An Update on the Use of Temporary Intravascular Shunting in the Era of Balanced Blood Product Resuscitation

Traumatic vascular injuries can oftentimes be challenging to manage because patients typically present with multiple life-threatening injuries. In addition, extremity vascular trauma is often accompanied by ipsilateral fractures, surrounding soft tissue destruction, and nerve injuries.1 Although most traumatic vascular injuries can be repaired at the time of the patient’s initial operation, there are some instances in which definitive treatment of the injury cannot be immediately accomplished. In these instances, a temporary intravascular shunt (TIVS) can be used to restore flow to the affected extremity while the patient is stabilized or while the associated fracture is repaired.2 Although the use of TIVS has been well documented in the military literature,3 there are presently few studies examining the use of TIVS in civilian trauma centers.1, 2 Furthermore, in the past decade, the resuscitation of critically ill patients has drastically changed and balanced blood product resuscitation (BBPR), in which blood components are given at a fixed ratio (1:1:1), has been shown to significantly reduce overall patient mortality.4 As the outcomes of TIVS use in the modern era of BBPR are not well understood, the purpose of this review was to not only examine the outcomes of contemporary TIVS cases in a civilian Level I trauma center, but to also compare these outcomes both before and after the implementation of BBPR. This was a single-center, retrospective review of patients who presented with vascular trauma requiring placement of a TIVS at Grady Memorial Hospital between January 2011 and January 2017. This cohort of patients was then compared with a similar cohort of patients who presented between January 2002 and January 2007, before the implementation of BBPR at our institution. After approval from the Emory University Institutional Review board, patients were identified using the Trauma Registry of the American College of Surgeons. Data were then collected by reviewing each patient’s medical record, blood bank record, and operative log. Both the decision to place a TIVS and the location of TIVS placement were made at the discretion of the attending trauma surgeon. Statistical analysis was performed using both Microsoft Excel and GraphPad Prism version 6.0 for Mac OS X (GraphPad Software, San Diego, CA). P < 0.05 was considered to be statistically significant. A total of 16,909 patients were admitted to the Emory Trauma Service between January 2011 and January 2017. Of these, 31 patients (0.2%) had a total of 39 TIVS placed. The majority of patients were male (26/31, 83.9%), and the average age of the cohort was 33.5 ± 11.9 years old. In regards to injury characteristics, 69.2 per cent of injuries (27/39) were arterial and were most often secondary to a penetratingmechanism of trauma (28/39, 71.8%). Overall mortality was found to be 16.1 per cent (5/31). The anatomic distribution of all shunts that were used is shown in Table 1. The most common indication for TIVS placement was damage control (29/39, 74.4%). Gustilo IIIc open fractures (7/39, 17.9%) and the need for extremity perfusion during definitive vascular repair (3/39, 7.7%) encompassed the remainder of the patient cohort. Within the group undergoing TIVS placement for damage control purposes, TIVS were placed in 23 peripheral injuries (58.9%) and six truncal injuries (15.4%). A total of nine patients (29.0%) had two TIVS placed during their initial operations. Eleven patients (28.2%) had their TIVS removed during their initial operation following orthopedic fixation of a fracture or after definitive vascular repair. Twenty (51.3%) patients left the operating room with 27 (69.2%) TIVS in place in 19 arteries (70.4%) and eight veins (29.6%). Average shunt dwell time in this group was found to be 33.3 ± 20.7 hours. Address correspondence and reprint requests to Dipan C. Patel, M.D., Assistant Professor of Surgery, Emory University School of Medicine, Glenn Memorial Building, 69 Jesse Hill Jr. Drive SE, Atlanta, GA 30303. E-mail: dipan.patel@emoryhealthcare.org.