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