Evaluation and Management of Peripheral
Vascular Injury
Part 2

Annotation for Point G

A peripheral vascular repair should never be left exposed at the completion of operation. Exposure of a lateral repair, end-to-end anastomosis, or saphenous vein graft will result in contamination leading to infection. In the hemodynamically stable patient, a decision must be made before the arterial repair is performed on whether there is enough healthy muscle available locally to cover the subsequent repair. If there is not, then a decision must be made in conjunction with the plastic surgery service on whether there is healthy muscle close enough to be transposed or rotated to cover the arterial repair.²¹ If neither of these approaches is possible and the arterial repair is likely to require segmental resection and an end-to-end anastomosis or interposition graft, an extraanatomic bypass graft is inserted in the hemodynamically stable patient.²² The approach separates injuries to the bone and soft tissue from the arterial repair. The operative technique includes the following: (1) debridement of soft tissue/ injured artery back to healthy tissue; (2) insertion of an extraanatomic saphenous vein or PTFE graft with both anastomoses and the graft covered with healthy soft tissue; and (3) open packing or a vacuum-assisted device applied to the defect in soft tissue. In the hemodynamically unstable patient, a lateral arteriorrhaphy is covered with a porcine xenograft placed under mesh gauze soaked in a saline-antibiotic solution.²³ When segmental resection of the arterial injury will be required, a temporary intraluminal shunt is inserted (see H), and the porcine xenograft-gauze combination is used to cover the area. Plastic surgery consultation is then obtained to determine which of a large number of options for coverage of the wound would be appropriate at the reoperation for removal of the shunt and insertion of an interposition graft.^24,25