Management of the Mangled Extremity

Annotation for Point H

Intraluminal shunts can be used as a temporizing measure to restore distal perfusion to the affected extremity, while the remainder of the evaluation is being conducted, or during bony evaluation/fixation.^29–32 Shunts have been successfully used as a temporizing bridge to definitive vascular repair even in the setting of contraindications to anticoagulation.³³  Some shunts, including the Pruiit-Inahara shunt, have a third arm that is particularly useful in effectively facilitating the intravascular administration of local anticoagulants and vasoactive medications. The use of shunts may particularly prove useful when long segment vascular loss is identified or in the setting of hemodynamic instability precluding extensive vascular repair at the initial operation. After the shunt is inserted, the surgeon should document flow to the distal extremity with a palpable pulse, Doppler signal, or an angiogram.

Level of Supporting Evidence: Level 4