IS POLYTETRAFLUOROETHYLENE (PTFE) THE CORRECT CHOICE TO TREAT CONTAMINATED TRAUMATIC VASCULAR INJURIES?

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1 IS POLYTETRAFLUOROETHYLENE (PTFE) THE CORRECT CHOICE TO TREAT CONTAMINATED TRAUMATIC VASCULAR INJURIES? Nigel Denis MD Class of 2016 University of Miami Miller School of Medicine Miami, Florida, USA

2 Disclosures I have no actual or potential conflicts of interest in relation to this program/presentation. I will not be discussing products that are investigational or not labeled for use under discussion.

3 Background Vascular traumas are a major cause of morbidity and mortality and often require direct repair via end-to-end anastomosis or lateral suture repairs. Historical evidence seems to show that prosthetic grafts such as polytetrafluoroethylene (PTFE) are resistant to infection, 4 maintains integrity if treated appropriately when infected, and are resistant to blow out 2-4.

4 Case Report 30 Male; GSW to R chest, L flank, & L abdomen; Glascow 12, SBP 106, HR 144 Exlap identified multiple jejunal and cecal enterotomies with active stool spillage, right ureter damage, transections of bilateral common iliac arteries (CIA) at the bifurcation of the internal iliac arteries (IIA), and right common iliac vein injury Initial Vascular repairs: bilateral IIAs were ligated and bilateral CIAs were shunted with 14-French Argyle shunts. The right common iliac vein was primarily repaired. Fasciotomy of the left leg.

5 Post-Exlap Imaging

6 Clinical Course POD 1: 6mm PTFE graft bilateral CIAs POD 20: RLQ intraabdominal collections POD 24: Massive exsanguination; breakdown of distal L CIA anastomosis; re-shunted and returned to ICU on heparin drip POD 27: Definitive repair with reversed femoral vein Post biologic course: No vascular complications; discharged to rehab facility with triphasic flow in bilateral lower extremities

7 Discussion Graft infection remains a serious limb-threatening and often life-threatening complication, reported after 0.5% to 6% of all arterial reconstructions 9. Vaughn et al. PTFE repairs spanning brachial/renal/femoral traumatic injuries: 49 instances of PTFE use in trauma without any complication secondary to thrombosis or graft infection 5 Most recent larger scale studies from Walter Reed propose PTFE as a valuable bridge from emergent re-vascularization to ultimate elective autologous vein bypass repair. Daenens et al.10-year reconstruction data of infected aortofemoral prosthesis using autogenous femoral veins: 5-year limb salvage rate of 98%; 5-year primary patency rate of 91%; no reinfection or aneurysmal changes in grafts.

8 Conclusion A literature search yielded historical recommendations and recent challenging evidence. This case provides evidence that a re-examination of historical recommendations could be warranted, and aligns with more recent literature challenging use of PTFE grafts as a final conduit.

9 References Martin LC, McKenney MG, Sosa JL, et al. Management of lower extremity arterial trauma. J Trauma. 1994;37: Shah DM, Leather RP, Corson JD, Karmody AM. Grafts in the rapid reconstruction of acute contaminated peripheral vascular injuries. Am J Surg. 1984;148: Rich NM and Hughes CW. The Fate of Prosthetic Material Used to Repair Vascular Injuries in Contaminated Wounds. J Trauma. 1972;12: Stone KS, Walshaw R, Suglyama GT, Dean RE, Dunstan RW. Polytetrafluoroethylene versus autogenous vein grafts for vascular reconstruction in contaminated wounds. Am J Surg. 1984;147: Vaughn GD, Mattox KL, Feliciano DV, Beall AC, and DeBakey ME. Surgical Experience with Expanded Polytetrafluoroethylene (PTFE) as a Replacement Graft for Traumatized Vessels. J Trauma.1979;19: Fox CJ, Gillespie DL, O Donnell SD, et al. Contemporary Management of Wartime Vascular Trauma. J Vasc Surg. 2005;41: Quan RW, Gillespie DL, Stuart RS, et al. The Effect of Vein Repair on the Risk of Venous Thromboembolic Events: A Review of over One Hundred Traumatic Military Venous Injuries. J Vasc Surg. 2008;47: Dhiraj M. Shah, Robert P. Leather, John D. Corson, Allastair M. Karmody. Polytetrafluoroethylene Grafts in the Rapid Reconstruction of Acute Contaminated Peripheral Vascular Injuries. Am J Surg. 1984;148: Ricco JB and Assadian O. Antimicrobial Silver Grafts for Prevention and Treatment of Vascular Graft Infection. Semin Vasc Surg. 2011;24: Daenens K., Foumeau I., Nevelsteen A. Ten-year Experience in Autogenous Reconstruction with the Femoral Vein in the treatment of Aortofemoral Prosthetic Infection. Eur J Vasc Endovasc Surg March; 25(3): Claglett GP, Bowers BL, Lopez-Viego MA, et al. Creation of a Neo-Aortoiliac System from Lower Extremity Deep and Superficial Veins. Ann Surg Sept; 218(3) Harris L, O'brien-Irr M, Ricotta JJ. Long-term assessment of cryopreserved vein bypass grafting success. J Vasc Surg Mar;33(3):

10 Acknowledgments Jorge Rey, MD, FACS, Associate professor of surgery, University of Miami. Miami, FL Xiaoyi Li, MD, General Surgery Resident, University of Miami. Miami, FL Nisha Garg, MS4, University of Miami. Miami, FL Gabriel Ruiz, MD, General surgery resident, University of Miami. Miami, FL Handel Robinson, MD, Associate professor of surgery, University of Miami. Miami, FL