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