To Shunt or Not to Shunt in Combined Orthopedic and Vascular Extremity Trauma

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 6 Level 1 trauma centers from 2004-2015 comparing patients who received a TIVS during their initial surgery versus those who did not. Non-shunted 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, 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 AIS (3.0 vs 2.8 p=0.04) and MESS (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 35yrs, 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 to those undergoing initial definitive vascular repair. Conclusion Lack of a temporary intravascular shunt 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. This paper has not been published elsewhere Corresponding author and person to whom reprint requests should be addressed: Jordan Wlodarczyk M.D. M.S. LAC+USC Medical Center/Keck Hospital of USC, Department of Surgery, General Surgery PGY-2, 2051 Marengo St. Los Angeles, CA 90033, Phone: (714) 357-9599, Email: jordan.wlodarczyk@med.usc.edu Presented at the 76th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery in Baltimore, MD, September 13-16, 2017. Disclosure Statement and Conflicts of Interests: The authors have nothing to disclose and no conflicts of interests were identified © 2018 Lippincott Williams & Wilkins, Inc.

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