thoracic Surgery, KEM Hospital, Parel, Bombay, India.
Polyvinylchloride (PVC) disposable endotracheal suction catheters were successfully used as temporary intravascular shunts in 5 patients of popliteal artery trauma. These simple shunts should be used routinely in such conditions to immediately re-establish blood supply to the ischaemic limb particularly in patients of polytrauma where systemic anticoagulation is contraindicated. This avoids the inherent delay prior to vascular repair and reduces the incidence of irreversible ischemia.
|How to cite this article:|
Husain A K, Khandeparkar J M, Tendolkar A G, Magotra R A, Parulkar G B. Temporary intravascular shunts for peripheral vascular trauma. J Postgrad Med 1992;38:68-9
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Husain A K, Khandeparkar J M, Tendolkar A G, Magotra R A, Parulkar G B. Temporary intravascular shunts for peripheral vascular trauma. J Postgrad Med [serial online] 1992 [cited 2020 Mar 29 ];38:68-9
Available from: http://www.jpgmonline.com/text.asp?1992/38/2/68/716
Blunt trauma to the extremities is often associated with fracture dislocation, extensive soft tissue damage and neurovascular disruption. The failure to restore blood supply within the critical period would make amputation inevitable. Expensive heparinised intravascular shunts have been used in surgical practice. The inexpensive and easily available PVC endotracheal suction catheters used in this study appear to be effective temporary intravascular shunts during the delay between the time of injury or presentation and the vascular repair.
Over a period extending from Oct. 1988 to Jan 1990 5 patients of popliteal artery trauma following vehicular accidents were managed using temporary intravascular shunts. Their age, sex distribution, mode of injury, vessels injured, details of other associated injuries and repair done are shown in [Table:1].
On suspicion of the vascular injury, the popliteal fossa was explored immediately and the traumatised popliteal artery and vein (in case of patient no. 1) delineated. The proximal and distal ends of this vessel were mobilised for a few centimetres. An 8 French size polyvinylchoride (PVC) endotracheal suction catheter measuring 12-15 cm in length was introduced proximally into the healthy popliteal artery. The catheter was deaired and introduced into the normal segment of the popliteal artery distal to the site of transaction or confusion. The catheter was secured in place and circulation restored by unclamping the catheter. Pulsations in the segment distal to the catheter ensured the adequate functioning of the shunt.
Prior to introduction of the temporary shunt, embolectomy of the proximal and distal segments of the popliteal artery was done in all patients. In patient no. 1, the transacted popliteal vein too was shunted.
During the shunt period, necessary investigations, fixation of the fractures and soft tissue debridement was done. Fasciotomy was performed in 3 patients. No systemic anticoagulation was used. Patients were subsequently taken for vascular repair.
The limb salvage rate was 100%. The ischaemic time, shunt time and and limb status after vascular repair are shown in [Table:2]. At discharge and subsequent follow up, all patients had normal pedal pulsation and a normally functioning limb.
In surgical practice, vascular trauma is common following limb injuries. Injury to the popliteal artery is fraught with the danger of amputation because of various anatomic reasons,. Amputation rates as high as 33% have been reported following popliteal artery injury. Various factors contribute to the increased incidence of amputation in such cases viz. aetiology of wounding agent, ischaemia time, multiple arterial injuries, technical problems, associated massive soft tissue and skeletal destruction, complications such as thrombosis and infection.
There is often a delay of a few hours before the patient is taken for repair of the artery and vein because most of the patients are in shock at the time of presentation. On many occasions, urgent abdominal or thoracic surgery is warranted due to traumatic lesions. If the ischaemia time exceeds the critical period (6-8 hours) irreversible muscle damage will occur.
It is during this interim period that these shunts can be used to temporarily re-establish distal flow and prevent irreversible muscle damage. During the shunt period, the patient's condition can be stabilized and necessary investigations and urgent surgery performed. The re-established flow also allows a more rational debridement of soft tissues,. The fractures too, can be stabilized during this period. As shown in our study, the shunts remained patent without local or systemic anticoagulation. Though Daugherty et al have used systemic anticoagulation in all patients with popliteal artery trauma without untoward effects, it would perhaps be more prudent to withhold heparin in patients particularly with multiple injuries following vehicular accidents. Javid shunts, balloon tipped shunts, nasogastric tubes and polyethylene tubes have been used as intravascular shunts before,,. We have used an easily available disposable PVC endotracheal suction catheter (Medicoplast) with excellent results. This is readily available in the emergency operation room in various sizes, is inexpensive and non-toxic (personal communication). As the distal pulsations are monitored continuously during this period, should the shunt get blocked or dislodged, it may be immediately reintroduced after flushing out the thrombus.
These shunts have been used in disrupted popliteal veins with equal success. In case no. 1, we used the shunt successfully both in the artery and vein. Post-operatively, there was mild temporary edema of the foot and no compartment syndrome though the latter was present before surgery in 3 patients (required fasciotomy). Thus, the temporary intravascular shunt is an important adjunct to the management of vascular trauma. It must be used to advantage while observing the important principles of treatment of vascular trauma, such as fasciotomy, early vascular repair, liberal debridement of unhealthy tissues, adequate cover to the vessels after repair and stabilisation of fractures, if present.
We are grateful to the Dean, Seth GS Medical College and King Edward Memorial Hospital, Mumbai for allowing us to publish this paper.
Snyder WH III. Vascular injuries near the knee:An updated series and overview of the problem. Surgery 1982; 91:502-506.|
|2||Snyder WH III, Watkins WC, Whiddon CC, Bone GE. Civilian popliteal artery trauma: An eleven year experience with 83 injuries. Surgery 1979; 85:101-108.|
|3||Brewer PL, Schranel RJ, Menendez VC, Creech O. Injuries of the popliteal artery; a report of 16 cases. Am J Surg 1969; 118:36-42.|
|4||Rich NK Jarstfer RS, Geer IM. Popliteal artery repair failure: causes and possible prevention. J Cardiovasc Surg 1974; 15:340-351.|
|5||Malan E, Tattoni G. Physico and anatomo-pathology of acute ischaemia of extremities. J Cardiovasc Surg 1963; 4:214-221.|
|6||Eger M, Goldman L, Goldstein A, Hirsh M. The use of a temporary shunt in the management of arterial vascular injuries. Surg Gynecol Obstet 1971; 132:67-70.|
|7||Khalil IM, Livingston DH. Intravascular shunts in complex lower limb trauma. J Vasc Surg 1986; 4:582-587.|
|8||Daugherty ME, Sachatello CR, Ernst CB. Improved treatment of popliteal arterial injuries using anticoagulation and extra- anatomic reconstruction. Arch Surg 1978; 113:1317-1321.|
|9||Majeski JA, Gauto A. Management of peripheral arterial vascular injuries with a Javid shunt. Am J Surg 1979; 138:324-325.