Temporary intravascular shunts (TIVS): indications, technique, and outcomes

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**Indications for Temporary Shunts**

Temporary intravascular shunts (TIVS) are employed to restore limb perfusion rapidly in the damage control surgery (DCS) setting when immediate definitive repair is not feasible.feasible [@rossaint2023]. Key indications include: [@fox2005]

* **Combined injuries:** Patients with concomitant orthopedic injuries requiring fracture stabilization before vascular reconstruction
* **Physiologic exhaustion:** Hypothermic, acidotic, or coagulopathic patients in the lethal triad who cannot tolerate prolonged vascular reconstruction [@rossaint2023]
* **Prolonged transfer:** Patients requiring inter-facility transfer to definitive vascular care
* **Mass casualty scenarios:** Triage situations where multiple patients require sequential care

**Technical Aspects**

* **Shunt selection:** Use appropriately sized silicone or polytetrafluoroethylene (PTFE) shunts; size should match the vessel diameter to prevent dislodgement or thrombosis. Javid, Pruitt-Inahara, and Argyle shunts are commonly employed [@fox2005].
* **Fixation:** Secure shunts with vessel loops, umbilical tapes, or proprietary securing devices. Inadequate fixation risks dislodgement and catastrophic hemorrhage.
* **Anticoagulation:** Systemic anticoagulation is generally avoided in polytrauma patients due to bleeding risk. Local heparinized saline flush (100 units/mL) is used for shunt priming. Some centers advocate for low-dose systemic heparin (3000–5000 units) if no contraindications exist [@fox2005].
* **Dwell time:** Shunts may remain in place for 6–24 hours, with some series reporting successful patency beyond 48 hours [@fox2005]. Definitive repair should be performed once physiologic derangements are corrected and competing injuries are stabilized.

**Outcomes**

Data from military conflicts in Iraq and Afghanistan demonstrate limb salvage rates exceeding 90% when temporary shunts are employed appropriately, compared to 50–60% with ligation alone [@rasmussen2011-vascular]. Civilian series confirm these benefits, with shunt patency rates of 85–95% and amputation rates of 5–15% when combined with staged definitive repair [@fox2005].

**Integration with endovascular trauma management (EVTM):** TIVS can be combined with endovascular techniques such as resuscitative endovascular balloon occlusion of the aorta (REBOA) to prioritize proximal hemorrhage control while maintaining distal limb perfusion [@trauma2016].[@castellini2021-resuscitative; @trauma2016]. See [[EVTM|Ch. 16]] for REBOA protocols and hybrid trauma workflows.