Hossny Ahmed
Vascular Surgery Department, Faculty of Medicine, Menofia University, Egypt.
J Vasc Surg. 2004 Jul;40(1):61-6. doi: 10.1016/j.jvs.2004.03.003.
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.
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.
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.
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.
在所有周围血管损伤中，因腘动脉钝性损伤导致的下肢完全缺血与最高的发病率和截肢率相关。本研究的目的是确定在因腘动脉钝性创伤导致下肢完全缺血的患者中常规使用临时性腔内动脉分流管可能带来的益处。
在3年多的时间里，对7例因腘动脉钝性损伤导致下肢完全缺血的患者在手术初期插入分流管进行治疗。分析这些手术的数据，并与回顾性收集的前5年中10例未使用分流管治疗的完全缺血损伤患者的数据进行比较。
分流管组的平均损伤严重程度评分和肢体毁损严重程度评分分别为9.3±3.49和5.7±0.95，非分流管组分别为9.9±3.57和5.9±0.56。分流管组术前、术中及总缺血时间的平均值分别为244.3、24.3和268.6分钟，非分流管组分别为273、56.5和329.5分钟。术中（P<.001）和总缺血时间（P<.05）差异有统计学意义。在整个组中，总缺血时间大于4小时的患者中有92.8%接受了筋膜切开术，100%需要再次手术，57.1%有并发症并需要进行筋膜切开伤口清创。所有缺血时间大于6小时的患者（100%）需要截肢，而缺血时间小于5小时的患者无一例需要截肢。分流管组有1例患者（14.3%）发生1例筋膜切开伤口并发症（11.1%），而非分流管组有7例患者（70%）发生8例并发症（88.9%）（P<.05）。分流管组再次手术的平均次数为0.8±1.06，非分流管组为1.9±0.73（P<.05）。分流管组有1例患者（14.3%）需要进行筋膜切开伤口清创，而非分流管组有7例患者（70%；P<.05）。分流管组和非分流管组的平均住院时间分别为14.4天和23天（P<.05）。非分流管组有4条肢体（40%）需要截肢，而分流管组的肢体保全率为100%。
下肢钝性创伤后使用临时性动脉分流管可显著缩短总缺血时间、减少并发症、再次手术、截肢和住院时间。我建议在因腘动脉钝性损伤导致下肢完全缺血的患者中常规使用分流管。
