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Direct-site endovascular repair (DSER): A novel approach to vascular trauma

Davidson, Anders J. MD; Neff, Lucas P. MD; DuBose, Joseph J. MD; Sampson, James B. MD; Abbot, Christopher M. MD; Williams, Timothy K. MD

Journal of Trauma and Acute Care Surgery: November 2016 - Volume 81 - Issue 5 - p S138–S143
doi: 10.1097/TA.0000000000001241
Damage Control Resuscitation & Surgery

ABSTRACT Peripheral vascular injuries carry significant risk for permanent functional impairment, limb loss, and death. Definitive correction of these injuries requires significant operative time and has traditionally been resource and skill set intensive. In the initial surgical treatment of the physiologically depleted trauma patient, faster techniques may prove more appropriate. Damage control techniques, including vascular shunting, rapidly restore distal flow but require additional vascular intervention and risk shunt thrombosis with prolonged use. To address these challenges, we present a technique, using an off-the-shelf endovascular device, for treatment of peripheral arterial injuries. Direct-site endovascular repair (DSER) is an open vascular surgical reconstruction technique using conventional endovascular stent grafts to create a “sutureless” anastomosis. We believe this technique to be a valuable adjunct to current repair options.

The values of this technique are that it is (1) rapid, (2) of low technical complexity, (3) requires very little equipment, and (4) may offer extended durability in damage control scenarios.

We describe three patients where this technique was used. In the first case, the technique was used to provide a temporary arterial shunt in a patient with a local infection and arterial disruption. In the second case, DSER was used for definitive repair of an injured artery after penetrating trauma. The third case involves DSER for definitive of both an artery and vein after penetrating trauma.

From the Department of Surgery (A.J.D., L.P.N., J.J.D., J.B.S.), UC Davis Medical Center, Sacramento, California; Department of General Surgery (A.J.D., L.P.N.), David Grant USAF Medical Center, Travis Air Force Base, California; Department of Surgery (J.J.D., J.B.S.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Vascular and Endovascular Surgery (L.P.N., J.J.D., J.B.S., T.K.W.), David Grant USAF Medical Center, Travis Air Force Base, California; and Department of Surgery (C.M.A.), Kaiser Permanente South Sacramento Medical Center, Sacramento, California.

Submitted: March 1, 2016, Revised: July 14, 2016, Accepted: July 14, 2016, Published online: September 16, 2016.

A version of this manuscript was presented at the Western Trauma Association annual meeting, February 28–March 4, 2016, in Tahoe, CA. This work has not been published elsewhere.

Disclaimer: The views expressed in this material are those of the authors, and do not reflect the official policy or position of the U.S. Government, the Department of Defense, the Department of the Air Force, the University of California Davis, or Kaiser Permanente.

While covered stent grafts are FDA approved for use in peripheral vasculature, we consider this technique an off-label use of this technology.

Address for reprints: Timothy K. Williams, MD, Department of Vascular and Endovascular Surgery, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535; email:

© 2016 Lippincott Williams & Wilkins, Inc.