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A Current Approaches to Popliteal Artery Repair

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A Current Approaches to Popliteal Artery Repair a Current approaches to popliteal artery repair JOHN T. MILES, MD, FRCS[C]; ALBERTO G. DE LA ROCHA, MD, FRCS(C]; RONALD J. BAIRD, MD, FRCS[C] Trauma to the popliteal artery is In this paper we review the patho- who did not undergo amputation subse- potentially dangerous, and limb loss genesis of injury and management, and quently had contracture deformities and may result, especially with delayed describe an illustrative case of popliteal persistent paresthesias in the foot. Pop- diagnosis. Three anatomic factors artery injury. liteal artery injuries in civilians there- contribute to the seriousness of the fore appear to be as dangerous as those outcome: proximity of the artery to Background incurred by the military in combat. bone, superficial position of the artery The relative danger of popliteal vas- and consequent lack of protection, DeBakey and Simeone' found that cular injuries must be stressed. While and frequent associated injury to 49% of all arterial injuries in Amer- the amputation rate for popliteal ar- associated collateral blood vessels. ican troops in World War II resulted tery injuries is 32%, the rate for all Diagnosis of injury to the popliteal in limb loss and that the proportion other extremity injuries has been 7% .' artery rests on suspicion and vigilance; was 72.5% when popliteal arterial the Doppler transcutaneous flow detector injuries alone were considered. The ad- Pathogenesis of injury: and angiography are often useful aids vances in vascular techniques follow- anatomic factors to diagnosis. Methods of treatment ing World War II led to improvement that have been used include arterial in the treatment of vascular injuries, The popliteal artery is not intrinsic- repair, grafting and fasciotomy, together though Rich, Baugh and Hughes2 noted ally different from other peripheral ar- with management of associated that 32% of 150 patients with popliteal teries of its size. Failure of treatment injuries. The bypass principle of artery injuries required amputation dur- may be related to its unique anatomic vascular reconstruction may improve ing the Vietnam conflict, a proportion situation and on some occasions to overall results. not significantly different from that re- difficulty in diagnosis and the subse- ported for the Korean War some 15 quent delay in management. Three fac- years earlier by Hughes.' tors are important: the course of the Le traumatisme de l'artere poplitee Civilian experience has also been dis- artery in relation to bone proximally est potentiellement dangereux, et un couraging. Drapanas, Hewitt and Wei- and distally, the lack of protection af- retard dans son diagnostic peut chert4 in 1970 reported a 43% failure forded the artery by any overlying entrainer Ia perte dun membre. Trols rate in 14 cases of popliteal injury, and structures and the frequency with facteurs anatomiques contribuent a in Canada A.R. Downs (personal com- which collateral vessels also are dam- Ia gravite des r6sultats: Ia proximite munication, 1976) from Winnipeg re- aged. de I'artere avec l'os, Ia position en ported an amputation rate of 40% for The popliteal artery originates at surface de l'artere et le manque de 33 such cases. A review of 10 such the tendinous hiatus of the adductor protection qui en resulte, et les lesions cases at the Toronto General Hospital magnus, where it is held firmly against frequentes des vaisseaux sanguins (K.W. Johnston: personal communica- the distal femoral shaft (Fig. 1). It collateraux limitrophes. Le diagnostic tion, 1975) revealed that four patients passes freely through the popliteal d'une lesion de l'artere poplitee repose underwent amputation and two patients fossa, arriving beneath the tendinous sur Ia suspicion et Ia vigilance; le d6tecteur transcutane de debit Doppler et langiographie sont souvent des appoints precieux pour le diagnostic. Les modes de traitement qui ont ete ADDUCTOR MAGNUS utilises comprennent Ia reparation V POPLITEAL ART. de lartere, Ia greffe et l'aponevrotomie, ainsi que le traitement des blessures assoclees. Le principe de derivation SUPERIOR MEDIAL appllqu6 a Ia reconstruction vasculaire GENICULAR ART est susceptible dameliorer les SUPERIOR LATERAL resultats globaux. GENICULAR ART. Injuries to the popliteal artery are uniquely dangerous. Both limb loss and other major disabilities, includ- ing flexion contracture deformities, INFERIOR LATERAL persistent paresthesias and trophic ul- INFERIOR MEDIAL GENICULAR ART cers, are far more common with pop- liteal artery injuries than with arterial GENICULAR ART trauma at other sites. All physicians dealing with traumatized patients should be aware of the treacherous na- ture of this injury and the increased ANTERIOR TIBIAL ART. risk that it bears. Early recognition of POSTERIOR TIBIAL ART the injury is sometimes difficult and delay worsens the prognosis. / SOLEUS Reprint requests to: Dr. John T. Miles, Toronto western Medical Building, Ste. 202, 25 Leonard Ave., Toronto, Ont. M5T 2R2 FIG. 1-Posterior view of popliteal structuri 606 CMA JOURNAL/MARCH 19, 1977/VOL. 116 arch of the soleus muscle, where it is We have found the Doppler trans- tomoses are placed away from a once again held firmly against the un- cutaneous flow detector a useful in- contaminated area in the case of a derlying bone. Since the artery is an- strument in the initial assessment of compound wound. chored at either end, it is susceptible popliteal artery injuries. Angiography In the immediate postoperative pe- to stretching; long segments of vessel may be useful in determining the exact riod continued observation is necessary, may be damaged, though intimal rup- site and extent of the injury, but its specifically with reference to the return ture and thrombosis may only occur routine use in the preoperative assess- of pulses and perfusion of the foot. at one point. This may lead to under- ment of obvious popliteal arterial in- Doppler flow and ankle pressure anal- estimation of the extent of the injury jury is not obligatory. ysis is indicated for both detection of at operation. Stretching injuries to the return of blood flow and continuous artery are probably most common when Treatment monitoring of flow. Preoperative angio- dislocations of the knee or fracture dis- Arterial repair and graphy is also of value in difficult locations involving the upper tibia are grafting cases. also present. Popliteal arterial trauma Repair should be attempted as soon associated with this type of orthopedic as possible after injury. Success is un- Primary amputation injury appears to have the worst prog- likely after 12 hours,6 but successful There undoubtedly nosis; five of seven patients with repairs have been documented as late is a group of pa- such combined injuries reported by tients with popliteal injuries for whom as 48 to 72 hours after injury. Good primary amputation is the approach Kennedy5 required amputation. Late collateral circulation has probably been of diagnosis is a problem in relation to choice. Patients whose limbs are ob- responsible for favourable results in viously not viable or whose limbs with associated severe orthopedic these cases. We believe that attempts massive injuries because of both extensive swel- at repair should be made at any time soft tissue trauma makes lower limbs ling and the use of splints that may when limb viability is still possible. unsalvageable are in this group. obscure the overall picture. The techniques used to repair this Fasciotomy Another anatomic factor in the pa- artery have included lateral suture, end- thogenesis of the injury is the artery's to-end anastomosis with or without ex- The use of fasciotomy in association position: it lies posteriorly and is un- cision of a portion of artery, saphenous with arterial injuries is controversial. protected in this relatively superficial vein interposition graft and saphenous In several instances fasciotomy has position. Blunt trauma here produces vein bypass graft. Arterial prostheses been thought to contribute to the even- injury of greater magnitude than would have also been used. Lateral repair and tual need for amputation by becoming occur to a more protected artery sub- end-to-end anastomosis with or with- a focus for sepsis. Downs (personal jected to the same force. Also, the col- out excision are rarely suitable in view communication, 1976) has cautioned lateral network about the knee is par- of the usual mechanisms of such in- strongly against the use of routirre fasci- ticularly prone to injury because of juries and the length of artery involved. otomy; it made little difference to the the dearth of surrounding protective Suturing without tension and without outcome in his 33 cases. An intelligent soft tissue; hence the "back-up system" narrowing the anastomotic site can be decision about the use of fasciotomy may be injured at the same time as the a problem. More commonly, reversed probably cannot be made until more primary conduit for flow into the distal saphenous veins are used in grafting. sophisticated methods are developed to part of the leg. Damage to collaterals Arterial prostheses are clearly a second measure deep compartment tissue ten- may result at the time of injury or choice in the management of trauma in sion against arterial pressure. At pre- later during surgical intervention. this area, where structures are highly sent the need for fasciotomy should be A third factor is the difficulty of mobile and sepsis is a possibility. determined at the discretion of the surgical exposure. Despite its super- The classic repair of this lesion is operating surgeon; the use of fascio- ficial position in the mid-fossa, the ar- excision and reversed end-to-end saph- tomy is not recommended as a routine tery is difficult to expose over its full enous vein grafting. In spite of meticu- concomitant of repair in popliteal ar- length. A medial incision is usually per- lous technical care this procedure has tery injuries. formed but access to the portion of not been highly successful.
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