The Belfast Approach to Managing Complex Lower Limb Vascular Injuries

Schematic of the pathophysiological consequences of combined arterial and venous injury in complex lower limb trauma.

A virtually dismembered leg at mid-thigh showing the bone ends (XX) of a fractured femur, a Javid shunt bridging a lengthy gap in femoral artery and perfusing the distal limb; another such shunt bridging adjoining femoral vein and draining the limb. Reproduced with permission from Barros D'Sa and Moorehead.²⁵

Aide-mémoire for the sequence of steps in the operative management of complex limb vascular injury: staunch the bleeding, snip damaged ends of vessels, scoop out clot, syringe in heparinised saline, shunt both artery and vein, survey the wound and identify nerve injury, perform scission of non-viable soft tissue, squirt saline to irrigate wound, stabilise fractured bones, stitch vessel grafts, swing tissue for cover, suture the wound (delayed primary if contaminated) and, if necessary, split fascia to decompress muscle. Reproduced with permission from Barros D'Sa.⁷

Schematic of the pathophysiology depicting the beneficial effects of early arterial and venous shunting in complex lower limb vascular injury.

After excision of devitalised muscle, debridement and stabilisation of fracture (XX) interposed vein grafts restore flow through the femoral artery and the deep femoral vein.

Popliteal artery, above (previously shunted), repaired using a reversed interposition vein graft (arrowed). Popliteal vein, below (with shunt in situ), being repaired by a panelled compound vein graft. Reproduced with permission from Barros D'Sa.²¹