Blunt popliteal artery injury with complete lower limb ischemia: is routine use of temporary intraluminal arterial shunt justified?

Abstract

Objective: Complete lower limb ischemia as a result of blunt popliteal artery injury is associated with the highest morbidity and amputation rates among all of the peripheral vascular injuries. The purpose of this study was to determine the possible benefits of routine use of a temporary intraluminal arterial shunt in patients with complete limb ischemia from blunt popliteal trauma.

Patients and methods: Over 3 years seven blunt popliteal artery injuries with complete lower limb ischemia were managed with insertion of a shunt at the initial phase of the operation. Data from these procedures was analyzed and compared with retrospectively collected data for 10 injuries with complete ischemia treated without shunts during the preceding 5 years.

Results: Mean injury severity score and mangled extremity severity score were 9.3 +/- 3.49 and 5.7 +/- 0.95, respectively, in the shunt group, and 9.9 +/- 3.57 and 5.9 +/- 0.56, respectively in the non-shunt group. Mean ischemic time was 244.3, 24.3, and 268.6 minutes, respectively, for preoperative, intraoperative, and total ischemic time in the shunt group, and 273, 56.5, and 329.5 minutes in the non-shunt group. The difference was significant for intraoperative (P <.001) and total (P <.05) ischemic time. In the entire group, 92.8% of patients with total ischemic time greater than 4 hours underwent fasciotomy, 100% required repeat operation, and 57.1% had complications and required fasciotomy wound debridement. All patients (100%) with ischemic time greater than 6 hours required amputation, compared with no patients with ischemic time less than 5 hours. One patient in the shunt group (14.3%) experienced one fasciotomy wound complication (11.1%), compared with seven patients in the non-shunt group (70%) had 8 complications (88.9%) (P <.05). Mean number of repeat operations was 0.8 +/- 1.06 in the shunt group, and 1.9 +/- 0.73 in the non-shunt group (P <.05). One patient in the shunt group (14.3%) required fasciotomy wound debridement, compared with seven patients in the non-shunt group (70%; P <.05). Mean hospital stay was 14.4 and 23 days, respectively, in the shunt and non-shunt groups (P <.05). Four limbs in the non-shunt group (40%) required amputation, compared with 100% limb salvage in the shunt group.

Conclusion: Temporary arterial shunting after blunt lower limb trauma significantly reduces total ischemic time, complications, repeat operations, amputation, and hospitalization. I recommend routine use of shunts in blunt popliteal artery injuries with complete lower limb ischemia.