Temporary intravascular shunt use improves early limb salvage following extremity vascular injury

Abstract Objectives Temporary intravascular shunts (TIVS) allow restoration of distal perfusion and reduce ischemic time in the setting of arterial injury. As a damage control adjunct shunts restore perfusion while life-threatening injuries are treated, or patients are evacuated to a higher level of care. Single center reports and case series demonstrate that TIVS use may extend the opportunity for limb salvage, but there have been few multi-institutional studies on the topic. The objective of this study is to characterize TIVS use through a multi-institutional registry and define its impact on early limb salvage. Methods Data from the Prospective Observation Vascular Injury Treatment (PROOVIT) registry was analyzed. Civilian patients 18 years of age or older who sustained an extremity vascular injury between September 2012 and November 2018 were included. Patients who had TIVS used in the management of vascular injury comprised the TIVS group and those who had management without TIVS served as the control group. Unadjusted comparison of the groups was conducted to evaluate differences in baseline and outcome characteristics. Double robust estimation combining logistic regression with propensity score matching was used to evaluate the effect of shunt utilization on the primary endpoint of limb salvage. Results TIVS use was identified in 78 patients from 24 trauma centers. The control group consisted of 613 patients. Unmatched analysis demonstrated that the TIVS group was more severely injured (mean injury severity score [ISS], 18.83 [SD=11.76] TIVS vs. 14.93 [SD=10.46] control; p=.002) and had more severely mangled extremities (mean abbreviated injury scale extremity score [AIS extremity] 3.23 [SD=0.80] TIVS vs. 2.95 [SD=0.87] control; p=.008). Logistic regression demonstrated that propensity matched control patients had a three times greater likelihood of amputation compared to TIVS patients (odds ratio: 3.6; 95% CI: 1.2 – 11.1; p=.026). Concomitant nerve injury and orthopedic fracture were associated with a greater risk of amputation. Median follow-up of the TIVS group was 12 days [IQR 4,25] compared to 9 days [IQR 4,18] Control. Conclusion This is the first multi-center, matched cohort study to characterize early limb salvage as a function of temporary vascular shunt use in the setting of extremity vascular injury. Shunts expedite limb perfusion and result in lower rates of amputation during the early phase of care. TIVS should be one part of a more aggressive approach to restoration of perfusion in the most injured patients and ischemic limbs.