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Acute Popliteal Arterial Injury: The Role of Angioscopy
Acute Popliteal Arterial Injury: The Role of Angioscopy Yves AfimL MD, Michel Lempidakis, MD, Olivier Hartung, MD, Bernard Lelong, MD, and Claude Juhan, MD, Marseille, France
Accurate identification of arterial injury in the emergency setting constitutes one of the essential prognostic factors in patients presenting with acute popliteal arterial injury (APAI). The modalities of angioscopy performed intraoperatively by the vascular surgeon, including the details of how angioscopy can contribute to therapeutic decisions in this setting, are presented. Between June 1987 and August 1993, 26 patients presenting with 27 APAIs (one patient had a bilateral APAI) were treated at our institution. Eighteen (67%) lesions were due to closed trauma, three (11%) to shotgun pellets, three (11%) to knife wounds, two (7%) to iatrogenic wounds, and one (4%) to a bullet wound. Between June 1987 and January 1992 (group I, n = 20), treatment consisted of 15 (75%) saphenous vein bypasses and five (25%) local repairs. Pre- or intraoperative arteriograms were obtained in 14 (70%) cases. Three (15%) major amputations were required after popliteal reconstruction. Between February 1992 and August 1993 (group II, n = 7), two (29%) saphenous vein grafts and five (71%) local repairs were performed after routine intraoperative angioscopy. Arteriograms were obtained in six (86%) instances. No amputations were necessary in this group. As a complement to arteriography, intraoperative angioscopy can determine the extent and number of injuries, provides direct visualization of the intima of the entire femoropopliteal artery, even when the latter is obscured by thrombus, and ensures a final control of popliteal artery repair at completion. After angioscopy, local repair was possible more often (71% vs. 25%, p = 0.03) and treatment was associated with a better functional result (0% vs. 15% amputation rate, p = 0.04) in group I1. (Ann Vasc Surg 1995;9:361-368.)
Acute popliteal artery injury (APAI) represents 5% to 10% of all arterial wounds in the civilian population. 1 It is associated with a high rate of amputation 2 in spite of the progress being made in vascular surgery and improvements in surgical technique over the past 10 years) Failure rates still range from 0% to 22%. 4-s Recognition of these arterial lesions and determination of their exact location without any u n d u e increase in the dura-
tion of ischemia are the primary objectives of the surgeon. This is made possible by intraoperative angioscopy, inasmuch as this procedure provides the surgeon with a three-dimensional view of the vascular lumen and can locate lesions of the intima. 9-11We report herein our recent experience, underscoring the contribution of angioscopy to therapeutic decision making in the management of APAI.
From the Service de Chirurgie Vasculaire and Service d'Orthopddie-Traumatologie, Hdpital Nord, Marseille, France. Presented at the Annual Meeting of the Socidtd de Chirurgie Vasculaire de Langue Fran~aise, Paris, France, June 25-26, 1993. Reprint requests: Yves Alimi, MD, Service de Chirurgie Vasculaire, H3pital Nord, Chemin des Bourrelly, 13326, Marseille Cddex, France.
PATIENTS Between June 1987 and August 1993, a consecutive series of 28 patients with APAI were seen at the H6pital Nord, Marseilles, France. Two patients were not included in this study: one who required a primary major amputation as a result of long-standing ischemia and one who had a 361
362
Annals of Vascular Surgery
A l i m i et al.
Table I. Pre-and intraoperative investigations according to the period of treatment
patients
Pre- or intraoperative arteriography
Intraoperative angioscopy
20 7
14 (70%) 6 (86%)
0 7 (100%)
No. of
Group I* IIt
*Patients treated between June 1987 and March 1992. tPatients treated between April 1992 and August 1993.
nearly complete traumatic amputation at the lower third of the thigh that was not*alvageable. The remaining 26 patients had a total of 27 popliteal artery injuries (one patient had bilateral lesions). There were 22 males and four females whose mean age was 32.7 years (17 to 56 years). They had sustained 18 (69%) closed and eight (31%) penetrating injuries. Of the former, 16 were due to traffic accidents and two were the result of a fall of a heavy object onto the popliteal fossa. Three of the penetrating injuries were due to lead pellets, two were iatrogenic, two were due to knife injuries, and one was a bullet injury. On admission the clinical presentation was acute ischemia in 18 patients, subacute ischemia in five, and hemorrhage in four. Associated lesions included major osteoarticular lesions in 18 (69%) patients. Five patients had dislocation of the knee joint, with fracture of the tibial plateau in two cases, five patients had isolated fractures of the tibial plateau, and eight patients had fractures of the femoral shaft, one of which was associated with an acetabular fracture. Eleven (41%) patients had severe nerve lesions and nine (33%) had an associated lesion of the popliteal vein. Patients were divided into two groups based on w h e n they were first examined using angioscopy (Table I). Between June 1987 and March 1992, 20 cases of APAI (group I) were seen: arteriograms were obtained in 14 (70%) of them. Excluding two patients w h o were operated on 7 and 10 days after their accidents, the mean delay between the trauma and the operation was 7.8 hours (range 2 to 36 hours). In the two delayed operations, subacute ischemia had been mistakenly attributed to a compartment syndrome in patients with fracture-dislocation of the knee joint. Between April 1992 and August 1993, seven patients
(group II) underwent routine intraoperative angioscopy, which was preceded in six (86%) cases by arteriography. The mean period of ischemia was 9.5 hours (range 3 to 30 hours).
INTRAOPERATIVE ANGIOSCOPY Patients were placed in the supine position. The lower part of the femoral triangle was approached through a 3 to 4 cm incision to gain control of the femoral bifurcation. An Esmarch bandage was placed around the limb from the tip of the foot to the upper third of the leg to prevent backflow of blood into the operative field. The common and deep femoral arteries were then clamped, also with the intent of decreasing blood flow into the operative field. An oblique arteriotomy was performed on the common femoral artery 1 cm proximal to the ostium of the superficial femoral artery. For this procedure a 2.2 m m flexible tube angioscope (Meadox Medicals, Inc., Oakland, Calif.) connected to an integrated column (Sopro, Meadox, France, Paris, France) was used including a charge couple device 0.5 inch color camera, a 150 W halogen light fountain, a 380 turns/min roller pump for high-speed irrigation, a bubble detector, and a color screen. The tube was introduced through the arteriotomy and advanced to the superficial femoral artery with no guidewire or introducer. The progression of the tube was followed on the screen. The entire length of the artery was visualized and evaluated from the femoral to the popliteal artery. This was especially useful w h e n there was a possibility of multiple lesions as in the case of shotgun wounds. The irrigation system enabled all reflux blood arising from the collateral vessels to be washed away. This cleared the visual field with a low volume and thus it was never necessary to inject >200 ml. Direct visualization of the arterial intimal damage is essential for evaluating the severity of the lesion. It allows determination of the size and site of the w o u n d with regard to the popliteal bifurcation and the presence of an intimal flap or entry orifice of dissection. The angioscope often comes into contact with a thrombus. In this event the angioscope is easily pushed between the thrombus and the arterial wall, thus allowing visualization of the wound. In four of our patients a small (a few millimeters) w o u n d was seen, and after angioscopy it was possible to treat the patient by
Vol. 9, No. 4 1995
Angioscopy in acute popliteal artery injury 363
Table II. Therapeutic modalities and amputation rates according to the results of pre- and intraoperative investigations Group I (N = 20)
Group II (N = 7)
Total (N = 27)
S a p h e n o u s vein bypass Local repair Resection- suture S a p h e n o u s vein p a t c h Lateral suture
15 (75%) 5 (25%) 2 3
2 (29%) 5 (71%) 2 1 1
17 (63%) 10 (37%) 4 1 4
Transluminal angioplasty Major amputation (%)
-3 (15%)
I 0
1 3 (11%)
p Value 0.03*
0.04t
*Kendall's test. tFisher's exact test.
means of a small resection-suture or tacking of an intimal flap. This contrasts with the results of arteriography, which showed extensive thrombosis and based on these findings might have led to a vein bypass graft.
wounds or to control the results of reconstruction after completion. Angioscopy may help to avoid rethrombosis after arterial reconstruction, a cause of secondary amputation, as the rates of thrombosis were 15% and 0% in groups I and II, respectively (Table II) (p = 0.04, Fisher's exact test).
RESULTS There were no deaths in this series. Five repeat operations were required between 6 and 24 hours for early thrombosis after reconstruction in group I. The operations included transformation of a saphenous v e i n patch to a vein graft and transformation of an intimal flap fixation to a resection-suture in one patient each, and prolongation of a vein bypass in three patients. Failure was attributed to misidentification of lesions at the time of initial surgery in all cases. Three (11.5%) above-knee amputations, all in group I patients, were performed on days 1, 2, and 30 after thrombosis of popliteal reconstruction by vein bypass graft. The details of popliteal arterial reconstructions and the number of reconstructions in each group are given in Table II. Twenty- four (88.5%) popliteal artery reconstructions were patent at the time of discharge from the hospital. The proportion of pre- and intraoperative arteriograms obtained did not differ significantly between groups I and II. In group II routine intraoperative angioscopy ensured better identification of lesions, which led to limited repair in more cases than in group I (71% vs. 25%, p <0.03, Kendall's test) (Table II). Moreover, intraoperative angioscopy performed after arterial reconstruction was useful to detect associated arterial
DISCUSSION Despite improvement in the overall management of arterial trauma, APAI is still associated with a high rate of amputation. Among the factors that might improve prognosis, early and accurate visualization of lesions appears to be essential. Arterial injury can be detected in 92% to 98% of cases by pre- and intraoperative arteriography. ~2 Appropriate therapeutic decisions may be difficult, however, w h e n the lesion is obscured by thrombus, w h e n the contusion is extended, or in cases of multilevel lesions. In our experience angioscopy can be performed in the operating room, by the vascular surgeon, without having to displace the patient or prolong ischemia. Visually monitored progression without the use of a guidewire or introducer guarantees safe and adequate visualization of the arterial intima. The ability to push the angioscope between an extended thrombus and the arterial wall enabled us to diagnose small (a few millimeters) intimal flaps in two patients (Fig. 1). In one case transluminal angioplasty was performed under the visual control of the angioscope (Fig. 2) to repair a traumatic popliteal artery dissection secondary to a shotgun wound. The need for a direct popliteal approach, always very hemorrhagic in the event of a shotgun wound, was circumvented.
364 Alimi et al.
Annals of Vascular Surgery
A
Fig. 1. A, Arteriogram of a 42-year-old patient who presented with extensive occlusion of the popliteal artery after being thrown down by a power shovel. B, The angioscope has been pushed between the arterial wall and the thrombus and shows an intimal flap elevated over a few millimeters; the entire popliteal artery can be seen.
Vol. 9, No. 4 1995
Angioscopy in acute popliteal artery injury
I2,
Fig. 1, c o n t ' d . C, After resection-suture of the popliteal artery, angioscopy is used to control the arterial reconstruction. D, Follow-up arteriogram demonstrating patency of the popliteal artery.
365
Annals of Vascular Surgery
366 Alimi et al.
A
B
C
Fig. 2. A, Arteriogram of a 36-year-old patient who presented with a dissection of the midpopliteal artery" following a hunting accident. An embolus is seen in the posterior tibial artery. 13, Angioscopic view showing the absence of other endothelial lesions and the site of the entry orifice of dissection. C, Transluminal angioplasty at the site of dissection under angioscopic visualization.
Vol. 9, No. 4
1995
Angioscopy in acute popliteal artery injury 367
13
E
Fig. 2, cont'd. D, Ballon dilatation of the popliteal artery. E, Follow-up arteriogram after embolectomy using a retromalleolar posterior tibial artery approach.
368
Annals of Vascular Surgery
Alimi et al.
Several authors have attributed the recent improvement in immediate results following surgical management of APAI to the use of the contralateral saphenous vein in 60% to 81% of cases. 4-7 Little information is available, however, concerning vein bypasses used in cases of trauma, usually in patients < 20 years of age. In group II five of seven patients were treated with a local procedure based on angioscopic findings, whereas the arteriographic images showed extended lesions, which would have led to vein bypass grafting. The percentage of vein bypass grafts decreased significantly from 75% (group I) to 29% (group II) after routine use of intraoperative angioscopy. A significant decline in major amputations was also noted in group II. CONCLUSION Angioscopy, used as an adjunct to preoperative arteriography, can be performed intraoperatively by the vascular surgeon within a reasonable period of delay. It is possible to visualize all femoropopliteal vessels in the search for multiple lesions. Accurate marking of intimal lesions permits limited treatment in the majority of cases. C~,ntrol of reconstruction is possible, limiting the risk of postoperative thrombosis, a source of secondary amputation.
REFERENCES 1. Snyder WH. Popliteal and shank arterial injury. Surg Clin North Am 1988;68:787-808. 2. Drapanas "1", Hewitt RL, Weichert RF III, et al. Civilian vascular injuries: A critical appraisal of three decades of management. Ann Surg 1970;172:351-360. 3. Lescalie F, Badatcheff F, Lenay P, et al. Facteurs pronostiques darts les traumatismes vasculaires de la r6gion poplit6e. Ann Chir 1990;44:382-387. 4. Lim LT, Michuda MS, Flanigan DP, et al. Popliteal artery trauma: 31 consecutive cases without amputation. Arch Surg 1980;115:1307-1313. 5. Snyder WH. Vascular injuries near the knee: An updated series and overview of the problem. Surgery 1982;91:502-506. 6. Downs AlL McDonald P. Popliteal artery injuries: Civilian experience with sixty-three patients during a twenty-four year period (1960 through 1984). J Vasc Surg 1986;4:55-62. 7. Weimann S, San Nicolo M, Sandbichler P, et al. Civilian popliteal artery trauma. J Cardiovasc Surg 1987;28:145-151. 8. Frandrich BL, Gnanadev DA. Traumatismes de l'art~re poplit6e: Aspects actuels et progr~s th~rapeutiques r6cents. Ann Chir Vasc 1988;2:332-335. 9. Marzelle J. Angioscopie: Apport actuel ~t la chirurgie vasculaire et perspective d'avenir. Sang Thrombose Vaisseaux 1990;2:79-84. 10. White RA, White GH. Angioscopic endovascular surgical techniques. In Lippincott JP, ed. Endovascular Surgery: International Techniques in Vascular Disease. Philadelphia: JB Lippincott, 1990, pp 113-127. 11. White GH. How angioscopy can be helpful to the vascular surgeon. In Veith FJ, ed. Current Critical Problems in Vascular Surgery, vol. 2. St Louis: Quality Medical Publishing, 1990, pp 301-306. 12. Littooy FN, Freeark RJ. Missed vascular injuries: Complications and prevention. In Flanigan DP, ed. CMlian Vascular Trauma. Philadelphia: Lea & Febiger, 1992, pp 52-57.
Accurate identification of arterial injury in the emergency setting constitutes one of the essential prognostic factors in patients presenting with acute popliteal arterial injury (APAI). The modalities of angioscopy performed intraoperatively by the vascular surgeon, including the details of how angioscopy can contribute to therapeutic decisions in this setting, are presented. Between June 1987 and August 1993, 26 patients presenting with 27 APAIs (one patient had a bilateral APAI) were treated at our institution. Eighteen (67%) lesions were due to closed trauma, three (11%) to shotgun pellets, three (11%) to knife wounds, two (7%) to iatrogenic wounds, and one (4%) to a bullet wound. Between June 1987 and January 1992 (group I, n = 20), treatment consisted of 15 (75%) saphenous vein bypasses and five (25%) local repairs. Pre- or intraoperative arteriograms were obtained in 14 (70%) cases. Three (15%) major amputations were required after popliteal reconstruction. Between February 1992 and August 1993 (group II, n = 7), two (29%) saphenous vein grafts and five (71%) local repairs were performed after routine intraoperative angioscopy. Arteriograms were obtained in six (86%) instances. No amputations were necessary in this group. As a complement to arteriography, intraoperative angioscopy can determine the extent and number of injuries, provides direct visualization of the intima of the entire femoropopliteal artery, even when the latter is obscured by thrombus, and ensures a final control of popliteal artery repair at completion. After angioscopy, local repair was possible more often (71% vs. 25%, p = 0.03) and treatment was associated with a better functional result (0% vs. 15% amputation rate, p = 0.04) in group I1. (Ann Vasc Surg 1995;9:361-368.)
Acute popliteal artery injury (APAI) represents 5% to 10% of all arterial wounds in the civilian population. 1 It is associated with a high rate of amputation 2 in spite of the progress being made in vascular surgery and improvements in surgical technique over the past 10 years) Failure rates still range from 0% to 22%. 4-s Recognition of these arterial lesions and determination of their exact location without any u n d u e increase in the dura-
tion of ischemia are the primary objectives of the surgeon. This is made possible by intraoperative angioscopy, inasmuch as this procedure provides the surgeon with a three-dimensional view of the vascular lumen and can locate lesions of the intima. 9-11We report herein our recent experience, underscoring the contribution of angioscopy to therapeutic decision making in the management of APAI.
From the Service de Chirurgie Vasculaire and Service d'Orthopddie-Traumatologie, Hdpital Nord, Marseille, France. Presented at the Annual Meeting of the Socidtd de Chirurgie Vasculaire de Langue Fran~aise, Paris, France, June 25-26, 1993. Reprint requests: Yves Alimi, MD, Service de Chirurgie Vasculaire, H3pital Nord, Chemin des Bourrelly, 13326, Marseille Cddex, France.
PATIENTS Between June 1987 and August 1993, a consecutive series of 28 patients with APAI were seen at the H6pital Nord, Marseilles, France. Two patients were not included in this study: one who required a primary major amputation as a result of long-standing ischemia and one who had a 361
362
Annals of Vascular Surgery
A l i m i et al.
Table I. Pre-and intraoperative investigations according to the period of treatment
patients
Pre- or intraoperative arteriography
Intraoperative angioscopy
20 7
14 (70%) 6 (86%)
0 7 (100%)
No. of
Group I* IIt
*Patients treated between June 1987 and March 1992. tPatients treated between April 1992 and August 1993.
nearly complete traumatic amputation at the lower third of the thigh that was not*alvageable. The remaining 26 patients had a total of 27 popliteal artery injuries (one patient had bilateral lesions). There were 22 males and four females whose mean age was 32.7 years (17 to 56 years). They had sustained 18 (69%) closed and eight (31%) penetrating injuries. Of the former, 16 were due to traffic accidents and two were the result of a fall of a heavy object onto the popliteal fossa. Three of the penetrating injuries were due to lead pellets, two were iatrogenic, two were due to knife injuries, and one was a bullet injury. On admission the clinical presentation was acute ischemia in 18 patients, subacute ischemia in five, and hemorrhage in four. Associated lesions included major osteoarticular lesions in 18 (69%) patients. Five patients had dislocation of the knee joint, with fracture of the tibial plateau in two cases, five patients had isolated fractures of the tibial plateau, and eight patients had fractures of the femoral shaft, one of which was associated with an acetabular fracture. Eleven (41%) patients had severe nerve lesions and nine (33%) had an associated lesion of the popliteal vein. Patients were divided into two groups based on w h e n they were first examined using angioscopy (Table I). Between June 1987 and March 1992, 20 cases of APAI (group I) were seen: arteriograms were obtained in 14 (70%) of them. Excluding two patients w h o were operated on 7 and 10 days after their accidents, the mean delay between the trauma and the operation was 7.8 hours (range 2 to 36 hours). In the two delayed operations, subacute ischemia had been mistakenly attributed to a compartment syndrome in patients with fracture-dislocation of the knee joint. Between April 1992 and August 1993, seven patients
(group II) underwent routine intraoperative angioscopy, which was preceded in six (86%) cases by arteriography. The mean period of ischemia was 9.5 hours (range 3 to 30 hours).
INTRAOPERATIVE ANGIOSCOPY Patients were placed in the supine position. The lower part of the femoral triangle was approached through a 3 to 4 cm incision to gain control of the femoral bifurcation. An Esmarch bandage was placed around the limb from the tip of the foot to the upper third of the leg to prevent backflow of blood into the operative field. The common and deep femoral arteries were then clamped, also with the intent of decreasing blood flow into the operative field. An oblique arteriotomy was performed on the common femoral artery 1 cm proximal to the ostium of the superficial femoral artery. For this procedure a 2.2 m m flexible tube angioscope (Meadox Medicals, Inc., Oakland, Calif.) connected to an integrated column (Sopro, Meadox, France, Paris, France) was used including a charge couple device 0.5 inch color camera, a 150 W halogen light fountain, a 380 turns/min roller pump for high-speed irrigation, a bubble detector, and a color screen. The tube was introduced through the arteriotomy and advanced to the superficial femoral artery with no guidewire or introducer. The progression of the tube was followed on the screen. The entire length of the artery was visualized and evaluated from the femoral to the popliteal artery. This was especially useful w h e n there was a possibility of multiple lesions as in the case of shotgun wounds. The irrigation system enabled all reflux blood arising from the collateral vessels to be washed away. This cleared the visual field with a low volume and thus it was never necessary to inject >200 ml. Direct visualization of the arterial intimal damage is essential for evaluating the severity of the lesion. It allows determination of the size and site of the w o u n d with regard to the popliteal bifurcation and the presence of an intimal flap or entry orifice of dissection. The angioscope often comes into contact with a thrombus. In this event the angioscope is easily pushed between the thrombus and the arterial wall, thus allowing visualization of the wound. In four of our patients a small (a few millimeters) w o u n d was seen, and after angioscopy it was possible to treat the patient by
Vol. 9, No. 4 1995
Angioscopy in acute popliteal artery injury 363
Table II. Therapeutic modalities and amputation rates according to the results of pre- and intraoperative investigations Group I (N = 20)
Group II (N = 7)
Total (N = 27)
S a p h e n o u s vein bypass Local repair Resection- suture S a p h e n o u s vein p a t c h Lateral suture
15 (75%) 5 (25%) 2 3
2 (29%) 5 (71%) 2 1 1
17 (63%) 10 (37%) 4 1 4
Transluminal angioplasty Major amputation (%)
-3 (15%)
I 0
1 3 (11%)
p Value 0.03*
0.04t
*Kendall's test. tFisher's exact test.
means of a small resection-suture or tacking of an intimal flap. This contrasts with the results of arteriography, which showed extensive thrombosis and based on these findings might have led to a vein bypass graft.
wounds or to control the results of reconstruction after completion. Angioscopy may help to avoid rethrombosis after arterial reconstruction, a cause of secondary amputation, as the rates of thrombosis were 15% and 0% in groups I and II, respectively (Table II) (p = 0.04, Fisher's exact test).
RESULTS There were no deaths in this series. Five repeat operations were required between 6 and 24 hours for early thrombosis after reconstruction in group I. The operations included transformation of a saphenous v e i n patch to a vein graft and transformation of an intimal flap fixation to a resection-suture in one patient each, and prolongation of a vein bypass in three patients. Failure was attributed to misidentification of lesions at the time of initial surgery in all cases. Three (11.5%) above-knee amputations, all in group I patients, were performed on days 1, 2, and 30 after thrombosis of popliteal reconstruction by vein bypass graft. The details of popliteal arterial reconstructions and the number of reconstructions in each group are given in Table II. Twenty- four (88.5%) popliteal artery reconstructions were patent at the time of discharge from the hospital. The proportion of pre- and intraoperative arteriograms obtained did not differ significantly between groups I and II. In group II routine intraoperative angioscopy ensured better identification of lesions, which led to limited repair in more cases than in group I (71% vs. 25%, p <0.03, Kendall's test) (Table II). Moreover, intraoperative angioscopy performed after arterial reconstruction was useful to detect associated arterial
DISCUSSION Despite improvement in the overall management of arterial trauma, APAI is still associated with a high rate of amputation. Among the factors that might improve prognosis, early and accurate visualization of lesions appears to be essential. Arterial injury can be detected in 92% to 98% of cases by pre- and intraoperative arteriography. ~2 Appropriate therapeutic decisions may be difficult, however, w h e n the lesion is obscured by thrombus, w h e n the contusion is extended, or in cases of multilevel lesions. In our experience angioscopy can be performed in the operating room, by the vascular surgeon, without having to displace the patient or prolong ischemia. Visually monitored progression without the use of a guidewire or introducer guarantees safe and adequate visualization of the arterial intima. The ability to push the angioscope between an extended thrombus and the arterial wall enabled us to diagnose small (a few millimeters) intimal flaps in two patients (Fig. 1). In one case transluminal angioplasty was performed under the visual control of the angioscope (Fig. 2) to repair a traumatic popliteal artery dissection secondary to a shotgun wound. The need for a direct popliteal approach, always very hemorrhagic in the event of a shotgun wound, was circumvented.
364 Alimi et al.
Annals of Vascular Surgery
A
Fig. 1. A, Arteriogram of a 42-year-old patient who presented with extensive occlusion of the popliteal artery after being thrown down by a power shovel. B, The angioscope has been pushed between the arterial wall and the thrombus and shows an intimal flap elevated over a few millimeters; the entire popliteal artery can be seen.
Vol. 9, No. 4 1995
Angioscopy in acute popliteal artery injury
I2,
Fig. 1, c o n t ' d . C, After resection-suture of the popliteal artery, angioscopy is used to control the arterial reconstruction. D, Follow-up arteriogram demonstrating patency of the popliteal artery.
365
Annals of Vascular Surgery
366 Alimi et al.
A
B
C
Fig. 2. A, Arteriogram of a 36-year-old patient who presented with a dissection of the midpopliteal artery" following a hunting accident. An embolus is seen in the posterior tibial artery. 13, Angioscopic view showing the absence of other endothelial lesions and the site of the entry orifice of dissection. C, Transluminal angioplasty at the site of dissection under angioscopic visualization.
Vol. 9, No. 4
1995
Angioscopy in acute popliteal artery injury 367
13
E
Fig. 2, cont'd. D, Ballon dilatation of the popliteal artery. E, Follow-up arteriogram after embolectomy using a retromalleolar posterior tibial artery approach.
368
Annals of Vascular Surgery
Alimi et al.
Several authors have attributed the recent improvement in immediate results following surgical management of APAI to the use of the contralateral saphenous vein in 60% to 81% of cases. 4-7 Little information is available, however, concerning vein bypasses used in cases of trauma, usually in patients < 20 years of age. In group II five of seven patients were treated with a local procedure based on angioscopic findings, whereas the arteriographic images showed extended lesions, which would have led to vein bypass grafting. The percentage of vein bypass grafts decreased significantly from 75% (group I) to 29% (group II) after routine use of intraoperative angioscopy. A significant decline in major amputations was also noted in group II. CONCLUSION Angioscopy, used as an adjunct to preoperative arteriography, can be performed intraoperatively by the vascular surgeon within a reasonable period of delay. It is possible to visualize all femoropopliteal vessels in the search for multiple lesions. Accurate marking of intimal lesions permits limited treatment in the majority of cases. C~,ntrol of reconstruction is possible, limiting the risk of postoperative thrombosis, a source of secondary amputation.
REFERENCES 1. Snyder WH. Popliteal and shank arterial injury. Surg Clin North Am 1988;68:787-808. 2. Drapanas "1", Hewitt RL, Weichert RF III, et al. Civilian vascular injuries: A critical appraisal of three decades of management. Ann Surg 1970;172:351-360. 3. Lescalie F, Badatcheff F, Lenay P, et al. Facteurs pronostiques darts les traumatismes vasculaires de la r6gion poplit6e. Ann Chir 1990;44:382-387. 4. Lim LT, Michuda MS, Flanigan DP, et al. Popliteal artery trauma: 31 consecutive cases without amputation. Arch Surg 1980;115:1307-1313. 5. Snyder WH. Vascular injuries near the knee: An updated series and overview of the problem. Surgery 1982;91:502-506. 6. Downs AlL McDonald P. Popliteal artery injuries: Civilian experience with sixty-three patients during a twenty-four year period (1960 through 1984). J Vasc Surg 1986;4:55-62. 7. Weimann S, San Nicolo M, Sandbichler P, et al. Civilian popliteal artery trauma. J Cardiovasc Surg 1987;28:145-151. 8. Frandrich BL, Gnanadev DA. Traumatismes de l'art~re poplit6e: Aspects actuels et progr~s th~rapeutiques r6cents. Ann Chir Vasc 1988;2:332-335. 9. Marzelle J. Angioscopie: Apport actuel ~t la chirurgie vasculaire et perspective d'avenir. Sang Thrombose Vaisseaux 1990;2:79-84. 10. White RA, White GH. Angioscopic endovascular surgical techniques. In Lippincott JP, ed. Endovascular Surgery: International Techniques in Vascular Disease. Philadelphia: JB Lippincott, 1990, pp 113-127. 11. White GH. How angioscopy can be helpful to the vascular surgeon. In Veith FJ, ed. Current Critical Problems in Vascular Surgery, vol. 2. St Louis: Quality Medical Publishing, 1990, pp 301-306. 12. Littooy FN, Freeark RJ. Missed vascular injuries: Complications and prevention. In Flanigan DP, ed. CMlian Vascular Trauma. Philadelphia: Lea & Febiger, 1992, pp 52-57.