Heroic procedures in vascular injury management: The role of extra-anatomic bypasses

https://doi.org/10.1016/S0039-6109(03)00144-0Get rights and content

Section snippets

HISTORY OF EXTRA-ANATOMIC BYPASS GRAFTING

Extra-anatomic bypass, the remaining heroic technique for limb salvage after arterial trauma, was first described for atherosclerotic occlusive disease in the early 1950s. A variety of techniques, including femorofemoral, thoracic aorta-to-femoral, obturator, and axillofemoral bypass grafts, were introduced during the 1960s and remain in use.16 These techniques have been used in atherosclerotic disease in high-risk patients in whom an exploratory laparotomy would not be tolerated, in patients

INDICATIONS FOR EXTRA-ANATOMIC BYPASS GRAFTING IN TRAUMA AND SEPSIS

In the acute care setting, the indications for the use of an extra-anatomic bypass graft include:

  • Loss of soft tissue over injured artery or vein

  • Postoperative wound infection with blowout of underlying arterial repair

  • Simultaneous infections in soft tissue and underlying native artery secondary to injection of illicit drugs

When there has been loss of soft tissue over an injured artery or vein, the choice of a standard vascular repair in situ mandates that a complex technique of management of

OPERATIVE TECHNIQUE

When an extra-anatomic bypass is needed for any of the traumatic or septic indications listed earlier, proximal and distal vascular control around the area of injury or infection is obtained in the usual fashion. Depending on the magnitude of the injury in soft tissue, the results of the patient's clotting studies, and the surgeon's experience in vascular surgery, it may be appropriate to administer intravenous heparin at a dose of 1 to 2 mg/kg at this point. Contused, necrotic or infected soft

Case 1

A 23-year-old man sustained a gunshot wound of the right antecubital fossa and brachial artery. A 6-mm PTFE interposition graft was inserted into the defect in the brachial artery and left exposed in the débrided defect in soft tissue. On the fourth postoperative day, the proximal artery-to-graft anastomosis partially dehisced resulting in significant hemorrhage. At a reoperation, the exposed graft and adjacent artery at the anastomotic sites were resected. An extra-anatomic saphenous vein

SUMMARY

The insertion of an extra-anatomic bypass graft is an accepted operative technique in highly selected patients with atherosclerotic occlusive disease and contraindications to in situ grafting. In similar fashion, the technique should be considered in injured or septic patients with large soft tissue defects or wound infections overlying arterial repairs or involving native arteries. The combination of vigorous débridement of injured or infected soft tissue and insertion of an extra-anatomic

First page preview

First page preview
Click to open first page preview

References (21)

There are more references available in the full text version of this article.

Cited by (17)

  • Vascular Trauma Revisited

    2018, Journal of the American College of Surgeons
    Citation Excerpt :

    At the time of long-term follow-up at 22 months, the patient had normal right radial and ulnar pulses and full range of motion of the right elbow (Fig. 4). The indications for performing an extra-anatomic vascular bypass in an injured extremity are listed in Table 4.112-114 Although the technique appears somewhat formidable to inexperienced trauma vascular surgeons, the steps in performing the operation are straightforward.

  • The Mangled Extremity

    2009, Current Problems in Surgery
    Citation Excerpt :

    These areas should be covered with local soft tissue flaps first. If this is not possible, temporary porcine xenografts can be used until local tissue granulates in around the area.125 Breakdown of a vascular anastomosis is more likely when left uncovered and the results can be catastrophic.

  • Audit of Positive Microbiological Cultures in Patients Undergoing Arterial Reconstruction

    2006, EJVES Extra
    Citation Excerpt :

    It is recognised that the incidence of infection is much greater in emergency surgery as compared with elective surgery and our study confirms this. Factors such as extended peri-operative hospital stay predisposing to virulent pathogens, less stringent adherence to perioperative prophylaxis or sterile technique, increased incidence of bowel injury, more extensive lymphatic manipulation or injury during dissection, repeat operations and prolonged operating times could all contribute to this.7–9 Our study shows that Staphylococci are responsible for the vast majority of positive cultures (MSSA 38%, MRSA 27%, Staphylococcus epidermidis 14%).

  • Salvage of the injured upper extremity

    2021, Trauma Surgery and Acute Care Open
View all citing articles on Scopus
View full text