Management of high-risk popliteal vascular blunt trauma: clinical experience with 62 cases

Systematic review and meta-analysis of endovascular therapy versus open surgical repair for the traumatic lower extremity arterial injury

OBJECTIVE

For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury.

METHODS

The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates.

RESULTS

A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21-0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20-0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75-1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%-27%).

CONCLUSION

Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.

Our Surgical Results in Popliteal and Infrapopliteal Artery Injuries: 21 Cases without Amputation

Objectives

Popliteal and infrapopliteal artery injuries have significant morbidity and mortality rates, especially in terms of amputation. In our study, we aimed to evaluate patients who operated due to popliteal and infrapopliteal vascular injuries in our clinic. Patients and Methods. Between 2016 and 2023; 21 patients who were operated in our clinic due to popliteal and infrapopliteal artery injuries were retrospectively evaluated.

Results

2 of the patients were female (9.5%) and 19 were male (90.5%). Age ranges were 21-78. The causes of injury were gunshot wounds in 9 patients (42.86%), blunt trauma in 7 patients (33.33%), and sharp object injuries in 5 patients (23.80%). Reversed saphenous vein interposition in 7 patients (33.33%), primary repair in 6 patients (28.57%), 6 mm polytetrafluoroethylene graft (PTFE) interposition in 3 patients (14.28%), end-to-end anastomosis in 2 patients (9.52%), saphenous-PTFE composite graft interposition in 2 patients (9.52%), and embolectomy in 1 patient (4.76%) were performed. Arterial ligation was not performed. Simultaneous orthopedic intervention was performed in 8 patients. Fasciotomy was performed in 3 patients. Venous repair was performed in 5 patients with venous injuries. Vein ligation was not performed. Mortality was observed postoperatively in 1 patient. No patient developed amputation. Foot drop developed with nerve damage in 2 patients.

Conclusion

Mortality and morbidity rates may increase in popliteal and infrapopliteal artery injuries in cases of hemodynamic disorder, simultaneous bone fracture, multivessel injury, and nerve transection. These rates can be reduced by appropriate surgical repair and ensuring hemodynamic stability.

Five-year outcomes after bypass graft versus Fogarty balloon catheter for the treatment of acute blunt popliteal artery injury

PURPOSE

To evaluate long-term clinical outcomes after revascularization by bypass graft versus Fogarty balloon catheter in acute blunt popliteal artery injury and identify risk factors contributing to amputation.

METHODS

A retrospective review was conducted in patients treated for acute blunt PAI between 2011 and 2019. Inclusion criteria were patients who underwent bypass graft and Fogarty balloon catheter. The cumulative limb salvage rate was calculated by the Kaplan-Meier test and compared with Breslow-Wilcoxon test. Cox proportional hazard model was performed to estimate the potential risk factors for amputation. Receiver operating characteristic (ROC) curve was used to determine the optimal cut-off value for the potential risk factors.

RESULTS

The overall limb salvage rate was 60.4% (29/48), including 24 patients (66.7%) in bypass graft, and 5 patients (41.7%) in Fogarty balloon catheter with mean follow-up of 5 years (range, 2-10 years). Among amputees, 15 patients (15/19, 78.9%) received primary amputation due to vascular failure or severe soft tissue damage, and 4 received secondary amputation because of chronic bone infection or neurologic deficit. Kaplan-Meier curves showed patients who received Fogarty balloon catheter had significantly higher amputation rate than those received bypass graft, with a hazard ratio of 3.801 (95% CI: 1.162-12.43, p = 0.009). In addition, Cox proportional hazard model revealed that MESS was the only independent risk factor for patients developing amputation, and the optimal cut-off value of MESS was 8.

CONCLUSION

Five-year outcome demonstrated that Fogarty balloon catheter is not a safe procedure and has significantly higher amputation rate in severe blunt PAI. MESS is the only risk factor for amputation.

Damage control of peripheral vascular trauma - Don't be afraid of axillary or popliteal fosses

Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient’s life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.

Blunt popliteal artery injury following tibiofemoral trauma: vessel-first and bone-first strategy

Purpose

Blunt popliteal artery injury (BPAI) is a potentially limb-threatening sequela of tibiofemoral (knee) dislocations and fractures. Associated amputation rates for all popliteal artery (PA) injuries range between 10 and 50%. It is unclear whether PA repair or bone stabilization should be performed first. We analyzed (long-term) clinical outcomes of BPAI patients that received initial PA repair (vessel-first, VF) versus initial external stabilization (bone-first, BF).

Methods

Retrospectively, all surgically treated BPAI patients between January 2000 and January 2019, admitted to two level 1 trauma centers were included. Clinical outcomes were determined, stratified by initial management strategy (VF and BF). Treatment strategy was determined by surgeon preference, based on associated injuries and ischemia duration. Primary outcomes (amputation and mortality) and secondary outcomes (claudication and complications) were determined.

Results

Of 27 included BPAI patients, 15 were treated according to the VF strategy (56%) and 12 according to the BF strategy (44%). Occlusion was the most frequently encountered BPAI in 18/27 patients (67%). Total delay and in-hospital delay were comparable between groups (p = 1.00 and p = 0.82). Revascularization was most frequently performed by PA bypass (59%). All patients had primary limb salvage during admission (100%). One secondary amputation due to knee pain was performed in the BF group (4%). During a median clinical follow-up period of 2.7 years, three PA re-interventions were performed, two in the BF group and one in the VF group. None suffered from (intermittent) claudication.

Conclusion

Blunt popliteal artery injury (BPAI) is a rare surgical emergency. Long-term outcomes of early revascularization for BPAI appear to be good, independent of initial management strategy. The BF strategy may be preferred in case of severe orthopedic injury, if allowed by total ischemia duration.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01632-0.

The Utility of Therapeutic Anticoagulation in the Perioperative Period in Patients Presenting in Emergency Surgical Department With Extremity Vascular Injuries

Extremity vascular trauma is a challenging surgical emergency in both civilian population and combat environment. It requires vigilant diagnosis and prompt treatment to minimize limb loss and mortality. A multidisciplinary team approach is required to deal with shock states, concomitant abdominal injuries, head injuries, and fractures with significant tissue loss and psychological stress.

Anticoagulation is frequently used during traumatic vascular repair to avoid repair site thrombosis, postoperative deep venous thrombosis, and pulmonary embolism (PE). In this review article, we are going to search about how frequent is the use of anticoagulation in terms of limb salvage rates, and mortality rates or side effects of anticoagulation in terms of risk of bleeding episodes, and the need for future prospective studies.

Extremity vascular trauma is managed by a variety of methods including open repairs, endovascular repairs, and nonoperative management. Most of the literature demonstrates the use of systemic or regional anticoagulation in the management of vascular injuries with the improvement in limb salvage rates and reduced morbidities but confounding factors lead to variable results. Some studies show an increased risk of bleeding in trauma patients with the use of anticoagulants in trauma settings without any significant effect on repair site thrombosis. More comprehensive studies and randomized controlled trials are needed to confirm the importance of perioperative anticoagulation while avoiding the confounding factors in terms of injury severity scores, ischemia time, demographics of patients, modes of injury, comorbidities, grades of shock, concomitant injuries that need anticoagulation like venous injuries or intracranial injuries that are contraindications to the use of anticoagulation, type of anticoagulation and expertise available as well as the experience level of the operating surgeon. Literature also reveals the use of new oral anticoagulants (e.g., dabigatran) to be associated with lesser bleeding episodes when compared to warfarin, so in future, we can check the feasibility of these agents to reduce the bleeding episodes and at the same time improve the limb salvage rates.

Comparison of traditional vascular reconstruction with covered stent in the treatment of subclavian artery injury

PURPOSE

To explore the significance of traditional vascular reconstruction and covered stent for limb salvage after subclavian artery injury.

METHODS

Patients with subclavian artery injury admitted to Beijing Jishuitan Hospital from January 2010 to December 2018 were retrospectively analyzed. All the injuries have been confirmed by intraoperative exploration, computed tomography angiography or digital subtraction angiography. Complete or partial amputation injuries were excluded. Mild artery defect or partial intimal damage was treated by interventional implantation, while other patients received open surgeries, including direct suture of small defect less than 2 cm and transplantation with autologous vein or artificial blood when the defect was more than 2 cm. Patients were divided into open surgery group and stent implantation group based on the treatment they received. Patients were followed up at 2 weeks (first stage) and 6 months (second stage) after operation to investigate limb salvage. Student's t-test was used to compare the general data between two groups and Chi-square test to analyze the rate of limb salvage.

RESULTS

Altogether 50 cases of subclavian artery injury were treated, including 36 cases of open surgery and 14 cases of stent implantation. Combination of nerve injury was observed in 27 cases (75.0%) in open surgery group and 12 cases (85.7%) in stent implantation group. Amputation developed in 3 cases with open surgery and 1 case with stent implantation. Consequently the rate of successful limb salvage was respectively 91.7% (33/36) and 92.9% (13/14), revealing no significant difference (p > 0.05).

CONCLUSION

Rapid reconstruction of blood circulation is crucial following subclavian artery injury, no matter what kinds of treatment strategies have been adopted. Interventional stent implantation can achieve a good effect for limb salvage.

Relationship Between the Middle Genicular Artery and the Posterior Structures of the Knee: A Cadaveric Study

Background:

The middle genicular artery (MGA) is responsible for the blood supply to the cruciate ligaments and synovial tissue. Traumatic sports injuries and surgical procedures (open and arthroscopic) can cause vascular damage. Little attention has been devoted to establish safe parameters for the MGA.

Purpose:

To investigate the anatomy of the MGA and its relation to the posterior structures of the knees, mainly the posterior capsule and femoral condyles, and to establish safe parameters to avoid harming the MGA.

Study Design:

Descriptive laboratory study.

Methods:

Dissection of the MGA was performed in 16 fresh, unpaired adult human cadaveric knees with no macroscopic degenerative or traumatic changes and no previous surgeries. The specimens were meticulously evaluated with emphasis on preservation of the MGA. The distances from the MGA to the medial and lateral femoral condyles were measured. The Mann-Whitney test was used for statistical analysis.

Results:

In all specimens, the MGA emerged from the anterior aspect of the popliteal artery, distal to the superior genicular arteries, and had a short distal trajectory toward the posterior capsule where it entered proximal to the oblique popliteal ligament. The artery lay in the midportion between the condyles. The distance between the posterior aspect of the tibia and the point of entry of the MGA into the posterior joint capsule was 23.8 ± 7.3 mm (range, 14.72-35.68 mm). There was no correlation between an individual’s height and the distance of the entrance point of the MGA into the posterior joint capsule to the posterior superior corner of the tibia.

Conclusion:

The middle genicular artery lies in the midportion between the medial and lateral femoral condyles.

Clinical Relevance:

This knowledge is important for the preservation of the blood supply during posterior knee surgical procedures and to settle a secure distance between the posterior aspect of the tibia and the MGA input. This could decrease and prevent iatrogenic vascular injury risk to the MGA.

Angiographic Findings of Patients with Blunt or Penetrating Extremity Injuries: Focus on Indications and Contraindications

OBJECTIVE

To determine the etiology, signs and symptoms, angiography indications and angiography findings in patients with limb penetrating injuries suspected to have arterial injury.

METHODS

This was a cross-sectional study being performed in Imam Reza Hospital affiliated with Mashhad University of Medical Sciences, Iran between September 2011 and March 2013. We included those patients with extremity blunt and penetrating injuries who were referred for angiography according to standard indications including abnormal distal pulses, complex fracture or dislocation, vascular proximity, fixed hematoma, distal nerve deficit, arterial bruit, thrill and massive soft tissue injuries.

RESULTS

During the study period, 148 patients (15 women and 133 men) with a mean age of 31±14.9 (11-82) years were evaluated. The most common cause of injury was motor vehicle accident (127 patients 85%). Angiography indications included abnormal distal pulse examination (124, 83.8%), complex fracture or dislocation (7, 4.7%), near arterial trauma (4, 2.7%), fixed hematoma (3, 2%), nerve damage (1, 0.7%). The angiography was found to be normal in 49 (33.1%) patients. In patients with abnormal angiography findings, 60 (60.6%) had cutoff with distal runoff, 21 (21.2%) had cutoff without runoff, 14 (14.1%) had arterial spasm. Other uncommon findings included active bleeding in 2 patients (2%), pseudoaneurysm in 1 (0.7%) and arteriovenous fistula in 1 (0.7%). Out of 4 patients (2.7%) with vascular proximity, only 1 (0.7%) had abnormal angiography.

CONCLUSION

The most  important  factor in prediction  of result of angiography was distal arterial pulses examination. But these data confirm the low incidence of vascular injury in asymptomatic patients with proximity. So the use of angiography when proximity is the sole indication in an asymptomatic patient with a normal vascular examination should be questioned.

The increasing rate of secondary amputation in popliteal arterial injury associated with multi-organ injuries and hypotension

OBEJECTIVES

To study the role of hypotension and associated injuries in increasing the chances of secondary amputation in lower limb with vascular injuries.

METHODS

This study was conducted in the Department of cardiovascular and thoracic surgery( CVTS ), Sher-i- Kashmir Institute of Medical Sciences, ( SKIMS ) Srinagar Kashmir India and comprised all patients sustaining vascular injury due to different causes like road traffic accident, fire arm and blast injuries or falling from height during the last five years. Following admission to our Department, the patients were divided into two groups. The first group with associated injuries was hemodynamically unstable during vascular repair or in post-operative period and the second group had no associated injuries and was hemodynamically stable during vascular repair and in post-operative period.

RESULTS

During the past five years, 95 patients were operated for lower limb vascular injury in our department. Of these 25 patients had associated multi-organ injuries and were hemodynamically unstable and needed intensive care monitoring after surgical intervention. Additionally, 10 patients died due to associated multiple organ injuries, 10 needed amputation due to recurrent thrombosis of their anastomosis, and in five patients limb salvage was achieved. Seventy patients who had isolated limb vascular injuries with no associated injuries or hypotension were hemodynamically stable and were kept in low dependency unit after vascular repair. Only Four patients from this group needed amputation for thrombosis of the anastomosis.

CONCLUSION

[corrected] Patients with shock and related injuries face significant rate of amputation. These patients whether with multi-organ injuries or isolated vascular injuries need judicious treatment for hypovolumic shock during surgical intervention and in post-operative period.