Role of Endovascular Grafts in Combined Vascular and Skeletal Injuries of the Lower Extremity: a Preliminary Report

BACKGROUND: A gunshot wound to the lower extremity with combined skeletal and vascular injuries can be difficult to manage. In clinical practice, it is not always possible to assemble a multispecialty team to work seamlessly to attain this goal, and the end result may be unnecessary prolonged ischemic time. A covered endovascular stent (EVS) can be used initially to restore perfusion without need of a time-consuming temporary shunt in select cases. OBJECTIVES: The objective of this study is to compare novel methods of repairing the superficial femoral artery to the traditional three-step operative approach in patients that have a concomitant femur fracture. PATIENTS AND METHODS: All patients with combined vascular and skeletal injuries to the lower extremity were reviewed retrospectively. Patients were divided into three groups: Group 1: EVS placed percutaneously. Group 2: EVS placed with a hybrid combination of open and endovascular technique. Group 3: Placement of temporary shunt followed by skeletal stabilization and definitive vascular repair. RESULTS: There were 16 patients identified. Group 1 = three, Group 2 = six, Group 3 = seven. EVS can shorten time to revascularization and prevents a second episode of vascular interruption at the time of the final vascular repair. The structural stability of the EVS was strong enough to withstand the skeletal manipulation without deformation of the stent. CONCLUSIONS: EVS is comparable to open repair and has the strength to withstand orthopedic manipulation in the short term when used in combined vascular and skeletal injuries to the lower extremity. Ischemic time is reduced significantly if final revascularization is accomplished at the onset with an EVS and the process is more efficient if the trauma surgeon is able to repair the vascular injury. With increasing sophistication of endovascular devices, this offers an appealing approach to vascular injuries that will decrease ischemic and total operative times when compared to the more traditional three-stage repair.