Temporary Vascular Shunting 
Mark Bowyer, Christopher Gross 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction 
Temporary vascular shunting is a surgical 
procedure used to rapidly restore blood flow to an 
area of the body when there is an injury or 
obstruction in a blood vessel. This technique 
involves inserting a temporary conduit, called a 
shunt, into the blood vessel to bypass the damaged or 
blocked segment. The shunt maintains perfusion to 
the tissues downstream of the injury, preventing 
ischemia (lack of blood flow) and potential tissue 
damage. 
This procedure is often used in emergency 
settings, such as during trauma surgery, to stabilize 
the patient and buy time until a more permanent 
vascular repair can be performed. Temporary 
shunting can be critical in saving limbs and organs 
by ensuring continuous blood supply during the 
initial stages of treatment.  
Temporary vascular shunting is a damage 
control technique that should be considered in 
patients who: 
• Have 
the 
lethal 
trauma 
triad 
(acidosis, 
hypothermia, and coagulopathy) and need time 
for stabilization in the ICU prior to definitive 
repair 
• Need initial orthopedic injury repair prior to 
definitive vascular repair 
• Need to be temporized before transferring to a 
higher level of care with necessary expertise and 
resources to perform definitive repair 
• Are involved in mass or multiple casualties with 
limited resources on hand.  
 
This chapter will focus on principles for 
temporary vascular shunt placement. In general, the 
surgical principles are as follows:   
• Gain vessel exposure 
• Gain proximal and distal control of transected 
artery 
• Dilate and clear any clots by inserting Fogarty 
catheter proximally and distally 
• Identify and prepare shunt to fit snugly into 
vessel  
• Trim shunt to extend about 1.5-2cm on either 
side of defect 
• Place 2-0 silk suture in the shunt center 
• Place and secure shunt with 2-0 silk ties 
• Shunt both the artery and vein when possible 
• Confirm distal flow with Doppler ultrasound or 
palpation 
 
Steps: 
1. Consider typical preoperative factors to prepare 
for operation (overall health, hemodynamic 
stability, assess vascular injury extent and distal 
tissue viability).  
2. General anesthesia is typically preferred, but 
regional anesthesia can be used under certain 
circumstances. 
3. Position, prepare and drape, and incise to provide 
optimal access to the injured vessel. Individual 
vascular exposures are described in separate 
chapters of this Manual.  
4. Dissect down to gain adequate exposure of the 
target vessel. 
5. After identifying the injured vessel, obtain 
proximal and distal control. Use vessel loops, 
which are elastic bands that occlude a vessel 
without causing damage when wrapped twice 
around the vessel (Pott’s technique). An 
alternative in resource-limited settings is the 
rolled cuff of a sterile glove, or a sterilized rubber 
band. Vascular clamps, if used, should not be 
clamped tightly. Ordinary clamps such as 
hemostats or right-angle clamps, will destroy a 
vessel and should not be used in this situation. 
 
Wrap vessel loops around the artery and vein, proximally and 
distally to the injury, to gain control of the vessels. 
 
Temporary Vascular Shunting 
Mark Bowyer, Christopher Gross 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Pass the vessel loop once, grasp it and then pass it under the 
vessel again in the same place. Now you can pull the vessel loop 
snug and occlude the vessel without causing damage. This is 
called Pott’s technique. 
 
6. Pass a Fogarty catheter distally and proximally. 
First inflate the catheter outside the vessel to 
visualize the balloon’s size relative to the amount 
of saline injected. Then deflate it again, insert it, 
inflate it, and then gently retract the catheter from 
vessel. You should feel only slight resistance: if 
there is an excess of resistance, deflate the 
balloon slightly. 
 
Hold the catheter in your dominant hand and the syringe of 
saline in your non-dominant hand. Test the balloon by inflating 
it and making a note of how much saline results in the 
appropriate amount of inflation, to approximate the size of the 
lumen of the artery. Then, deflate the catheter and insert it into 
the vessel.  
 
 
As shown here, as you pull the balloon back and it nears the 
transected end of the vessel, a clot will emerge. If you have 
removed all the clot, pulsatile bleeding will occur from a 
proximal vessel and non-pulsatile back-bleeding will occur 
from a distal vessel. If these things do not occur, pass the 
embolectomy catheter again.  
 
7. Do not debride an injured vessel at the time of 
shunt placement- leave it until definitive repair 
operation to preserve vessel length. 
 
Shunt Preparation Steps 
8. Commercially 
available 
shunts 
are 
recommended; however, chest tubes and IV 
tubing can be used as well. Pick the largest 
possible arterial shunt and cut the edges smoothly 
so they do not damage the intima of the vessel.  
 
Select an appropriately sized shunt (IV tubing shown here) that 
fits snugly into vessel and then place a suture in the center of 
the shunt.  
 
9. All shunts must be carefully secured to prevent 
dislodgement using ties (or, less commonly, 
clamps or slings). This is especially important for 
patients requiring physical transport to another 
location for definitive repair.   
10. Measure the length of the defect and fashion the 
shunt to be about 4 cm longer than the gap 
between the vessels. In this way, the shunt can 
extend about 1.5-2 cm into the proximal and 
distal lumens of each transected artery. 
Temporary Vascular Shunting 
Mark Bowyer, Christopher Gross 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Trim the shunt to have about 2cm of length extending into both 
proximal and distal segments of the transected artery.  
 
11. After trimming the shunt to the appropriate 
length, secure it with 2-0 silk tie in the center of 
the shunt and a clamped hemostat to occlude flow 
and serve as marker. 
12. Note the transected artery typically experiences 
vasospasm. Therefore, topical papaverine plus 
gentle dilation can be used to relax the vessel, 
allowing larger shunt insertion.  
13. Place prepared shunt 1.5-2 cm into proximal end 
of the transected artery and secure shunt with a 
2-0 silk about 5 mm from the vessel’s cut end. 
 
Both the silk tie and the clamp are at the center of the vessel, 
allowing you to control blood flow and to gauge when the shunt 
is inserted far enough into the vessel. Pass another silk tie 
around the vessel 5mm from the end and tie it, securing the 
shunt within the vessel. 
 
14. Remove the clamped hemostat in center of shunt 
and temporarily release proximal vessel control 
to confirm pulsatile blood flow. Re-clamp the 
hemostat after confirmation.  
 
Release the clamp temporarily to confirm blood flow (this photo 
shows a cadaver perfused with colored saline solution.)  
 
15. Insert the other end of the shunt 1.5-2 cm into the 
distal 
lumen 
of 
the 
transected 
vessel, 
compressing the vessel onto the shunt. Secure it 
with a 2-0 silk again, about 5mm from the 
vessel’s cut edge. Release the vessel loop as you 
do this, so that the backflow removes any air 
from this vessel.  
 
When inserting the other end of the shunt into the distal 
transected vessel, you can manipulate the shunt via the clamp 
at its mid-portion and the vessel by grasping it with a forceps. 
 
 
After inserting the shunt into the distal end of the vessel, secure 
it again with a silk tie 5mm from the transected end of the vessel.  
Temporary Vascular Shunting 
Mark Bowyer, Christopher Gross 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
16. Join the ties under slight tension on both distal 
and proximal ends of the vessels. This stabilizes 
the shunt and helps prevent shunt migration or 
dislodgement. Cut both ends of excess suture tie. 
 
Secure the shunt by tying both vessel ties to the central tie, 
under slight tension to prevent the shunt from becoming 
dislodged.  
 
17. Release distal vascular control and confirm 
pulsatile flow distal to shunt placement. 
18. Repeat the same procedure for the adjacent vein, 
if possible. Veins tolerate ligation much better 
than arteries, but your eventual repair has a better 
chance of success if it includes both the artery 
and the vein.  
 
Completed shunting of both an artery and a vein.  
 
19. After placing a shunt, be sure to document a 
thorough distal exam, using palpation or Doppler 
ultrasound if available, and note time of shunt 
placement.  
20. Close each tissue layer using appropriate suture.  
 
Temporary Shunt Considerations 
• Shunt removal should occur as soon as the 
patient’s physiology allows and there is 
appropriate surgical expertise to perform 
definitive repair.  
• Definitive repair is necessary after temporary 
shunt. However, prior to definitive repair, the 
temporary shunt must be removed, and the vessel 
will require debridement back to healthy tissue 
beyond location where the tie was tied around the 
vessel (i.e. >1.5-2 cm distally and proximally of 
transected artery). Do not use any of the vessel 
that was under the ties that secured the shunt.  
• It is not always necessary to heparinize vascular 
shunts. Additionally, not every vessel needs to be 
shunted. For example, there are high rates of 
thrombosis in shunts placed above and below the 
knee, without changes in rates of limb loss, 
indicating these vessels do not require shunting.  
 
Ligation Considerations 
Sometimes vascular shunting or repair is not 
possible or practical, and therefore requires ligation 
to gain control over life-threating hemorrhage. Most 
every vessel in the extremis CAN be ligated with 
varying levels and types of consequences. The 
common vessels suitable / that can tolerate ligation 
include but are not limited to: 
• Common carotid artery 
• External carotid arteries 
• Subclavian artery (distal to thyrocervical trunk) 
• Axillary artery 
• Brachial artery (distal to profunda branch) 
• Either ulnar or radial artery individually (radial is 
better tolerated because ulnar is generally the 
dominant vessel) 
• Celiac trunk 
• Internal iliac artery 
 
Conversely, some vessels may not be 
amenable to ligation (i.e. leading to critical ischemia 
or stroke) and include, but are not limited to the 
following: 
Temporary Vascular Shunting 
Mark Bowyer, Christopher Gross 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
• Internal carotid artery (~15-20% incidence of 
stroke) 
• Superior mesenteric artery 
• External iliac artery 
• Common femoral artery 
• Popliteal artery 
Keep in mind that serious ischemia is much 
more likely in situations where collateral circulation 
is destroyed and other significant soft tissue injury 
exists. Lastly, regarding veins, nearly all veins can be 
ligated, including the inferior vena cava and the 
popliteal vein (which should be repaired or shunted 
when possible). 
 
Definitive Vascular Repair 
After a temporary shunt has been placed, or 
if definitive vascular repair is available at time of 
injury, the steps are similar to placing a temporary 
vascular shunt and proceed as follows: 
1. After making the appropriate incisions to gain 
adequate exposure of the vessel, identify the 
injury and obtain proximal and distal control.  
2. During definitive repair, debride the injured 
segment distally and proximally to the level of 
healthy vessel tissue. 
3. Clear target vessel of clots by passing a Fogarty 
catheter (usually 3 French) proximally and 
distally. 
4. Achieve 
regional 
heparinization 
with 
heparinized saline solution (5000 units in 100 mL 
normal saline), 50mL proximally, and 50 mL 
distally followed by reapplication of the vessel 
clamps. 
5. Prior to definitive repair, use Potts scissors to 
trim the proximal and distal ends of the 
transected artery, with beveling of vessel as 
needed to make the repair. 
6. Use the Fogarty catheter to gently dilate the vein 
graft and any small caliber arteries. Regional 
papaverine and/or local anesthetic can be applied 
to counteract any vasospasm.  
7. Definitive repair is achieved by primary repair or 
by using a reversed autologous vein graft as 
conduit 
(a 
[polytetrafluoroethylene] 
PTFE 
interposition graft remains last resort.) The 
vascular anastomosis is performed using a 
running or interrupted monofilament. Although 
the specific techniques for making a definitive 
vascular repair are described elsewhere in this 
Manual, some types of repair include: 
• Lateral arteriorraphy or venorraphy 
• Patch angioplasty 
• Resection with end-to-end anastomosis 
• Resection 
with 
interposition 
graft 
(vein, 
PTFE/Dacron, CryoVein, Artegraft, etc.) 
• Bypass graft 
• Extra-anatomic bypass 
• Stent-graft repair 
 
Mark W. Bowyer, MD, FACS, FRCS 
Uniformed Services University of the Health Sciences 
Maryland, USA 
 
Christopher Gross, MD 
University of North Carolina – Chapel Hill 
North Carolina, USA 
 
August 2024 
