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Temporary arterial shunts in damage control: Experience and outcomes

Mathew, Sarah MD; Smith, Brian P. MD; Cannon, Jeremy W. MD; Reilly, Patrick M. MD; Schwab, C. William MD; Seamon, Mark J. MD

Journal of Trauma and Acute Care Surgery: March 2017 - Volume 82 - Issue 3 - p 512–517
doi: 10.1097/TA.0000000000001334
Original Articles
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BACKGROUND: Arterial shunting is a well-described method to control hemorrhage and rapidly reestablish flow, but optimal shunt dwell times remain controversial. We hypothesized that prolonged shunt dwell times of more than 6 hours are related to adverse outcomes after major arterial injury.

METHODS: A review (2005–2013) of all patients with arterial shunts placed after traumatic injury at our urban Level I trauma center was undertaken. Patients who died prior to shunt removal (n = 7) were excluded. Shunt complications were defined as dislodgement, thrombosis, and distal ischemia. Patients were compared on the basis of shunt complications with respect to clinical parameters.

RESULTS: The 42 patients who underwent arterial shunting after major vascular injury were primarily young (median, 26 years; interquartile range [IQR], 22–31 years) males (97.6%), severely injured (Injury Severity Score, 17.5 [IQR, 14–29]; shunted vessel Abbreviated Injury Scale score, 4 [IQR, 3–4]) by gunshot (85.7%) requiring neck/torso (33.3%) or upper-extremity (19.1%) or lower-extremity (47.6%) shunts. Thirty-five patients survived until shunt removal, and 5 (14.3%) of 35 developed shunt complications. Demographics and clinical characteristics were compared between those with shunt dwell times of less than 6 hours (n = 19) and more than 6 hours (n = 16). While patients appeared to have a greater injury burden overall in the group with dwell times of more than 6 hours, there were no statistical differences between groups with respect to age, gender, initial systolic blood pressure or hemodynamics during the shunt dwell period, use of vasopressors, Abbreviated Injury Scale score of the shunted vessel, Injury Severity Score, or outcomes including limb amputation or mortality. No patients (0/19) with shunt dwell times of less than 6 hours developed complications, whereas 5 (31.3%) of 16 patients with dwell times of more than 6 hours developed shunt complications (p = 0.05).

CONCLUSIONS: In this civilian series, 14% of patients with arterial shunts developed shunt complications. Our data suggest that limiting shunt dwell times to less than 6 hours when clinically feasible may decrease adverse outcomes.

LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

From the Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

Submitted: May 20, 2016, Revised: October 7, 2016, Accepted: October 14, 2016, Published online: December 28, 2016.

This work was presented as a podium presentation at the 17th European Congress of Trauma & Emergency Surgery, April 26, 2016, in Vienna, Austria.

Address for reprints: Mark J. Seamon, MD, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 51 N 39th St, Medical Office Bldg, 1st Floor Suite 120, Philadelphia, PA 19104; email: mark.seamon@uphs.upenn.edu.

© 2017 Lippincott Williams & Wilkins, Inc.