Popliteal Artery Trauma - SUNY Downstate Medical Center · Post-Op • EBL 1500 cc • Ischemia Time – 6 Hrs • Transfused 8 units pRBC, 4 FFP, 1 unit platlets, 1 cryo • VAC

Blunt Popliteal Artery Trauma David Radvinsky MD August 20, 2015

www.downstatesurgery.org

Case Presentation • 41 yo male s/p motorcyclist struck by motor vehicle (8PM)

• + Helmeted • (+) LOC • On backboard with left lower extremity in splint • C-collar in place

• Primary Survey

• Airway intact

• Bilateral Breath sounds – 99% on 2L NC

• Circulation - BP 155/95 HR 86


anterior tibial artery posterior tibial

dorsalis pedis artery

2+ 2+

2+

2+ 2+

Absent

Absent

• No evidence of expanding hematoma

• Delayed capillary refill • Cool compared to right foot


Presenter

Presentation Notes

Anterior tibial artery

Secondary Survey • HEENT: no scalp lesions, PERRLA, EOMI, no facial tenderness,

no blood in the ear canal or nasal passages. • C-spine: no midline tenderness • Thorax: +5x5cm area of road rash over right shoulder (3rd

degree). no chest wall tenderness, with equal chest rise. RRR • Abdomen: soft, obese, NT/ND • Pelvis: stable, tenderness over left posterior pelvis/hip • T/L-spine: no midline tenderness • Extremities: (as described)

• Motor (LLE) – limited by pain • Sensory (LLE) – common peroneal nerve distribution


Sensory & Motor

• Superficial Peroneal • Foot Eversion

• Deep Peroneal • Foot Dorsiflexion • Toe Extension


Presenter

Presentation Notes

FIX

Re-Evaluation & Adjuncts • Vitals: BP: 90/48 HR 98 SpO2: 96% on 2L NC • Transfused 1 unit pRBC

• PMHx: denied • PSHX: denied • Allergies: NKDA • Meds: None

• CXR: negative • PXR: (as shown) • FAST: negative

• Tib/Fib placed into traction • Improved capillary refill • Pulse exam unchanged • NO expanding hematoma


Imaging • CT Head: negative • CT c-spine: negative • CT chest: negative • CT abd/pel: acute displaced left ASIS fracture with

adjacent intramuscular hematoma • CTA LLE: abrupt cutoff of contrast in the popliteal artery 2cm

distal to Hunter’s canal

• Knee Dislocation?


Presenter

Presentation Notes

ADD LABS

CTA (9:15) www.downstatesurgery.org





















To OR • EX- FIX FIRST!?!

• (10 PM)

• Left Lower extremity angiogram (11:30 PM)


• Superficial Femoral Artery to Below Knee Popliteal Artery Bypass (12 AM) • PTFE graft (25 cm) • 4 compartment fasciotomy

PTFE graft


• Completion Angiography (4 AM)


Post-Op • EBL 1500 cc • Ischemia Time – 6 Hrs • Transfused 8 units pRBC, 4 FFP, 1 unit platlets, 1 cryo • VAC closure

• POD#0 - DP/PT pulse present

• 4 units pRBC, 2 units FFP • Hct 24 -> 21 (transfused additional 2 units pRBC) -> 27 • CK peaked at 34K -> bicarb drip started

• POD#2 – Hct -> 20.7 (transfused additional 1 units pRBC) -> 20.7 • POD#3 – Hct -> 19.5 (transfused additional 2 units pRBC) -> 24.8

• CTA – graft patent; iliac wing hematoma slightly larger; no collections • POD#4 – Heparin gtt started once HCT stabilized

• CK trending down -> 9K


Post-Op • POD#7 – fever to 102 -> pan-cultured -> vanco/zosyn

• Urine – Enterococcus Diarrhea – Flagyl – c.diff negative x2

• CTA LLE – no collections, patent graft • POD#9 – OR for washout

• Cultures – stenotrophomonas and Enterobacter -> Levaquin • POD#11 – OR for washout – purulence from lateral fasciotomy site • POD#14 – Guillotine BKA

• Hardware removed -> Knee immobilizer • Myonecrosis

• POD#18 – MRI – posterior knee hematoma/collection • PCL, ACL, MCL, LCL, posterolateral corner and MPFL are all torn

• POD#20 – OR for evacuation of hematoma in posterior knee and debridement of guillotine stump

• Cultures – Pseudomonas -> Gentamicin • POD#25 – Graft excision and AKA


Questions?


Epidemiology • Popliteal Vessel Injuries rare – 0.2% of all traumas • High-energy mechanisms

• Pedestrian Struck • Motorcycle Accidents • Automobile Accidents

• Mechanism of blunt injury to the popliteal artery • Anterior dislocation • Posterior dislocation • Tibial plateau fracture

• Associated fractures (80% to 100%) • Associated venous injury (15% and 35%) – popliteal vein • Associated nerve injury (10%) – common peroneal nerve


Anatomy • Continuation of superficial femoral art. • Hunter’s canal • Popliteal fossa • Lower border of popliteus muscle • Branches to anterior tibial artery and

tibioperoneal trunk


Presenter

Presentation Notes

The popliteal artery is a deeply placed continuation of the femoral artery after it passes through the adductor hiatus, or opening in the distal portion of the adductor magnus muscle. It courses through the popliteal fossa and ends at the lower border of the popliteus muscle, where it branches into the anterior and posterior tibial arteries.

Diagnosis • Physical Exam

• Hard Signs • Absent distal pulse • Palpable thrill or audible thrill • Actively expanding hematoma • Active pulsatile bleeding

• Soft Signs • Diminished distal pulse • History of significant hemorrhage • Neurologic deficit • Proximity of wound to named vessel

• An abnormal pedal pulse identified popliteal artery injuries with a sensitivity of 85% and specificity of 93%

• Ankle-to-brachial index (ABI) - less than 0.90 predicted the injury with 87% sensitivity and 97% specificity


• Imaging • Plain radiographs to evaluate for fractures and/or dislocations • CTA to evaluate vessel integrity

• Transection • Dissection • Thrombosis

• ANGIOGRAPHY


Management • Limb salvage vs. primary amputation

• Mangled Extremity Severity Score • Gustilo III - C skeletal injuries • Transected tibial or sciatic nerve • Shock and life-threatening associated injuries • Below-knee arterial injury • Extensive soft tissue loss • Crush injury • Multiple fractures • Elderly with medical comorbidity • Severe contamination • Patient preference


Management • Limb salvage vs. primary amputation

• Mangled Extremity Severity Score • Gustilo III - C skeletal injuries • Transected tibial or sciatic nerve • Shock and life-threatening associated injuries • Below-knee arterial injury • Extensive soft tissue loss • Crush injury • Multiple fractures • Elderly with medical comorbidity • Severe contamination • Patient preference


Mangled Extremity Severity Score • Successful limb salvage vs future amputation • 1990 – Limb salvage versus amputation. Preliminary results

of the Mangled Extremity Severity Score – Johansen et al. • MESS ≥7 had a 100% predictable value for amputation

• Lower Extremity Assessment Project (LEAP) • NIH funded, multicenter, prospective observational study

• No support of any examined lower extremity injury severity index • Indices lack sensitivity, but were in some cases specific. • Not useful in identifying patients that would require amputation • Useful in predicting limbs which could be successfully salvaged


Presenter

Presentation Notes

A number of scoring systems have been developed to objectify this difficult decision that is so often clouded by subjective and wishful thinking, often at the patients expense. Although none have been found to be prospectively useful in predicting amputation or the degree of functional impairment, they do focus attention on those factors which most closely correlate with outcome, and which must be a part of the treatment decision.

Limb Salvage vs. Amputation • Mangled Extremity Severity Score


Approach www.downstatesurgery.org

Presenter

Presentation Notes

Natural dissection planes exist in exposing the above-knee popliteal artery (ie, popliteal space) with the exception of the need to divide the fibers of the adductor magnus that envelopes the distal superficial femoral artery (Hunter’s canal) To completely expose the popliteal space, the medial attachments of the sartorius, semitendinosis, semimembrinosis, and gracilis to the medial condyle of the tibia can be divided. Distal exposure by division of the gastrocnemius and soleus from the tibia allows dissection to the anterior tibial origin and the tibial-peroneal trunk. Extraanatomical bypass can also be performed without the need to expose the injured segment


Revascularization (Shunting)


Presenter

Presentation Notes

Temporary intraluminal shunting may also be of value for some injuries when the limb is severely ischemic and revascularization is delayed because of fracture fixation, complex soft tissue injury, or associated life–threatening injuries. This technique allows early restoration of limb perfusion, which lessens the likelihood of ischemic damage and distal thrombosis. Débridement, fasciotomy, fracture fixation, neurorrhaphy, or vein repair can then be performed in a deliberate and unhurried fashion, before arterial reconstruction. Shunt patency varied based on location, being 86% when proximal (above the elbow or knee) and 12% when distal (below the elbow or knee). Most shunts were in place for less than 2 hours, but patency was noted in proximally placed shunts of up to 18 hours without systemic heparin. Other investigators have documented shunt patency for more than 3 hours without systemic heparinization.

Fasciotomy www.downstatesurgery.org

Presenter

Presentation Notes

single longitudinal incision placed halfway down leg 2 cm anterior to fibular shaft,� or alternatively placed halfway between the tibial crest and the fibula; 2 cm posterior� to posterior medial palpable edge of the tibia; he need for fasciotomy following successful repair of the popliteal artery is an area of continuing controversy. Since the popliteal artery is in essence an end artery, profound muscle ischemia is possible with only brief periods (>4–6 hr) of warm ischemia. Our approach is to selectively perform fasciotomy depending on the length of warm ischemia, concomitant popliteal venous injury, and associated orthopedic and soft tissue injury. If fasciotomy is required, a complete four-compartment fasciotomy through a two-incision approach is recommended.

Orthopedic • Orthopedic repair follows vascular repair

• Temporary fixation • Definitive repair delayed


Options for Definitive repair • Lateral arteriorrhaphy or venorrhaphy • Patch angioplasty • Resection with end-to-end anastomosis • Resection with interposition graft • Bypass graft • Extraanatomic bypass


Presenter

Presentation Notes

The popliteal artery is usually repaired using the traditional medial approach. This approach permits extension of the incision proximally or distally, depending on the extent of the injury. The alternative posterior approach to the popliteal artery does not provide adequate exposure for complex injuries and is not recommended for trauma patients. To help reduce blood loss, a sterile pneumatic tourniquet at the thigh may be used to rapidly establish proximal control in the actively bleeding extremity or during the dissection and popliteal repair. The opposite leg should be prepared in all instances in case the saphenous vein is needed for a bypass. Vein should not be harvested from the injured leg. If both legs are injured, cephalic or basilic vein can be used for a conduit. Synthetic grafts have been used successfully for traumatic injuries in multiple anatomic sites; however, for politeal artery repairs, autogenous vein should be used for arterial reconstruction. Primary repair of the popliteal artery is advised whenever possible, even if it means sacrificing selected geniculate collateral vessels to mobilize sufficient artery to fashion a tension-free anastomosis. These small collateral vessels are not likely to be important in a nonatherosclerotic, acutely traumatized artery. Interposition vein grafts are necessary to bridge larger defects

Autogenous vs. Graft • 1 year patency rates in infrapopliteal position

• 70-80% with autogenous vein • 30-50% for prosthetic grafts

• Autogenous – saphenous vein (ipsilateral or contralateral) • Prosthetic options

• Dacron • PTFE • Antiplatelets or anticoagulants

• Adjunctive vein cuff at the distal anastomosis of graft improves patency


Presenter

Presentation Notes

Saphenous vein should be harvested from the opposite leg, with the proximal vein being preferred. The vein is reversed and the anastomoses are completed with 5–0 or 6–0 monofilament suture. All arterial repairs should undergo an on-table completion angiogram or duplex scan, even with a palpable distal pulse. Technical problems, anastomotic narrowing, intimal flaps, and distal thrombus should be immediately corrected.

Role for Endovascular? • Becoming more popular with newer techniques • Case reports in the literature

• Thrombosis • Pseudoaneurysm • AV Fistula • Dissection


Venous injury • Up to 1/3 of patients with arterial injuries have venous injury • Vein injury should be repaired

• Leg edema • Compartmental hypertension • Occlusion of arterial repair • Higher amputation rates • Allow for collateralization • Risk of acute thrombosis at the site of repair

• pulmonary embolism


Presenter

Presentation Notes

One third of the patients with these arterial injuries have an associated popliteal vein injury. If venous continuity is not restored, leg edema and compartmental hypertension increase, deleterious effects that can lead to occlusion of the arterial repair. Historically, ligated venous injuries were associated with higher amputation rates; therefore, whenever possible, the venous injury should be repaired. Repair can be achieved by lateral repair, primary repair, or a venous interposition graft. The goal of venous repair is to maintain early patency to augment venous return in the early postoperative period while collateral venous channels develop. Thrombosis of the venous repair can subsequently occur but is usually asymptomatic if collateral channels have developed. The risk of developing acute thrombosis at the site of repair with subsequent pulmonary embolism does exist. This risk can be minimized by dextran or heparin sodium in the early postoperative period.

Soft Tissue • Soft tissue debridement at initial operation

• Cover vascular repair with viable muscle • Decreases risk of infection and limb sepsis

• Monitor for Infection • Devitalized tissue • Hematoma • Fasciotomy sites

• Wound sepsis -> return to the OR • Open contaminated wounds -> broad spectrum abx • VAC assisted closure to promote healing of fasciotomy sites • Fasciotomy that cannot be closed primarily

• Skin graft once the muscle swelling has subsided


Nerve Injury • Common Peroneal Nerve – 10%

• Loss of function of foot - dorsiflexion • High-stepping walk (steppage gait or footdrop gait).

• Should undergo surgical exploration at emergency • Recover spontaneously

• Full recovery of partial peroneal palsies (76% to 87%) • Full recovery of complete lesions (20% to 35%)

• Repair indicated for lack of recovery after 2-5 months • Direct Repair – 84%

• Grafting (sural nerve) • <6 cm – 75% • >6cm – 16-38%

• Tendon transfer • Restoration of dorsiflexion


Post-Op • Secondary Amputation

• Failure of the arterial repair • Limb sepsis in the presence of a patent artery • Extensive muscle necrosis and nerve injury with a patent repair

• Patient’s functional status • Persistence of nerve deficit • Ankle–foot orthosis • Remedial operations to correct foot drop deformity

• REHAB


Presenter

Presentation Notes

These factors have been applied over the course of the last two decades in several scoring systems to predict primary amputation. Although the scoring systems have validated these factors to be associated with a worse prognosis for limb salvage, none have adequate prospective reliability to permit a definitive decision for amputation to be made solely based on a score alone.

• Meta-analysis • 45 studies – lower extremity vascular trauma • Significant prognostic factors

• associated major soft tissue injury • compartment syndrome • multiple arterial injuries • duration of ischemia exceeding 6 h • associated fracture • Blunt mechanism of injury • age over 55 years • Male sex


Presenter

Presentation Notes

Another major consideration in this decision is whether the injury is in the upper or lower extremity, as the former is less likely to require amputation, being more tolerant of deficits in protective sensation, motor function, weight-bearing concerns, and length discrepancy, and prostheses tend to be less satisfactory. This decision must be a matter of clinical judgement based on each individual case, and it must always involve a consensus of the entire health care team, including the trauma, orthopedic, vascular and plastic surgeons, rehabilitation specialist, psychologist, nursing, and most importantly the patient and family. The sophistication of limb prostheses, prompt return to work, short hospitalizations and lower costs and morbidity following early amputation are often preferable to salvage efforts which may take months or years and still fail. The ultimate goal is to return the patient to a comfortable, self-sufficient and productive life as quickly as possible.

Post-Op www.downstatesurgery.org

Presenter

Presentation Notes

Postoperative arterial thrombosis occurs in as many as 10% of cases. Any diminution in pulse or Doppler pressure should alert the surgeon to the potential for occlusion. Color-flow duplex scan is essential in confirming the diagnosis of graft thrombosis and eliminates the need for contrast angiography. Patients in whom postoperative arterial bypass graft occlusion occurs should be returned to the operating room for exploration. In perhaps 50% of patients, distal small vessel thrombosis is a contributing factor. Fogarty catheter thrombectomy of infrapopliteal vessels, as well as irrigation with heparinized saline through the distal popliteal artery, might salvage the repair. On occasion, direct instillation in the operating room of thrombolytics into the distal circulation can lyse persistent thrombus and improve distal runoff. However, catheter-directed thrombolytic therapy is contraindicated as a result of the potential systemic lytic effects in patients with other associated injuries. Factors associated with a significantly higher incidence of limb loss included the presence of severe soft tissue injury, clinical evidence of preoperative ischemia, use of bypass grafts for arterial repair, absence of systemic anticoagulation during operation, absence of a pedal pulse within 24 hours of operation, and development of deep soft tissue infection.

Summary

• Gustilo III - C skeletal injuries • Old age/severe co-morbidity • Sciatic or tibial nerve injury • Destructive soft tissue injury • Significant wound contamination • Multiple/severely comminuted fx • Elderly with medical comorbidity • Shock and life-threatening

associated injuries • Prolonged ischemia (6 hr) • Muscle Necrosis • Failed revascularization • Limb sepsis

• Limb Salvage vs. Primary Amputation? • OR – on table arteriogram • Arterial Shunt • 4 compartment fasciotomy • External Skeletal fixation • Definitive vascular repair • Soft tissue Debridement/Nerve

• Definitive Orthopedic repair • Close fasciotomy vs. skin graft • Nerve Repair vs. tendon transfer • Limb Salvage vs. Secondary

Amputation?


Presenter

Presentation Notes

Gustilo III - C skeletal injuries Transected tibial or sciatic nerve Below-knee arterial injury Extensive soft tissue loss Crush injury Multiple fractures Severe contamination Patient preference Immediately posterior to the tibia by opening the fascial compartment and retracting the gastrocnemius and soleus muscles posteriorly and the adductor muscles anteriorly. The popliteal artery is identified medial to the posterior tibial nerve and the popliteal vein.

References • Fischer's Mastery of Surgery, 6e Edited by Josef E. Fischer, Daniel B. Jones, Frank B. Pomposelli and Gilbert R.

Upchurch. December 2011 • Rutherford's Vascular Surgery References, 8e 8th Edition by Jack L. Cronenwett MD, K. Wayne Johnston MD

FRCSC. May 5, 2014. • Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the

Surgery of Trauma practice management guideline. Fox N, Rajani RR, Bokhari F, Chiu WC, Kerwin A, Seamon MJ, Skarupa D, Frykberg E. J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4):S315-20.

• Limb salvage and outcomes among patients with traumatic popliteal vascular injury: an analysis of the National Trauma Data Bank. Mullenix PS, Steele SR, Andersen CA, Starnes BW, Salim A, Martin MJ. - J. Vasc. Surg. - July 1, 2006; 44 (1); 94-100.

• Lower Extremity Assessment Project (LEAP) – The Best Available Evidence on Limb-Threatening Lower Extremity Trauma. Thomas F. Higgins MD, Joshua B. Klatt MD and Timothy C. Beals MD Orthopedic Clinics of North America, The, 2010-04-01, Volume 41, Issue 2, Pages 233-239.

• Salvage versus amputation: Utility of mangled extremity severity score in severely injured lower limbs. Kumar MK, Badole C, Patond K. - Indian J Orthop - July 1, 2007; 41 (3); 183-7.

• Characteristics and clinical outcome in patients after popliteal artery injury. Nikolaus W. Lang MD, Julian B. Joestl MD and Patrick Platzer MD, PhD. Journal of Vascular Surgery, 2015-06-01, Volume 61, Issue 6, Pages 1495-1500, Society for Vascular Surgery

• Outcome Predictors of Limb Salvage in Traumatic Popliteal Artery Injury. Anahita Dua, Sapan S. Desai, Jaecel O. Shah, Robert E. Lasky, Kristofer M. Charlton-Ouw, Ali Azizzadeh, Anthony L. Estrera, Hazim J. Safi and Sheila M. Coogan. Annals of Vascular Surgery, 2014-01-01, Volume 28, Issue 1, Pages 108-114

• Factors Associated with Amputation Following Popliteal Vascular Injuries. Jessica Keeley, Matthew Koopmann, Huan Yan, Christian DeVirgilio, Brant Putnam, David Pluradand Denis Kim. Annals of Vascular Surgery, 2015-07-01, Volume 29, Issue 5, Pages 881-881


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Documents

Popliteal Artery Trauma - SUNY Downstate Medical Center · Post-Op • EBL 1500 cc • Ischemia Time – 6 Hrs • Transfused 8 units pRBC, 4 FFP, 1 unit platlets, 1 cryo • VAC