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Intraoperative Consultation For Complex Limb-threatening Traumatic Vascular Injury In A Hemodynamically Unstable Patient
Nicola M. Habash1, Fari Fall
2, Babak Abai
2, Michael Nooromid
2.
1Sidney Kimmel Medical College, Philadelphia, PA, USA,
2Thomas Jefferson University Hospital, Philadelphia, PA, USA.
DEMOGRAPHICS: Patients with gunshot wounds (GSW) resulting in extensive vascular injury necessitate immediate surgical intervention to control bleeding and restore circulation. This case illustrates the role of vascular surgeons in managing such emergencies and achieving limb salvage.
HISTORY: A 20-year-old patient with a GSW to the left lower extremity was urgently taken to the operating room (OR) by the trauma team. Vascular surgery was consulted intraoperatively after identifying severe hemorrhage from a complex injury involving the bifurcations of the left common femoral artery (CFA) and vein.
PLAN: We obtained control of the bleeding after exposure of the common femoral, superficial femoral, and profunda femoris arteries and veins (Figure 1A). Temporary vascular shunts were placed between the CFA and superficial femoral artery (SFA) and between the common femoral vein (CFV) and femoral vein (FV) (Figure 2). The patient was then taken to the intensive care unit for ongoing resuscitation with the plan of early return to the OR for definitive repair. We returned to the OR that evening and initiated the reconstruction by sewing the back walls of the femoral and profunda femoris veins (PFV) together. The left great saphenous vein, which was already disconnected proximally, was harvested, and a spiral vein graft was prepared using a 32 Fr chest tube (Figure 1B). This vein graft was then used to anastomose the CFV to the FV and PFV (Figure 1C). The CFA, SFA, and PFA were reconstructed using a CryoVein graft. An interposition graft was sewn from the CFA to the SFA, followed by a jump graft from the mid-graft to the PFA. After these revascularization procedures, blood flow was restored, and limb salvage was achieved (Figure 1D).
DISCUSSION: Vascular surgeons' expertise is crucial in achieving favorable outcomes, including limb salvage, in patients with life-threatening traumatic vascular injuries. Temporary vascular shunts allowed for initial hemorrhage control and patient stabilization, while definitive repair facilitated limb salvage. The application of vein and cryopreserved vascular grafts demonstrates the versatility and adaptability required in vascular surgery.
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