Gunshot wounds can cause severe vascular injuries to the extremities. These injuries are associated with a high risk of critical limb ischemia and limb amputation. In a limited resources scenario, managing vascular injuries to the extremities is a challenge. In warfare areas, medical supplies are constantly interrupted. In civil life, many hospitals do not have the resources (medical staff and materials) to treat these injuries. Portugal represents a country where many hospitals lack medical personnel in all different areas of medicine due to wrong and neglectful health politics (e.g., the government is closing maternity hospitals all around the country, putting pregnant women and their unborn children at risk of needing damage control procedures). If you work in such a place, this post is for you.
In that setting, damage control (control the bleeding, avoid contamination, do no more harm) is mandatory and can save limbs. If a doctor cannot repair a vascular injury or does not have the appropriate material, temporary vascular shunting is a good option.
A paper published by Dr. Volodymyr Rogovskyi et al. from Kyiv, Ukraine, reports a case of a gunshot wound to the lower limbs during war first treated with a temporary arterial shunt. A male patient was shot in the lower limbs. A tourniquet was applied on the battlefield, and 40 min later was admitted to the hospital. Injury to the left superficial femoral artery was diagnosed with complete rupture. Tourniquet was removed, a temporary arterial shunting was placed, and the patient was transferred to another hospital for vascular repair (picture). Arriving at the definitive hospital (6 hours after injury), the left lower limb was warm, with preserved movements and detectable tibial pulsation.
On the other hand, the right lower limb presented critical ischemia, and a right popliteal artery injury was diagnosed with compartment syndrome. Mangled Extremity Severity Score (MESS) indicated a borderline risk for limb amputation. The patient was immediately operated on.
The right lower limb was submitted to decompressive fasciotomies before proceeding to arterial repair. In this setting, and according to the authors, fasciotomies must be performed before vascular repair to avoid vein thrombosis, prevent a significant decrease in blood supply, and decrease the risk of muscle ischemia and necrosis. The right popliteal artery was then reconstructed with a saphenous vein graft. Returning to the left lower limb, the temporary shunt was fully functioning. Reconstruction was accomplished with saphenous vein bypass. No fasciotomies were necessary for the left lower limb. The patient was discharged for rehabilitation 29 days after the injuries, with both vein grafts fully functioning.
In a scenario of limited surgical resources (war or civil), temporary vascular shunting is a well-known method to decrease the risk of critical ischemia and consequent limb amputation or even death. Dr. Volodymyr et al. highlight that vascular repair was successful because it was accomplished within 6 hours. They continue saying that other reviews support temporary arterial shunting to prevent critical ischemia within 6 hours after injury. This paper shows that temporary arterial shunting allows a limb to be saved even if more than 6 hours have passed since the injury (the classical time limit till irreversible ischemia is established), I think. We must not forget that in the high-level hospital and 6 hours after the injury, the right lower limb presented critical ischemia, and the left lower limb was warm and with palpable pulsation. The temporary arterial shunting gave the patient and the surgical team time to save the right lower limb while keeping the left lower limb preserved for more than 6 hours until definitive vascular repair. Additionally, temporary arterial shunting is associated with decreased risk of compartment syndrome, the reason why there was no need for fasciotomies in the left lower limb.
In sum, and according to the authors, “we consider the temporary vascular shunting as a damage control measure to be associated with high chances of limb salvage in ongoing warfare”. As doctors, we must remember these case reports, because in a civil environment and in hospitals with limited resources like the majority in Portugal, temporary vascular shunting (e.g., with a silastic tube) can be used to save limbs while the patients await transportation to another hospital.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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