Popliteal Artery Trauma
Joel Arudchelvam
Injury to the popliteal vessels
CommonAmputation rates are highest. Our experience
Popliteal arterial injury – 32.5% of all injuries –commonest vascular injury (during war time 21%)
34.8% amputation rate.
•WHY?
Anatomyit is tethered to the
distal femur (adductor hiatus) and to tibia by the tendinous soleal arch.
This collateral network is frail and subject to obliteration and thrombosis by disruption or soft tissue swelling.
Popliteal vein travels proximally in a dense sheath with the popliteal artery
surrounding artery with venous communication
This proximity explains the frequent coexistence of popliteal venous trauma when the artery is injured.
The popliteal artery is an end artery
with a tenuous collateral supply.
The popliteal vein provides the bulk of lower leg and foot drainage.
HISTORYThe first use of a vein graft to repair on a
traumatic aneurysm of the popliteal artery in 1906.
Ligation remained a standard management through World Wars I and II
72.5% amputation rate32% amputation rate during the Korean
War .same rate in the Vietnam conflict
Reasons givenlack of
transportation unsanitary conditions absence of effective blood banking Antibiotics anesthesia
prevented repair on a large scale.
Significant improvement in limb salvage has continued since Vietnam war.
These results were extrapolated quickly to the civilian sector, where further improvements in limb salvage
PROGNOSTIC FACTORSTime interval – common cause of limb loss in most series
Mechanismpenetrating wounds better outcomes than from blunt
injury because surrounding tissue damage to be less severe. Difficult to diagnose because associated organ and
tissue injuries
compilation of 1209 published cases of civilian popliteal artery trauma from 24 series
Penetrating 56% (678/1209) - 10.5% amputationBlunt trauma resulted in amputation in 27.5% of
all cases, ranging as high as 71%.
Our series – overall amputation rate 34.8%
NOT because of bad surgery!
Civilian setting – blunt – 25 – 75%
Our experience – 1/23 (0.04%)
Associated injuries skeletal injuries (with posterior knee dislocation , popliteal vein, tibial
and peroneal nerve, and soft tissue and tendon)
chronic vascular disease
accurate diagnosis of an acute vascular injury may be obscured by the chronic existence of pulse deficit
the clinical presentation of popliteal vascular injury
injuries that present with frank ischemia active hemorrhage shock
have a poorer prognosis
Injury to the popliteal artery accounted for 12% of all arterial injuries -in World War I20% of those in World War II13 26% - in the Korean War,21.7% of - in the Vietnam War.
Our experience – war time – 21% Present series - 32.5%
Diagnosis Most cases of popliteal vascular trauma
present with obvious clinical manifestations, or ‘‘hard’’ signs of vascular injury
Active bleedingExpanding haematomaBruitEvidence of distal ischaemia
the 6 Ps: in trauma???? Pain Pallor Paralysis Paresthesiae Poikilothermy or coolness DISTAL PULSE
Soft Signs
Hematoma/ swelling
Proximity injuries: fractures, nerve injuries
Any vascular imaging or diagnostic test is unnecessary
Doppler, ultrasound, contrast angiography
•WHY?
Doppler pressure measurements and duplex ultrasonography – provide no advantage over clinical judgment
But needed in certain cases
complex trauma cause extensive bone and soft
tissue injury manifest “hard signs” that do not
arise from vascular injury but from soft tissue and
bone bleeding, nerve damage
Multiple level injury
Elderly with OAD
ArteriographyOn table
Investigations
Patient presenting withDelayAVFFalse aneurysm
Preoperative angiography
TREATMENTSurgical Repairprompt transport to operating roomGeneral anesthesiaCleaning entire leg and be able to visualize
the foot and palpate distal pulses.Contra lateral limb – for venous harvest Supine – knee flexed ,support under ,hip
abductedMedial approach
Arterial ends trimmedBalloon thrombectomySystemic and distal heparinisationInterposition graft
Unit experience – 88.2% RSVG
Prosthesis lower patency
Stab wounds leading to lateral injury – patch angioplasty, ? Lateral arteriorrhaphy
Downs AR, MacDonald P: Popliteal artery injuries: Civilian experience with sixtythree patients during a twenty-four year period (1960 through 1984). J Vasc Surg 4:55–62, 1986
Our series – none underwentExtra-anatomic bypass
Severe soft tissue injuryInfectionIf artery not accessible
Our series – none underwent
Completion angiography – show anastomotic abnormality in 10%
Lim LT, Michuda MS, Flanigan P, et al: Popliteal artery trauma: 31 consecutive caseswithout amputation. Arch Surg 115:1307–1313, 1980
We do not perform routinely
Nonoperative ObservationFor non occlusive injuries i.e.
Vessel narrowing Intimal flaps Small false aneurysm AVF
May progress to false aneurysm – 10%None result in limb loss
• Callow AD, Ernst CB (eds): Vascular Surgery: Theory and Practice. Stamford, CT,Appleton & Lange, 1995, pp 985–1037
• Frykberg ER, Crump JM, Dennis JW, et al: Nonoperative observation of clinically occult arterial injuries: A prospective evaluation. Surgery 109:85–96, 1991
• Frykberg ER, Dennis JW, Bishop K, et al: The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: Results at one year. J Trauma 31:502–511, 1991
Popliteal vessel injury – esp high risk injury for compartment syndrome
Liberal Fasciotomy is indicated
Combined Vascular and Skeletal Extremity Traumahigher risk for limb loss and morbidity than
either injury alone.Revascularization should be performed before
skeletal fixationTemporary shunting before fixation
Primary amputation extensive crush injuries and soft tissue damage
multiple comminuted skeletal fractures with
bone loss
life-threatening problems
multiple failures of revascularization
sciatic or tibial nerve transection.
Thank You