causes and outcome of popliteal arterial injury

1. Joel Arudchelvam

2. Injury to the popliteal vessels
Common
Amputation 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?

3. Anatomy
 it 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.

4.  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.

5.  The popliteal artery is an end artery
 with a tenuous collateral supply.
 The popliteal vein provides the bulk of lower leg and
foot drainage.

6. HISTORY
 The 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 rate
 32% amputation rate during the Korean War .same
rate in the Vietnam conflict

7. Reasons given
 lack of
 transportation
 unsanitary conditions
 absence of effective blood banking
 Antibiotics
 anesthesia
 prevented repair on a large scale.

8.  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

9. PROGNOSTIC FACTORS
 Time interval – common cause of limb loss in most series
 Mechanism
 penetrating wounds better outcomes than from blunt injury
 because surrounding tissue damage to be less severe.
 Difficult to diagnose because associated organ and tissue injuries

10.  compilation of 1209 published cases of civilian
popliteal artery trauma from 24 series
 Penetrating 56% (678/1209) - 10.5% amputation
 Blunt 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!

11.  Civilian setting – blunt – 25 – 75%
 Our experience – 1/23 (0.04%)

12.  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

13.  Injury to the popliteal artery accounted for
 12% of all arterial injuries -in World War I
 20% of those in World War II
 13 26% - in the Korean War,
 21.7% of - in the Vietnam War.
 Our experience –
 war time – 21%
 Present series - 32.5%

14. Diagnosis
 Most cases of popliteal vascular trauma present with
obvious clinical manifestations, or ‘‘hard’’ signs of
vascular injury
 Active bleeding
 Expanding haematoma
 Bruit
 Evidence of distal ischaemia
 the 6 Ps: in trauma????
 Pain
 Pallor
 Paralysis
 Paresthesiae
 Poikilothermy or coolness
 DISTAL PULSE

15. Soft Signs
Hematoma/ swelling
Proximity injuries:
fractures, nerve injuries

16.  Any vascular imaging or diagnostic test is unnecessary
 Doppler, ultrasound, contrast angiography
•WHY?

17.  Doppler pressure measurements and duplex
ultrasonography – provide no advantage over clinical
judgment

18. 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

19.  Arteriography
 On table

20. Investigations
 Patient presenting with
 Delay
 AVF
 False aneurysm
 Preoperative angiography

21. TREATMENT
Surgical Repair
 prompt transport to operating room
 General anesthesia
 Cleaning 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 abducted
 Medial approach

22.  Arterial ends trimmed
 Balloon thrombectomy
 Systemic and distal heparinisation
 Interposition graft
 Unit experience – 88.2% RSVG
 Prosthesis lower patency

23.  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 underwent
 Extra-anatomic bypass
 Severe soft tissue injury
 Infection
 If artery not accessible
 Our series – none underwent

24.  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

25. Nonoperative Observation
 For 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

26.  Popliteal vessel injury – esp high risk injury for
compartment syndrome
 Liberal Fasciotomy is indicated

27. Combined Vascular and Skeletal
Extremity Trauma
 higher risk for limb loss and morbidity than either
injury alone.
 Revascularization should be performed before skeletal
fixation
 Temporary shunting before fixation

28. 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.

29. Thank You