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Tue Aug 1 17:50:53 BST 2006

I agree with all of this.

  In a warm, stable patient with a clean wound and plenty of time on your hands, it's sensible to repair whatever venous injury you have in front of you. In a hypothermic, shocky patient and a contaminated field, every venous structure inferior to renal veins - including the IVC - is fair game for ligation. After all, prior to IVC filters we treated all recalcitrant thromboembolism with caval ligation. The femoral veins are still commonly taken  for autologous bypass as well.

  I'm curious about the discussion of anatomic reconstruction here. Aside from use limited to the intraoperative period, the role for temporary shunts would be extremely limited. An axillary popliteal bypass is a definitive, clean revascularization manuever and can be performed in not much more time than it would take to sew in a temporary conduit - typically less than 90 minute for someone working alone, less time for two operating surgeons. 

  A shunt requires very short term removal and re-intervention and would require systemic anticoaguation (contraindicated in the majority of trauma patients) to stay open even for brief periods. In the absence of soft tissue coverage patency would be profoundly poor and infection rate essentially 100%. Insertion of a retained foreign body intra-arterially through contaminated fields would make systemic sepsis a concern as well.

  I don't believe a contaminated penetrating femoral injury would ever be handled with nonautogenous anatomic bypass if presenting to a vascular surgeon here in the states. And as stated above by Dr. Frykberg, the decision to pause for autolougous conduit harvest would be dictated by the patient's general condition - unlikely to be favorable in the conditions you describe.

docrickfry at aol.com wrote:
  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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SGW to Femoral triangle