Asian Cardiovasc Thorac Ann 1999;7:247-249
© 1999 Asia Publishing EXchange Pte Ltd
Delayed Repair of Popliteal Artery Following Blunt Injury
Abha Chandra, MCh,
Dronamraju Dilip, FRCS,
Srinivas Kola, MS,
Sreeram Eswara Vara Prasada Rao, MD,1,
Pramod Pal, DM,2
Department of Cardiovascular and Thoracic Surgery
1 Department of Radiology
2 Department of Neurology
Sri Venkateswara Institute of Medical Sciences
Tirupati, Andhra Pradesh, India
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For reprint information contact: Abha Chandra, MCh Tel: 91 8574 51222 Ext. 2378/2289 Fax: 91 8574 25211 email: drabha{at}hotmail.com Department of Cardiovascular and Thoracic Surgery, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh 517507, India.
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Abstract
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Popliteal artery injury resulting from blunt trauma carries a risk of limb loss. Severe ischemia of prolonged duration is a strong determinant of poor outcome. We report a case of popliteal artery injury in an 18-year-old male who underwent successful repair after a delay of 20 hours.
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Introduction
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The diagnosis and repair of vascular injuries of the lower extremities are difficult and survival is occasionally threatened by the time lapsed after sustaining the injury. Amputation or retention of a painful functionless limb are the most serious untoward results of severe injury or inadequate treatment. An increase in limb survival has been achieved by improvement in transportation, antibiotics, blood replacement, diagnostic facilities, and operative techniques. However, in remote areas of a country like India, much time may be lost before the patient reaches expert hands. We describe the case of a patient with popliteal artery trauma who underwent arterial reconstruction 20 hours after the injury.
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Case Report
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An 18-year-old male sustained a direct blunt injury in a traffic accident and reached our hospital after a time lapse of 20 hours. He presented with bilateral nasal bleeding, pain, and inability to move the left lower limb, with no loss of consciousness or vomiting. He was hemodynamically stable. The left lower limb was found to have bruises, abrasions, and a large hematoma over the left popliteal region, which extended to the middle of the thigh. His leg was cold, clammy, swollen, and pale with loss of sensation and restriction of movement. Peripheral pulses (popliteal, posterior tibial, and dorsalis pedis) were absent. There was no bone injury or dislocation of the knee joint. Intravenous heparin 5000 IU was given immediately along with antibiotics.
Because of the time delay, no vascular study was undertaken. The patient was explored under general anesthesia via the conventional medial approach. A huge hematoma was found in the region of the popliteal artery, which had dissected into the muscle planes in the thigh and lower leg. On evacuating the hematoma, the popliteal vein was found to be completely transected and the popliteal artery was exposed to reveal contusion and thrombosis 3 cm above the trifurcation. The arterial injury was transmural and involved a length of approximately 4 cm. It was decided to resect the abnormal segment of the artery and repair it with interposition of a reversed saphenous vein graft harvested from the right thigh. Repair was performed under systemic heparinization (1 mg•kg–1) and general anesthesia. An end-to-end anastomosis was carried out with 6/0 polypropylene sutures, which resulted in good distal flow. The popliteal vein was repaired by direct end-to-end anastomosis with 7/0 polypropylene sutures. This was accompanied by a 4-compartment fasciotomy.
Postoperatively, the patient was treated with antibiotics, systemic heparinization, and nitroglycerin infusion. Distal perfusion improved one hour after the repair; the foot became warm and the dorsalis pedis pulse was palpable. After 12 hours of sustained good perfusion, the nitroglycerine infusion was discontinued. However, within one hour, the patient developed graft thrombosis that was detected clinically. The popliteal artery region was reexplored under sedation and local anesthesia and the thrombus was evacuated with a Fogarty catheter. Good distal flow returned and intravenous nitroglycerin infusion was continued for 72 hours along with systemic heparinization. The patient's limb recovered almost completely except for foot drop and a trophic ulcer in the region of the heel, which healed. The fasciotomy wounds were skin-grafted after 10 days and the patient was discharged a week later; he was able to walk. At a follow-up study, a limited neurological examination showed left foot drop and impaired sensation over the planter and dorsal aspect of the left foot. A nerve-conduction study revealed damage to the common peroneal and posterior tibial nerves. A Doppler study demonstrated biphasic flow with minimum occlusion (Figure 1
). Angiography revealed minimal anastomotic stenosis of the proximal end of popliteal saphenous graft (Figure 2).
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Figure 2. Digital subtraction angiography of the left popliteal artery showing the reversed saphenous vein graft with anastomotic stenosis of the proximal end of the popliteal-saphenous anastomosis.
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Discussion
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Popliteal artery injuries constitute 5% to10% of civilian wounds, of which 25% to 50% are caused by blunt trauma.1,2 Popliteal artery trauma results in amputation more often than any other arterial injury, with 22% to 30% limb loss.2,3 Adjacent tissue damage commonly accompanies vascular injuries, especially with blunt trauma. The functional severity of a popliteal artery injury is a direct consequence of ischemia, increased by associated traumatic attrition. Failure to recognize and effectively treat these associated injuries can lead to complications that jeopardize vascular repair and increase mortality.2 Delayed treatment leading to distal vessel wall thrombosis and muscle necrosis is a major deterrent to limb salvage after popliteal artery injury.2,4 The anatomy of the popliteal artery predisposes to ischemia after acute traumatic occlusion. The collateral arterial network around the knee is abundant but frail. No large vessels run parallel to the popliteal artery and some of the geniculate collaterals may be involved in the segmental occlusion. These delicate vessels maintain some distal perfusion but they are easily obliterated by swelling of the surrounding soft tissue. This partly explains why fewer limbs are salvaged after diffuse injury than after a sharp penetrating injury. The paucity of resilient high-flow arterial channels around the knee increases the risk of distal small-vessel thrombosis.
An absolute time limit for limb salvage is difficult to define but urgent operation is indicated in patients with popliteal artery injuries with signs of distal ischemia, as in our patient. Heparin should be given immediately to prevent distal small-vessel thrombosis and restore arterial and venous flow. Four-compartment fasciotomies are required to restore and preserve adequate distal flow.5 Pretre and colleagues6 noted deleterious effects of delayed revascularization resulting in peripheral neurologic deficit found in 50% of popliteal artery injuries in non-amputated limbs. The conventional medial approach gives good exposure for precise repair. Arterial reconstruction can be carried out with a reverse saphenous vein graft that is easily available and avoids inadequate resection or anastomotic tension. It is important to obtain patency of the infrapopliteal arteries. The vein conduit should be obtained from the contralateral limb, especially in the setting of concomitant arterial and venous injury, to lessen the risk of chronic venous insufficiency. For the same reason, reconstruction of the injured vein is indicated to enhance the patency of an arterial repair. We advise passing a no. 3 Fogarty catheter distally to retrieve any emboli prior to arterial repair. A four-compartment fasciotomy should be performed in patients with prolonged ischemia. Early referral to a vascular surgeon is essential when popliteal artery injury is suspected, to avoid potential limb loss. We recommend that even if the duration of injury is prolonged, arterial reconstruction should be attempted.
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References
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Kelly G, Eiseman B. Civilian vascular injuries. J Trauma 1975;15:507–14.[Medline]
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Faris IB, Raptis S, Fitridge R. Arterial injury in the lower limb from blunt trauma. Aust NZ J Surg 1997;67:25–30.[Medline]
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McNeil JW, McGee GS. Popliteal artery injury in a lumberjack. Southern Med J 1994;87:958–60.[Medline]
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Downs AR, MacDonald P. Popliteal artery injuries: civilian experience with sixty-three patients during a twenty-four year period (1960 through 1984). J Vasc Surg 1986;4:55–62.[Medline]
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Synder WH III, Watkins WL, Whiddon LL, Bridges RA, Thal ER. Civilian popliteal artery trauma: an eleven year experience with 83 injuries. Surgery 1979;85:101.[Medline]
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Pretre R, Bruschweiler I, Rossier J, Chilcott M, Bednarkiewicz M, Kursteiner K, et al. Lower limb trauma with injury to the popliteal vessels. J Trauma 1996;40:595–601.[Medline]
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Abstract
Introduction
