Davidson Anders J, Neff Lucas P, Grayson J Kevin, Clement Nathan F, DeSoucy Erik S, Simon Logan Meryl A, Abbot Christopher M, Sampson James B, Williams Timothy K
From the Department of Surgery (A.J.D., L.P.N., E.S.C., M.A.S.-L.), UC Davis Medical Center, Sacramento, California; Department of General Surgery (A.J.D., L.P.N., E.S.D.), David Grant USAF Medical Center, Travis Air Force Base, California; Clinical Investigation Facility (J.K.G.), David Grant USAF Medical Center, Travis Air Force Base, California; Department of Pathology (N.F.C.), David Grant USAF Medical Center, Travis Air Force Base, California; Heart, Lung and Vascular Center (M.A.S.-L, J.B.S., T.K.W.), David Grant Medical Center, Travis Air Force Base, California; and Department of Vascular Surgery (C.M.A.), Kaiser Permanente South Sacramento Medical Center, Sacramento, California.
J Trauma Acute Care Surg. 2017 Sep;83(3):457-463. doi: 10.1097/TA.0000000000001614.
The small diameter of temporary vascular shunts for vascular trauma management may restrict flow and result in ischemia or early thrombosis. We have previously reported a clinical experience with direct, open surgical reconstruction using expandable polytetrafluoroethylene stent grafts to create a "sutureless" anastomosis as an alternative to standard temporary vascular shunts. We sought to characterize patency and flow characteristics of these grafts compared with standard shunts in a survival model of porcine vascular injury.
Twelve Yorkshire-cross swine received a 2-cm-long near-circumferential defect in the bilateral iliac arteries. A 14 Fr Argyle shunt was inserted into one randomly assigned artery, with a self-expanding expandable polytetrafluoroethylene stent deployed in the other. At 72 hours, conduit patency was evaluated by angiography. Arterial flow measurements were obtained at baseline, immediately after intervention, and after 72 hours via direct measurement with perivascular flow meters. Blood pressure proximal and distal to the conduits and arterial samples for histopathology were obtained during the terminal procedure.
Angiography revealed no difference in patency at 72 hours (p = 1.0). While there was no difference in baseline arterial flow between arteries (p = 0.63), the stent grafts demonstrated significantly improved blood flow compared with shunts both immediately after intervention (390 ± 36 mL/min vs. 265 ± 25 mL/min, p = 0.002) and at 72 hours (261 ± 29 mL/min vs. 170 ± 36 mL/min, p = 0.005). The pressure gradient across the shunts was greater than that of the stent grafts (11.5 mm Hg [interquartile range, 3-19 mm Hg] vs. 3 mm Hg [interquartile range, 3-5 mm Hg], p = 0.013). The speed of deployment was similar between the two devices.
Open "sutureless" direct site repair using commercially available stent grafts to treat vascular injury is a technically feasible strategy for damage control management of peripheral vascular injury and offers increased blood flow when compared with temporary shunts. Furthermore, stent grafts may offer improved durability to extend the window until definitive vascular repair. The combination of these traits may improve outcomes after vascular injury.
Epidemiologic/Prognostic, level III.
用于血管创伤处理的临时性血管分流器直径较小，可能会限制血流，导致局部缺血或早期血栓形成。我们之前报道了一项临床经验，即使用可扩张聚四氟乙烯支架型人工血管进行直接开放手术重建，以创建“无缝合”吻合术，作为标准临时性血管分流器的替代方法。我们试图在猪血管损伤存活模型中，比较这些人工血管与标准分流器的通畅性和血流特征。
12只约克夏杂交猪双侧髂动脉出现2厘米长的近环周缺损。将一个14F的阿盖尔分流器插入一条随机分配的动脉，另一条动脉植入自膨式可扩张聚四氟乙烯支架。72小时时，通过血管造影评估管道通畅情况。在基线、干预后即刻和72小时后，使用血管周围流量计直接测量获得动脉血流测量值。在终末手术期间，获取管道近端和远端的血压以及用于组织病理学检查的动脉样本。
血管造影显示72小时时通畅性无差异（p = 1.0）。虽然动脉之间的基线动脉血流无差异（p = 0.63），但与分流器相比，支架型人工血管在干预后即刻（390±36毫升/分钟对265±25毫升/分钟，p = 0.002）和72小时时（261±29毫升/分钟对170±36毫升/分钟，p = 0.005）的血流均显著改善。分流器两端的压力梯度大于支架型人工血管（11.5毫米汞柱[四分位间距，3 - 19毫米汞柱]对3毫米汞柱[四分位间距，3 - 5毫米汞柱]，p = 0.013）。两种装置的展开速度相似。
使用市售支架型人工血管进行开放“无缝合”直接原位修复治疗血管损伤，在技术上是一种可行的策略，用于外周血管损伤的损伤控制处理，与临时性分流器相比，可增加血流。此外，支架型人工血管可能具有更好的耐久性，可延长至确定性血管修复的时间窗。这些特性的结合可能改善血管损伤后的治疗效果。
流行病学/预后，III级。
