SGW to Femoral triangle

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The ligated veins will do fine--there may be some postop leg swelling from venous ligation, but this is minimized by fasciotomy as you did. and leg wrapping and elevation.  Little chance of requiring venous reconstruction down the road.  There really is no longer any place for any type of complex venous reconstruction given the added time it takes for little benefit (typically clot no matter, altho can recanalize down the road)--complex equals anything more than lateral suture or end to end anastomosis.  All arterial conduits in the original open wound, and therefore uncovered, as well as all temporary shunts, are going to have to be replaced--they willl fail, by breaking down at the anasomotic sites and acute bleeding--might as well redo them as soon as possible and not after they are in shock.  Either extra-anatomic bypass, or in the open wound IF a full thickness flap can be swung to cover.  One other long forgotten option--still temporizing tho-- is to cover the arterial repair with pigskin, which will protect long enough for the wound to heal and a definitive repair then done.  There is no increased risk of DVT or PE from any reconstructed veins--an old unfounded urban legend
ERF
 
 
-----Original Message-----
From: KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: Mon, 31 Jul 2006 1:33 PM
Subject: SGW to Femoral triangle


I really appreciated and enjoyed the many persons who had suggestions  
regarding our patients with close range SGW to the groin and injury to soft  
tissue, 
femoral vein and femoral artery, with a significant blast  cavity.    
 
As you can imagine, our staff also had discussions about the options you  
cited.    These included the use of temporary arterial shunts,  ligation of 
veins, use of ringed PTFE in the venous injuries as an  interposition, extra 
anatomic  bypass, use of a panel venous conduit, use  of Dacron graft, use of 
PTFE 
graft, as well as primary amputation.    One person suggested a bovine conduit, 
another suggested using the internal  jugular vein, and still another 
suggested using an autogenous artery, like the  contralateral iliac, and put 
Dacron 
in that donor position.    My  personal suggestion was to use temporary shunts 
in the artery and venous  positions, replacing if necessary until the initial 
blast cavity was healing and  options had been fully discussed.    The 
surgeons who were on  acutely did other options.   
 
In each case vascular control was achieved and a PTFE graft was placed as  an 
arterial conduit, as high as the external iliac artery as an insertion  site. 
  In no case was an immediate extra anatomic bypass felt to be  the best 
arterial option.   In one case, a lateral femoral venous  closure was possible, 
although it was narrowed.    Fasciotomies  were performed.     In no case was 
any "autogenous" veins or  arteries used.  
 
The continuing question to the web site members is now what do you think is  
going to happen to the conduits, the ligations, and is reconstruction of the  
venous side possible.   Is there an increased incidence of  PE?    Will post 
phlebetic limb develop.  ?
 
k
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