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1. The Role of temporary vascular shunting as a previous
intervention on lower extremity arterial injury in military
practice
BY
DR. ALI AHMED BARAT
VASCULAR SURGEON
SUPERVISOR
DR. NABIL AL-MUDHWAHI
VASCULAR CONSULTANT
HEAD OF VASCULAR PROGRFM

2. INTRODUCTION
Vascular injuries of the extremities are rare in civilian practice. Their
frequency is estimated to be between 1 and 4% of trauma patients.
In military practice, vascular injury to the extremities is typically due to
multiple perforating limb wounds from explosive devices and occurs in 9 to 13% of
wounded patients depending on the conflict.
In this context, the management of extremity arterial injuries should be based on
damage control techniques; the main goals are to quickly obtain hemostasis and restore
peripheral arterial flow. A key technique for vascular damage controls the use of temporary
vascular shunts (TVS).
The management of war-related extremity injuries is
challenging; if not properly managed, these injuries may result
in such significant outcomes as limb loss or death.

3. INTRODUCTION
The approach and timing of
vascular repair in patients
with complex extremity
injuries can prove difficult
and time consuming.
The increasing use of high-energy weapons in modern warfare is
associated with severe vascular injuries and multiple organic trauma
(as communicated limbs open fractures, abdominal, chest, and head
penetrating trauma).
The goal of this retrospective study was to clarify the effect of
TVS as a previous intervention in cases of war-related arterial
injuries.

4. MATERIALS AND METHODS
Study Design and Patients
• Our study is retrospective study, and data were
collected from the medical records of two hospitals. The
first one- Al-Gomhory hospital In Hajjah City- (From
January 2017 to October 2020- 46 months). we analyzed
data of 75 war-related patients, who were injured during
the current war against our country, and received vascular
injury of limbs, or combined vascular and other trauma.
•The second hospital is Al Hazm Hospital in Al
Jawf governorate when I was sent to cover work
as a vascular surgeon in December 2020, during
my work period, the files of the injured arriving at
the hospital were reviewed, (From March 2020 to
December 2021 – 22 months) We analyzed data
from medical record 21 war-related patients,

5. MATERIALS AND METHODS
Study Design and Patients
•All patients had a previous intervention at the battle site, including compression
(n=34, 35%), TVS (n=24, 25%), tourniquet (n=20, 21%), and ligation/ clampage
(n=18, 19%) and were then admitted to both hospitals (Table 2)
•Ninety-six patients were divided into two groups: those in which TVS was
performed as a previous intervention on admission (TVS group, n=24) and those
in which compression, tourniquet, and ligation/clampage were performed as a
•previous intervention on admission (non-TVS group, n=72).

6. MATERIALS AND METHODS
Study Design and Patients
Table 2. Distributions of previous
interventions on admission
34
Previous intervention n %
Compression 34 35
Temporary vascular shunt 24 25
Tourniquet 20 21
Ligation / Clampage 18 19
•A massive soft tissue defect was recorded in those cases when, during injury or
after primary surgical treatment in the wound of the inlet or outlet of the wound
channel significant soft tissue defect ( 10 cm in diameter or in the longitudinal-
transverse direction).

7. MATERIALS AND METHODS
Table 3 demonstrates the patient demographics with respect to average age, gender, mechanism of
injury, clinical findings, concomitant pathologies, MESS, DoI, and amputations.
Overall TVS+EF group Control group p
(n=96) (n=24) (n=72) (p<0.05)
Age, mean ±SD 25.32±10.16 24±10.06 28.41±10.33 0.87a
Injury mechanism, n (%)
Gunshot
19 (39) 9 (41) 10 (44) 0.25b
Explosive 28 (57) 13 (59) 15 (56)
Clinical findings on admission
Hematocrit (%), mean ±SD
29.12±4.24 29.85±3.63 28.7±4.48 0.25a
Systolic blood pressure (mmHg), mean ±SD 92.47±9.1 94.9±9.24 91.6±8.81 0.08a
Injured vascular structure, n (%)
Arterial
25 (51) 13 (54) 12 (50) 0.81b
Arterial and vein 22 (49) 10 (46) 12 (50) 0.81b
Bone fracture, n (%) 18 (37) 8 (36) 10 (40) 0.63b
Major soft tissue disruption, n (%) 39 (83) 18 (81) 21 (84) 0.63b
Major nerve injury, n (%) 26 (55) 11 (50) 15 (60) 0.43b
Mangled extremity severity score, mean ±SD 7.17±1.75 6.45±1.67 7.44±1.82 0.02a
Duration of ischemia, mean ±SD 5.37±1.91 4.84±1.84 5.95±1.92 0.016a
Fasciotomy, n (%) 31 (32) 4 (17) 27 (38) 0.23b
Wound infection, n (%) 15 (26) 5 (21) 10 (28) 0.59b
Amputation, n (%) 12 (13) 1 (4) 11 (15) 0.037b
Mortality, n (%) 2 (4) 0 (0) 2 (3) 1.00

8. Surgical Management
• Operative exploration of these cases varied.
• In cases of injuries caused by bullets, exploration was performed
according to standard arterial exposure.
• In patients with severe tissue loss due to explosive devices and
following hemodynamic stabilization and wound
decontamination, exploration was conducted to expose and
repair vascular structure as soon as proven possible.
• Arterial injuries were repaired prior to bone, nerve, and tendon repair.
• In patients in the TVS group, shunts were removed after clamping. Systemic
heparinization was performed except for a great deal of soft tissue and muscle destruction.
• Fogarty catheters were routinely used proximally and distally to remove any thrombus.
• Primary repair or end to end anastomosis was preferred, but where it was not possible, the
greater saphenous vein graft was used for interposition graft. Polypropylene sutures were
used for anastomosis. Concomitant vein injuries were repaired whenever possible.

9. • Concomitant soft tissue, tendon, and most
nerve injuries were repaired at the same time.
Before revascularization, fasciotomy was
performed at the same time of placed TVS, and
before started anther indication for damage
control (for example laparotomy).
Surgical Management
• The decision for secondary amputation was decided after surgical
intervention in the event of weak/faint pulse, coldness of extremity,
massive soft tissue loss, existing massive infection, or other life-
threatening condition.

10. RESULTS
• Ninety six cases with war-related arterial injury were transferred to the
emergency services, and overall amputation rate (primary and
secondary) was 13% (12of 96patients).
• On admission, we realized that some form of intervention (compression,
TVS, tourniquet, or ligation/clampage) had been applied to all patients
at a different first aid center near the battle sites
Vascular Shunt for Small
Vessel Trauma in a
Polytrauma Patient
• Ninety-six patients were divided into two
groups:
* those in which TVS was performed as a
previous interv. on admission (TVS group,
n=24)
* and those in which compression, tourniquet,
and ligation/clampage
were performed as a previous intervention on

11. RESULTS
• In comparing injury pattern, there
was no difference between the two
groups. In addition, mean hematocrit
level, systolic blood pressure, the
incidence of concomitant vein injury,
nerve injury, soft tissue damage, and
bone injury were similar in both
groups.
• The overall amputation rate was 13%. There were a total
of 12 amputations, with 1 (4%) in the TVS group and 11
(15%) in the non-TVS group.
• The difference on amputation rate was statistically
significant.

12. RESULTS
Overall TVS group Non TVS group p
(n=96) (n=24) (n=72) (p<0.
05)
Artery injured, n (%)
Femoral arteries 45 (46) 12 (50) 33 (45) 0.36
Popliteal artery 37 (38) 9 (37) 28 (38) 0.81
Crural arteries 36 (37) 5 (20) 31 (43) 0.23
Arterial procedure, n (%)
End to end
anastomosis 29 (30) 9 (35) 21 (30) 1.00
Saphenous vein interposition 51 (47) 10 (41) 41 (46) 0.82
Artery suture 15 (15) 5 (20) 10 (14)
Vein injuries n=61 (%) n=20 (%) n=41 (%)
Vein repair, n (%) 46 (75) 14 (70) 32 (78) 0.53

13. DISCUSSION
• War-related arterial injuries are a
challenge to manage and may result in
different ways, from simple injuries
caused by low energy basic devices to
complex injuries caused by high
energy explosive and destructive
devices.
• We are now regularly encountering
these kinds of injuries due to the
current War in parallel to the literature.
• In previous years, most war-related
injuries encountered were shooting
injuries, but now the majority of such
injuries caused by high powered and
destructive weapons developed in
parallel with advancements in
technology.

14. DISCUSSION
• The use of TVSs has emerged as a viable treatment
option for military surgeons in the forward operating
arena and has proven successful for hemorrhage
control, shorter ischemia time, and temporary limb
perfusion.
• Temporary vascular shunting is a method
of timely restoration of flow and is well
described in settings of damage
control in both the military and civilian
sectors.

15. Results of revascularization after injuries of the main arteries of the lower
extremities
Indicator
Saved
limbs (n=84)
Amputations
(n=12)
TVS+EF
group n=23
Control group
n=61
TVS+EF
group n=1
Control group
n=11
Factors affecting outcome
Mine blast injury 14 (58 %) 32(44 %) 1 (100%) 4 (36 %)
Bullet wound 10 (42%) 40(56%) ------ 7 (63 %)
Extensive soft tissue defect 11(39%) 28(46 %) 1 (100%) 7 (63 %)
Delayed evacuation to a specialized stage 7 (22 %) 7 (22 %) 1 (100 %) 5 (45%)
Severe general condition 16 (50 %) 34 (56 %) 1 (100 %) 9 (81 %)
Collateral damage 15 (47 %) 41 (67 %) ---- 7 (63 %)
Combined damage 18 (78%) 35 (57 %) ---- 8 (72%)
Operations
Autovenous prosthetics 10(43 %) 41(46 %) ---- 6 (75%)
End-to-end 9 (34) 21 (32) 1 (25%) 5 (35%)
Artery suture 4 (12%) 19 (20%) -----
Autovenous plasty of an artery defect 3 (13%) 10 ( 16%) ------
Temporary bypass prior to specialized care 3 (13%) 0 -----
Fasciotomy of an injured limb segment
during the first 8 hours from the moment of injury
7 (29%) 23 (38%) 2 (25%)
Fatal outcome --- 2 (25%)

16. DISCUSSION
• Consistent with the literature, femoral artery injuries
were the most commonly injured arterial structures in
our study and comprise almost 38% of all arterial
traumas compared in the recent series.
• In many studies, fasciotomy and vein repair are recommended especially in
patients who have combined arterial and venous insufficiency, have DoI >6
h, or where bone and soft tissue trauma associated with vascular injury and
compartmental pressures have risen seriously.

17. DISCUSSION
• The MESS described by Johansen was used to
determine the viability of an extremity after
trauma. According to the author, when the score is
<7, limb-salvage can be performed; if it is >7,
amputation is recommended.
• The MESS was determined upon admission.
MESS is one of these scoring systems, providing
an idea of the viability of an extremity after
trauma and whether to undergo amputation.
• In our study, MESS was used as a scoring system, and revascularization
• was performed despite the fact that 31 (32%) of 96 patients had MESS ≥7.
Secondary amputation was applied to 12 (13%) of these patients.

18. DISCUSSION
• Performing a TVS provides urgent and effective control of
bleeding and sufficient distal perfusion after major vascular
injury.
• In our study, DoI and amputation rates were significantly
lower in favor of the TVS group (p<0.05). In the current
study, we emphasize being able to perform a TVS as the
first intervention is really important in enabling patients
with lower extremity arterial injuries to keep those
extremities because it provides time to surgeons to cope
with the negative effects of ischemia and undertake
bleeding control and revascularization.

19. In conclusion,
• the aim of the present study was to analyze the effect of using
TVS as a previous intervention. We think that it may be
beneficial for patients to consider a TVS to reduce DoI and
gain time for surgical revascularization.
• As a result, the present study demonstrates that the use of TVS
may successfully serve as a bridge between initial injury and
definitive repair with a reduction in amputation rates.