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To shunt or not to shunt in combined orthopedic and vascular extremity trauma

Wlodarczyk, Jordan R., MD; Thomas, Alexander S., MD; Schroll, Rebecca, MD; Campion, Eric M., MD; Croyle, Caroline, MPH; Menaker, Jay, MD; Bradley, Matthew, MD; Harvin, John A., MD; Collum, Morgan L., MD; Cho, Jayin, MD; Seamon, Mark J., MD; Leonard, Jennifer, MD; Tiller, Michael, MD; Inaba, Kenji, MD; Moore, Margaret M., MD

Journal of Trauma and Acute Care Surgery: December 2018 - Volume 85 - Issue 6 - p 1038–1042
doi: 10.1097/TA.0000000000002065
ORIGINAL ARTICLES
Editor's Choice

BACKGROUND There exists a long established but not validated practice of placing temporary intravascular shunts (TIVS) in cases of combined vascular and orthopedic extremity trauma. Though logical to prioritize blood flow, large-scale data to support this practice is lacking. We hypothesize that the order of repair yields no difference in outcomes in combined vascular and orthopedic extremity trauma and offer a larger-scale analysis than is previously available.

METHODS A retrospective chart review was conducted at six Level I trauma centers from 2004 to 2015 comparing patients who received a TIVS during their initial surgery versus those who did not. Nonshunted patients were further divided into initial definitive vascular repair versus initial orthopedic fixation groups. Metrics were used to control for sampling bias while revision rate, amputation, hospital length of stay (HLOS), and development of thrombosis and compartment syndrome were used to assess outcomes.

RESULTS Of 291 total patients, 72 had TIVS placement, 97 had initial definitive vascular repair, and 122 had initial orthopedic fixation. The shunted group had a higher Abbreviated Injury Scale (3.0 vs. 2.8 p = 0.04) and Mangled Extremity Severity Score (6.1 vs. 5.7 p = 0.006) and a significantly lower rate of compartment syndrome (15% vs. 34% p = 0.002). Among patients who developed compartment syndrome, those who were shunted were younger (23 vs. 35 yrs, p = 0.03) and were more likely sustain a penetrating injury (p = 0.007). Those receiving initial orthopedic fixation had a longer HLOS (HLOS >15 days in 61% vs. 38%, p = 0.049) and a higher amputation rate (20% vs. 7%, p = 0.006) when compared with those undergoing initial definitive vascular repair.

CONCLUSION Lack of TIVS was associated with a significant increase in the development of compartment syndrome. Though it seems to have become common practice to proceed directly to vascular repair during the initial surgery, morbidity is improved with the placement of a TIVS.

LEVEL OF EVIDENCE Therapeutic cohort, level III.

From the Department of Surgery (J.R.W., J.C., K.I.), LAC/USC Hospital, Los Angeles, California; Department of Surgery (J.R.W., A.S.T., R.S.), Tulane University, New Orleans, Louisiana; Department of Surgery (E.M.C., C.C.), Denver Health, Denver, Colorado; Department of Surgery, Shock Trauma (J.M., M.B.), Baltimore, Maryland; Department of Surgery (J.A.H., M.L.C.), University of Texas Health Science Center at Houston, Houston, Texas; Department of Surgery (MJS, J.L., M.T.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Surgery (M.M.M.), Louisiana State University, New Orleans, Louisiana.

Submitted: August 31, 2017, Accepted: August 27, 2018, Published online: September 11, 2018.

Presented at the 76th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery in Baltimore, MD, September 13–16, 2017.

Address for reprints: Jordan Wlodarczyk, MD, Department of Surgery, General Surgery, LAC+USC Medical Center/Keck Hospital of USC, PGY-2, 2051 Marengo St. Los Angeles, CA 90033; email: jordan.wlodarczyk@med.usc.edu.

Combined vascular and orthopedic extremity trauma carries significant risk for the affected limb and remains a difficult management problem. When the injury is due to isolated penetrating arterial trauma, limb salvage rates can approach 95%.1 However, when concomitant skeletal injury exists, amputation rates have been reported as high as 72.5%.2

Traditional teaching has advocated for temporary intravascular shunting (TIVS) to restore blood flow while orthopedic fixation is performed to reduce prolonged ischemia and avoid iatrogenic damage to the vascular repair during aggressive orthopedic manipulation.3,4 Once complete, the shunt is removed and definitive arterial repair performed.

The concept of TIVS to maintain distal blood flow is long established. First mentioned in 1915, silver tubes were used to bridge between injured vessels.5 In World War II, glass and plastic tubes were used.6 Temporary intravascular shunt was temporarily abandoned because of thrombosis until Eger described its utility in arterial injuries in 1971.7 Since then, TIVS gained popularity particularly in the military.

Current Joint Trauma System clinical practice guidelines for combined vascular and orthopedic extremity trauma state that restoration of blood flow can be achieved by TIVS and definitive vascular repair should only be considered when a significant delay in transport to a higher level of care is anticipated.Vascular Injury. 2016; En ligne. Accessed: 04/20/2018.','400');" onMouseOut="javascript:ImageWrapperControl_ImageMouseOut();">8 Shunting has become the standard management in military trauma with several case series and retrospective studies demonstrating success.9–11

In the civilian sector TIVS is used less consistently. The 2002 Eastern Association of Trauma clinical practice guidelines state that restoration of blood flow should precede management of the skeletal injury to allow for skeletal stabilization unless the injury is not unstable, in which case definitive arterial repair can be performed first.1 The literature supporting this recommendation, however, is limited. In 2012, a retrospective study of 26 patients with combined lower extremity injuries concluded that to minimize amputation rates and revascularization procedures, the optimal order of repair places a TIVS, stabilizes the orthopedic injury and then proceeds with definitive arterial repair.12

Given the paucity of data supporting the clinical practice guidelines, we conducted a multicenter retrospective review to examine the order of repair in combined orthopedic and vascular extremity trauma. We hypothesized that the order of repair yields no difference in outcomes and that use of TIVS provides no benefit over definitive vascular repair whether before or after orthopedic stabilization.

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METHODS

We conducted a multicenter, retrospective review of patients with combined orthopedic and vascular extremity trauma. We included six ACS-verified Level I trauma centers (University Medical Center-New Orleans, Los Angeles County+University of Southern California, University of Pennsylvania, University of Texas Health Science Center at Houston, Denver Health Medical Center and Baltimore Shock Trauma). After International Review Board approval, data were abstracted from the medical record for patients with combined orthopedic and vascular extremity trauma from January 2004 to December 2015. Patients excluded included those who died or underwent amputation during the initial operation, underwent ligation of their vascular injury, or had splints or casts rather than operative orthopedic fixation.

Data collected included age, sex, location of injury, mechanism of injury, Abbreviated Injury Scale (AIS), Mangled Extremity Severity Score (MESS), Glasgow Coma Scale, Injury Severity Score (ISS), associated non-limb injuries, mortality, hospital length of stay (HLOS), vital signs, and laboratory values. Procedures performed in the initial surgery and any additional and subsequent surgeries during that period of admission were also collected. The primary outcome measured was the need for delayed amputation. Secondary outcomes measured were the development of compartment syndrome, rhabdomyolysis, rate of vascular revision, need for operative thrombectomy, and HLOS over 15 days.

The group that received TIVS was compared those who did not receive TIVS (no-TIVS). The no-TIVS group was subdivided into patients undergoing initial definitive vascular repair followed by orthopedic stabilization and those undergoing initial orthopedic stabilization followed by definitive arterial repair. A subsequent analysis was also performed comparing the TIVS group directly to the initial arterial repair group.

Data were abstracted using a standardized data collection tool. Continuous data were expressed as means with standard deviations (SD) or medians with interquartile ranges (IQR) and categorical or ordinal data were expressed as proportions (%). The Student's t test was used for comparison of normally distributed continuous data and the Wilcoxon rank-sum test was used to compare distributions of non-normal continuous variables. Either Pearson's χ2 or Fisher's exact test was used to compare proportions of categorical variables. All statistical tests were two-tailed, and statistical significance was considered when p value is 0.05 or less.

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RESULTS

During the 10-year study period, 533 patients presented with combined orthopedic and vascular extremity trauma and 291 patients qualified for analysis. The average age was 36 years (SD, 14 m; range, 15–89 m) and 66.0% were male. Blunt trauma was the most common mechanism of injury (72.5%) with motor vehicle collisions accounting for 27% of all injuries, motorcycle collisions for 13.0%, and motor-pedestrian collisions for 13.0%. Gunshot wounds caused 27.4% of all combined vascular and orthopedic extremity trauma. The mean AIS score was 2.9 (SD 0.6), the average MESS was 5.8 (SD, 1.9) and the median ISS was 10 (IQR, 9–18). On arrival to the emergency department, the presenting systolic blood pressure was 126 mm Hg (SD, 30) and the presenting heart rate was 102 beats per minute (SD, 24). There was one mortality. All patients were taken to the operating room for management of their injuries.

A total of 72 patients had a TIVS shunt placed during their initial operation. Two hundred nineteen patients did not have a TIVS placed and had either definitive vascular repair before orthopedic fixation (n = 97) or after orthopedic fixation (n = 122). Prophylactic fasciotomies were performed in 150 patients (51.9%) and was most often performed in the TIVS group (Table 1). The specific vascular and orthopedic repairs are listed in Table 2.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

Both AIS score and MESS were higher in the TIVS group than in the no-TIVS group and there were no other demographic differences between the two groups. The TIVS group had significantly shorter ischemia time than the no-TIVS group (Table 1). Regarding primary outcome measures, there was no difference in amputation rate between the two groups. Secondary outcomes measured demonstrated no differences between the TIVS group and the no-TIVS group, with the exception of the development of compartment syndrome. Patients who had TIVS during the initial operation had a significantly lower rate of compartment syndrome than did the no-TIVS group (Table 3).

TABLE 3

TABLE 3

Among those who did not receive TIVS during the initial operation, 97 patients received definitive arterial repair and 122 patients underwent orthopedic repair first. The orthopedic first group had a higher AIS score, was more commonly from blunt trauma, and had a higher rate of prophylactic fasciotomy (Table 1).

There was a significantly higher rate of amputation and longer median ischemia time in the primary orthopedic stabilization. The median HLOS for the entire cohort was 17 days and there was no difference in HLOS between the TIVS and no TIVS group overall. Within the subset of patients who did not receive a TIVS, the group who underwent initial orthopedic stabilization had a longer HLOS (Table 3).

Secondary analysis between the TIVS group and the arterial first group there found a higher incidence of amputation in the TIVS group than in the arterial first group. The ischemia time was longer in the initial arterial repair group than it was in the TIVS. There was no difference in the rate of vascular revision, the development of thrombosis, rhabdomyolysis or HLOS between the two groups. There was a statistically significant increase in the development of compartment syndrome in the initial arterial repair group when compared to the TIVS group. The rate of prophylactic fasciotomy in these two groups was not significantly different (Table 4).

TABLE 4

TABLE 4

Finally, prophylactic fasciotomies were performed far more frequently in patients who received a TIVS than in those who did not. When we excluded patients receiving a prophylactic fasciotomy from the analysis, the sample size decreased and the statistical significance disappeared though a trend toward an increase in the development of compartment syndrome remained.(Table 5)

TABLE 5

TABLE 5

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DISCUSSION

The main function of TIVS is to preserve tissue viability and maximize limb salvage. Maximum limb salvage and preservation of function is realized when control of hemorrhage and restoration of blood flow is expediently obtained.13 While shunt use has become routine in echelon II military facilities, reported shunt incidence in civilian vascular trauma is only 3% to 9%.14,15 From 2001 to 2005, the National Trauma Data bank only recorded the placement of 395 shunts and of the hospitals included, only six inserted more than five.16 In the largest and most recent multicenter study, 213 TIVS shunts were placed comprising 2.7% total of vascular injuries. Only one third of them were placed for combined orthopedic and vascular injuries.17

Despite rare civilian use, TIVS are well described in both civilian and military literature.9,12,16,18 There is, however, insufficient evidence to guide the correct order of repair. The 2012 Eastern Association of Trauma Practice Management Guidelines state that the primary indication for TIVS are in patients undergoing damage control procedures in trauma and in Gustilo IIIc open fractures requiring vascular repair.1,15 Use of temporary shunts to restore blood flow is suggested in the presence of a concomitant bone injury while immediate vascular repair is advised for stable skeletal injuries.3 This debate focuses on time to reperfusion, concern for disrupting the vascular anastomosis, and the potential need for vascular revision should orthopedic stabilization occur after definitive repair.17 Amputation rates had also previously been reported to be higher when orthopedic injuries were addressed prior to repair of the vascular injury.12

Our study aimed to determine if TIVS and the order of repair affects outcomes in combined injuries. We hypothesized that the rate of amputation, development of compartment syndrome or rhabdomyolysis, need for subsequent revascularization or thrombectomy, and HLOS would not differ whether the patient received a TIVS or proceeded directly to definitive vascular repair before or after orthopedic stabilization.

Of the 291 patients with combined orthopedic and vascular injury, only 72 received initial TIVS mirroring civilian literature’s paucity of TIVS usage. Our primary outcome measured was the rate of amputation. A more recent study in Iraq and Afghanistan that compared TIVS usage in extremity trauma found similar amputation between the two groups.11 Analysis of the NTDB demonstrated the amputation rate in civilians with upper and lower extremity arterial injuries to be 1.3% and 7.8%, respectively.19 A 2016 study looking at the use of TIVS shunts in vascular extremity trauma identified a 3.5% amputation rate.18

The amputation rate in our study was 16.3%, with no difference between the TIVS and no-TIVS groups. There was, however a significantly higher rate of amputation in the TIVS group when compared directly with the group undergoing arterial repair prior to orthopedic stabilization. In the no-TIVS group, the amputation rate was also significantly higher when orthopedic stabilization took place prior to definitive arterial repair (Table 3).

The development of compartment syndrome is of high concern after reperfusion of the acutely ischemic extremity. Prophylactic fasciotomy has been advised in these patients, particularly if the time to reperfusion of the extremity is greater than 6 hrs or if the compartments are tense following repair. Early revascularization of the extremity reduces this requirement and the use of TIVS had previously been associated with a decreased need for fasciotomy.20 We found that the incidence of compartment syndrome was significantly lower in the group of patients who received a TIVS but we also found a significantly higher rate of prophylactic fasciotomy. This does not seem to be an isolated finding. Subramanian et al.14 in 2008 examined TIVS shunt use in Civilian Level I trauma and reported that 80% of patients who received TIVS for extremity vascular injury received a prophylactic fasciotomy.19 The Joint Trauma System guidelines for the management of extremity vascular trauma also state that both a TIVS and a prophylactic fasciotomy should be performed at the Echelon II facility prior to transferring to a higher definitive level of care.Vascular Injury. 2016; En ligne. Accessed: 04/20/2018.','400');" onMouseOut="javascript:ImageWrapperControl_ImageMouseOut();">8 When comparing TIVS use to initial definitive vascular repair, the rate of prophylactic fasciotomy was not significantly different, and in that same subset analysis, the incidence of the development of compartment syndrome remained higher in the TIVS group.

Our study was limited in several ways. In order to capture a large sample size, we included patients from 2004 to 2015. Over that period, resuscitation strategies have changed and our study may not account for developments in the understanding of fluid shifts and tissue edema. Further, we did not collect information on concomitant venous injuries. Repair of venous injuries had previously been recommended as it aids in maintaining the arterial repair and reduces post-operative edema.21 Use of TIVS for venous injuries provides drainage and decreased venous hypertension, and there is evidence that shunting of the vein and repair is associated with a decreased incidence of compartment syndrome, fasciotomies and amputation.20,22 Another major limitation of our study was that we did not have complete data on ischemia times and the collection of ischemia times was not actively standardized across institutions. Much of our supplemental background information was taken from the military's Joint Trauma System, which included numerous small studies of a few cases across a wide spectrum of combat casualty care. Our hypothesis was created based on extrapolation of these conclusions.

In conclusion, TIVS was associated with a significant decrease in the development of compartment syndrome. Though the common practice now seems to proceed directly to definitive vascular repair, morbidity is improved with the placement of a TIVS. We therefore suggest to minimize ischemia time of the extremity before definitive management can be accomplished a TIVS can be considered followed by orthopedic stabilization and definitive arterial repair.

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AUTHORSHIP

J.W., A.T. and M.M. designed the hypothesis and designed the model for data collection. J.W., A.T., C.C., M.B., M.C., J.C., J.L., M.T. performed the data collection and consolidation. M.M. and J.W. performed the calculations. J.W., M.M., A.T. wrote the article with input from all authors. J.W. and M.M. conceived the study and were in charge of overall direction and planning. R.S., M.M., J.M., J.H., K.I., M.S. were supervisory and in charge of editing and oversight.

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DISCLOSURE

The authors have nothing to disclose and no conflicts of interests were identified.

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Keywords:

Temporary shunt; extremity injury; orthopedic; vascular; shunt

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