Twenty five years of vascular trauma in Northern IrelandBMJ 1995; 310 doi: http://dx.doi.org/10.1136/bmj.310.6971.1 (Published 07 January 1995) Cite this as: BMJ 1995;310:1
- Aires A B Barros D'Sa
Surgeons have learnt the value of intraluminal shunting
Perhaps the quarter century of futile terrorism and internecine strife in Northern Ireland is coming to an end, leaving in its wake over 3100people dead and 36500 injured. The civil population and those defending it have endured physical suffering and grief with dignity and spirit, while the fabric of their lives has been blighted by the systematic destruction of their homes and places of work and leisure. The cease fire has generated a mixture of relief, scepticism and hope.
Belfast's largest teaching hospital, the Royal Victoria, took on the main responsibilities of a front line evacuation centre. Staff treated casualties, often from major disasters, while ensuring that specialist practice, undergraduate teaching, postgraduate training, and research continued undeterred. Despite witnessing horrific injuries and having little access to counselling they have remained uninured to pain and distress.
Over the past 25 years vascular surgeons in this province have dealt with an estimated 1500 injured major blood vessels.1 2 3 Progress in managing vascular trauma has usually been made in wartime,4 5 and this conflict offered unique opportunities.6 7 8 9 10 11 In contrast with the situation on the battlefield, most casualties arrived within half an hour, including those with injuries to the major vessels, who otherwise would have died at the scene. The nature and severity of vascular injuries reflected the energy dissipated on impact by shrapnel (from bombs, mines, mortar shells, and rockets) and by high and low velocity bullets. Punishment shootings (or “knee cappings” in which the victim is shot in or near the knee at close range) accounted for many injuries to limb vessels.1 2 3 6 7 8 9 10 11 12
In high velocity injuries of the great vessels in the neck and superior mediastinum, repair was achieved because the airway had been secured early with a cuffed endotracheal tube and surgeons were prepared to proceed to median sternotomy.3 6 13 14 Early repair of the carotid artery using shunts prevented cerebral infarction and occasionally reversed a developing neurological deficit. High velocity injuries of subclavian vessels presented a challenging test of technique in gaining access for control and repair, especially on the left side; as with injuries to the axillary vessels, damage to the brachial plexus was common.6 14 15
One in four patients with penetrating trauma of the abdomen also sustained intrathoracic damage. Fatal exsanguination from large vessels was prevented by vigorous resuscitation and definitive surgery; half of those with aortic and caval injuries survived.6 Control of the subdiaphragmatic aorta was an essential prerequisite to exploring an expanding retroperitoneal haematoma. In major injuries of the inferior vena cava—a valveless conduit draining systemic, portal, and hepatic flow—proximal and distal control was imperative, preferably around a shunt to ensure adequate venous return.16
Over the past 15 years routine intraoperative shunting of both transected artery and vein in vascular trauma to the lower limbs has improved management. The technique has been increasingly adopted abroad and continues to be studied experimentally.17 Its value is especially borne out in complex wounds typified by concomitant arterial and venous injury, fracture and comminution of bone, severe disruption of tissue, nerve injury, and contamination. Striated muscle rarely survives warm ischaemia beyond 6 hours (this depends on the level of arterial injury, collateral flow, degree of shock, and vasoconstriction), and delays in diagnosis or vascular repair therefore carry a penalty. Duplex scanning is impractical in penetrating wounds, whereas angiography will competently delineate arterial injury: by excluding damage when clinical signs are equivocal it strengthens confidence not to intervene.11 18 Ischaemia reperfusion injury increases capillary permeability, muscle swelling, and compartment pressure, thereby attenuating tissue perfusion sufficiently to invite the sequelae of the compartment syndrome, ischaemic contracture, ischaemic nerve palsy, aseptic muscle necrosis, and amputation.7 8, 9 10
An awareness that time crucially affects outcome promotes hurry and leads to lapses in technique which may compromise survival of the limb. These lapses include vascular repair with lateral suture or end to end anastomosis under tension, interposition grafting with a vein of suboptimal calibre or length, ligation of a major vein, and disruption of a vessel repair by late fixation of a fracture.6 7 8 9 10 19
By halting the race against time intraluminal shunting has made these lapses less likely, and by introducing a logical sequence of steps it has encouraged a multidisciplinary operative strategy, improved the quality of operative technique, reduced complications, and kept amputations to a minimum.8 9 10 An inlying shunt bridging a severed artery (or an outlying shunt when tissue loss is extensive) instantaneously revitalises the limb. A similar shunt reconnecting a severed vein restores drainage and reduces the need for fasciotomy. Better demarcation of non-viable tissue makes for precise debridement, and only at this stage may discrimination between a potentially salvageable and an irretrievably damaged limb become clear. Restoration of skeletal integrity will safeguard subsequent vessel repair. The debate over whether artery or vein is repaired first is rendered obsolete. A compound vein graft, matching the calibre of the host vessel,1 2 3 6 7 8 9 or an extra-anatomic vein graft bypassing an open contaminated wound may be constructed at leisure.9 10
These improvements in managing vascular injuries represent dividends from an experience in which the victims of inhumanity have been the key contributors. The hope remains that “one day the people of peace will come into their own in Northern Ireland.”20