SGW to Femoral triangle - Synthetic vs "autogenous"

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Hi Guys,

I am very interested in this as it goes against pretty much everything we in
Australasia have ever been taught about contaminated complex vascular wounds
(ie Dogma - eminence based rather than evidence based probably), and given
that I am sitting the fellowship in 3 weeks it might be nice if I had a bit
more clarification.... :-)

I have just reviewed the EAST guidelines and it states that vein repair is
preferable but that PTFE is an acceptable alternative.  I have always taken
this to mean that it should be a case of "God first and Gore second", but
has there been a paradigm shift to PTFE as a primary choice of conduit for
complex traumatic injuries (where expedience of repair may have benefit over
and above time taken for a venous repair and where longevity might not
matter?).  The assumption in most units I have worked in has been that PTFE
is acceptable as conduit where vein is either not available (pretty rare) or
where there is size discrepancy etc, but not as a primary choice if there is
vein available.

My understanding is that there is also evidence that suggests that injuries
in the lower limb that require revascularisation to distal
SFA/popliteal/tibial segements uniformly do better with autogenous conduit,
and that when PTFE is used, the rates of graft thrombosis are higher, and
that limb salvage rates are worse (uniform amputation in PTFE failure).  Is
there new evidence in this setting ?

I look forward to hearing from ERF and KM about this.

Thanks

Mark Hamilton
mark at vascularsurgery.co.nz


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of docrickfry at aol.com
Sent: Wednesday, 2 August 2006 6:50 a.m.
To: trauma-list at trauma.org
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"

 I must chime in in support of Dr Mattox's statement here, which studies
from his institution established back in the 80"s--I frequently get
responses like the post below, and it oftne is from vascualr surgeons--this
is old and unfounded dogma that will do your patients a disservice in
settings like this unless you become familiar with the vascular trauma
literature--some of the greatest resistance I have found to modern tenets of
vascualr trauma are from vascular surgeons who never do trauam, and make the
mistake of thinking that truama to vessels is handled like elective vascular
surgical problems--not true.  The biggest flaw in this thinking is that the
two patient populations are entirely different.
ERF
 
 
-----Original Message-----
From: KMATTOX at aol.com
To: trauma-list at trauma.org
Sent: Tue, 1 Aug 2006 1:03 PM
Subject: Re: SGW to Femoral triangle - Synthetic vs "autogenous"


 
In a message dated 8/1/2006 11:54:54 A.M. Central Standard Time,
mmcbridemd at yahoo.com writes:

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.


THere is NO non-autogenous material to use as a conduit.  As soon as a  vein
or artery is removed from its bed to be used elsewhere in the body, it
becomes a DEAD collagen tube,  a foreign body and is MORE conducive to bad  
complications than synthetic material.   This has been established in  more
than 
50 
basic science and clinical papers.   The old "right"  answer that in
potential 
contaminated wounds, the vascular conduit of choice is  the autogenous 
saphenous vein, is no longer considered  correct.     
 
Kenneth L. Mattox, M.D.  
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