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Encounters with pseudoaneurysms in orthopaedic practice
Injury, Int. J. Care Injured 32 (2001) 771– 778 www.elsevier.com/locate/injury
Encounters with pseudoaneurysms in orthopaedic practice Anil Dhal a,*, Manish Chadha a, Hitesh Lal a, Tejveer Singh a, Sanjay Tyagi b a
Department of Orthopaedics, Maulana Azad Medical College and associated Lok Nayak Hospital, Delhi 110002, India b Department of Cardiology, Maulana Azad Medical College and associated G.B. Pant Hospital, Delhi 110002, India Accepted 12 June 2001
Abstract Thirteen pseudoaneurysms are presented of which five were caused as a complication of pin/wire placement of external fixators (one conventional and four Ilizarov frames). The most common symptom was the presence of profuse persistent bleeding from either the wound or the pin/wire site. In nine patients the pseudoaneurysm was directly caused by a fracture or subsequent fracture stabilisation. Pre-operative evaluation included radiography, arteriography, Doppler and computed tomography (CT) angiography. Depending on the site and size of the pseudoaneurysm management consisted of either ligation, resection and end-to-end anastamosis/vein grafting, lateral suture, endoaneurysmorrhaphy or selective embolisation. A high index of suspicion needs to be maintained following penetrating injury in the vicinity of a major vessel, particularly in the presence of persisting symptoms. External fixators are widely used to treat complex orthopaedic problems. The procedure is technically demanding, requiring a sound knowledge of cross-sectional limb anatomy. Injudicious use may result in potentially life/limb threatening complication of pseudoaneurysm. © 2001 Elsevier Science Ltd. All rights reserved.
1. Introduction Pseudoaneurysms are associated with penetrating injuries resulting from a tangential laceration through all the three layers of the wall of an artery. In civilian practice stab wounds, industrial accidents and road traffic accidents with/without associated fractures are the usual causes. With the use of external fixators there is an inherent risk of pseudoaneurysm caused by the insertion of pins/wires, and the added trauma of distraction. We report our experience in treating 13 cases of false aneurysm of which a significant number were caused as a result of external fixation performed on the extremities.
2. Material and methods Thirteen patients with suspected post-traumatic peripheral pseudoaneurysms were admitted to the depart* Corresponding author. Present address: G-41 Lajpat Nagar III, New Delhi 110024, India. Tel.: + 91-11-683-6146; fax: +91-11-6918788. E-mail address: [email protected] (A. Dhal).
ment of Orthopaedic surgery between 1991 and 1999. Clinical suspicion was based on the presence of, 1. profuse persistent bleeding from either the wound or pin site; 2. progressive pulsatile swelling. A detailed history and physical examination was recorded for each patient at the time of admission to determine, 1. the mode of injury; 2. site of injury; 3. associated injuries and/or complications; 4. previous operative procedures if any. Besides routine investigations, pre-operative evaluation included plain radiographs, arteriography, Doppler and computed tomography (CT) angiography. Once the diagnosis was confirmed, patients underwent exploration and appropriate stabilisation of any associated fractures. Depending on the size and site of the pseudoaneurysm surgical management consisted of either ligation, resection and end to end anastamosis/vein grafting, lateral suture or endoaneurysmorrhaphy. In two patients selective embolisation was chosen since the pseudoaneurysms were involving non-critical blood vessels. One patient recovered spontaneously.
0020-1383/01/$ - see front matter © 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 1 ) 0 0 0 9 4 - 8
A. Dhal et al. / Injury, Int. J. Care Injured 32 (2001) 771–778
772
Table 1 Patient profile according to outcome (all were male) Serial number Age (years)
Artery
Etiology
Associated injuries Procedure
Outcome
Fracture tibia and fibula Nil Fracture pelvis
Healed Healed
1
32
Posterior tibial
Bone fragment
2 3
24 34
Popletial Internal iliac
Stab injury Fracture pelvis
4
20
Anterior tibial
Proximal osteotomy
5
52
Peroneal
Sprain ankle
Fracture tibia with bone loss Nil
6
18
Brachial
Scissors
Nil
7
34
External fixator
8
18
Profunda femoris Deep femoral
9
12
Deep femoral
10 11
28 30
Deep femoral Deep femoral
12
33
Deep femoral
13
26
Common femoral
Open fracture femur Ilizarov fixator Intercondylar fracture tibia Fracture femur fragment Fracture femur Fracture femur fragment Fracture femur Ilizarov fixator Open fracture femur Ilizarov fixator with Open fracture distal femoral osteotomy femur Bullet injury Nil
Most patients were operated upon under regional anaesthesia using indwelling epidural catheters. These were retained for 48 h post-operatively for sympathetic blockade. None of the patients were heparinised. Postoperatively the limb was nursed at body level. Vasodilators and low molecular weight dextran were used in all cases. Following the surgical procedure patients were assessed clinically as well as by post-operative arteriography and Doppler studies to document resolution of the pseudoaneurysm and the continuity of arterial flow across the repair site. The patients were followed up regularly and surgical procedures for associated injuries were undertaken as necessary.
Spontaneous cure Pulses+ Lateral suture Selective embolisation Ligation
Healed
EndoaneurysmorhHealed apphy Resection and Pulses+ end to end suture Selective Pulses+ embolisation Lateral suture Pre-operative foot drop, recovered Lateral suture Pulses+, preop footdrop recovered Ligation Pulses absent, limb survived Ligation Amputation for gangrene Amputation Resection and vein graft
Primary amputation for infection and bleeding Recurrence, died due to exsanguination
Most commonly the pseudoaneurysms were caused as a complication of pin placement of external fixators (case numbers 4, 7, 8, 11, 12). Bone fragments in severely comminuted/open fractures resulted in four pseudoaneurysms (case numbers 1, 3, 9, 10). Three resulted from penetrating injuries and one from blunt trauma with no fracture (Table 2). Of the 13 patients nine (69.2%) had associated fractures which either directly caused the pseudoaneurysm or subsequent fracture stabilisation led to the same. Two patients had pre-operative footdrop as a result of pressure over the adjacent nerve. Both recovered following management of the pseudoaneurysm by lateral suture.
3. Observations and results Thirteen patients with traumatic pseudoaneurysms of the peripheral vascular system were treated in the department of Orthopaedic Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital in an 8-year period (1991– 1999; Table 1). All were male patients with an average age of 27.8 years (range 12–52 years). The commonest vessel to be involved was the deep femoral artery (five cases) while the internal iliac, profunda femoris, common femoral, popliteal, posterior tibial, peroneal, anterior tibial and brachial arteries were involved in one case each.
Table 2 Aetiology of pseudoaneurysm formation Aetiology Penetrating injury (a) Bullet injury (b) Sharp object (c) Industrial accident Iatrogenic (a) Conventional AO fixator (b) Ilizarov(ring) fixator Fracture fragments Blunt injury
Number of cases
1 2 0 1 4 4 1
A. Dhal et al. / Injury, Int. J. Care Injured 32 (2001) 771–778
The commonest presenting symptom of the pseudoaneurysms was persistent profuse bleeding, inconsistent with the magnitude of injury, several days after trauma/ external fixation from either the wound sustained as a result of the trauma or from a pin site. It should be noted that five cases (38.5%) were caused as a direct result of external fixation. One of these cases was seen with a conventional AO type of external fixation performed for an open fracture of the femur. Persistent profuse bleeding was observed from one of the pin sites, though distal pulses were palpable. The external fixator was removed by the treating surgeon and referred to us with a suspected vascular injury. An angiogram revealed a false aneurysm of a branch of the profunda femoris artery, probably injured at the time of surgery by a drill bit/Schanz screw tip. Selective embolisation was successfully performed for the pseudoaneurysm as it involved a non-critical blood vessel (Fig. 1a and b). Distraction at the corticotomy site of an Ilizarov procedure caused a pseudoaneurysm in one of our cases. A 20-year-old male was operated for gap non-union of the tibia. An Ilizarov frame was applied with a proximal tibial corticotomy for bone transport. The post-operative period was uneventful, but after nearly 2 months of distraction the patient developed frequent breakdown of soft tissue at the corticotomy site associated with profuse bleeding, which continued despite stopping distraction. An angiogram revealed a pseudoaneurysm of the anterior tibial artery. It was felt that the arterial injury resulted from a misguided osteotome. The tear may have initially sealed off by a blood clot but subsequent distraction at the osteotomy site would have increased the size of the rent and the resultant leakage led to pseudoaneurysm formation. The wounds healed following exploration and ligation of the anterior tibial artery (Fig. 2a and b). The other three cases were seen in relation to Ilizarov fixator frames applied for open fractures of the femur (case numbers 11, 12) and an open intercondylar fracture of the tibia (case number 8). The patients presented with a similar history of persistent profuse bleeding from pin sites, inconsistent with the extent of their injuries. Angiography revealed pseudoaneurysms in close proximity to the transfixing wires. One of these patients (case number 12) had to undergo primary amputation as a life saving procedure in presence of gross infection and persistent, profuse, life-threatening bleeding (Fig. 3a and b). Case number 11 had a similar presentation of infection and bleeding and underwent ligation of the femoral artery in an attempt to save the limb but gangrene resulted since there was inadequate collateral circulation and subsequent amputation was performed. In the third patient, the offending wire was removed and lateral suture done resulting in a full recovery.
773
Fig. 1. (a) Angiogram of case number 7 showing a false aneurysm arising from a branch of the profunda femoris artery. (b) Following selective embolisation.
In one patient ligation was performed for a pseudoaneurysm of the femoral artery (case number 10). Distal pulses were absent following surgery. However, the limb survived with good neuromuscular function due to the excellent collateral circulation. One patient with pseudoaneurysm of the common femoral artery sustained as a result of a bullet injury (case number 13) underwent exploration followed by resection and reconstruction using a saphenous vein graft. The immediate post-operative period was uneventful. During follow up in the out patient department recurrence of the pseudoaneurysm was noticed. Angiography revealed leakage from the proximal anastamosis with a patent vein graft (Fig. 4a–c). Immediate admission for investigations and reexploration was advised but the patient refused. Subsequently, the pseu-
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A. Dhal et al. / Injury, Int. J. Care Injured 32 (2001) 771–778
doaneurysm burst with profuse bleeding and the patient died as a result of exsanguination by the time he could reach the hospital. One patient recovered spontaneously while selective embolisation was performed in two cases since the pseudoaneurysm involved non-critical blood vessels.
Fig. 3. (a) Dissected specimen of the amputated limb of case number 12. (b) The wire is placed in the lumen of the deep femoral artery, which is continuous with the sac.
The procedures performed in our study are listed in Table 3.
4. Discussion
Fig. 2. (a) Case number 4 presented with frequent breakdown of soft-tissue cover and profuse bleeding from the corticotomy site, 2 months following application of Ilizarov fixator for gap non-union tibia. (b) Angiogram of the patient revealed a pseudoaneurysm of the anterior tibial artery.
Traumatic pseudoaneurysms follow incomplete disruption of an artery and result in leakage of blood into the surrounding tissues. The uninjured portion of the arterial wall prevents the vessel from contracting leading to unbridled extravasation, which in due course organises and develops a fibrous capsule [1]. However, turbulent blood flow continues in the central region (Fig. 5). The classical presentation is that of an enlarging pulsatile swelling. A systolic bruit may be audible and a thrill may be present. Distal pulsations are usually present. Distal arterial insufficiency is therefore rare [2]. Aneurysms may mimic soft-tissue masses including abscesses, neoplasms or ganglions [3–7]. The inflammation that results subsequent to organisation of the haematoma may masquerade as an infection because local heat and tenderness are usually present. If mis-
A. Dhal et al. / Injury, Int. J. Care Injured 32 (2001) 771–778
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Fig. 4. (a) Pseudoaneurysm arising from the common femoral artery caused as a result of a gunshot injury. (b) Vascular reconstruction using saphenous vein graft after resection of the pseudoaneurysm. (c) Six weeks post-operative angiogram showing recurrence of the pseudoaneurysm at the proximal anastamosis site with a patent vein graft.
taken for an abscess, inadvertent incision and drainage will cause a major problem [1]. Hence, it is advisable to aspirate all abscesses before incision. Alertness on the part of resident doctors was instrumental in preventing such a catastrophy in two of our cases (case numbers 9, 13). Incision and drainage was abandoned when aspiration in theatre yielded blood and a subsequent angiogram and Doppler study revealed a pseudoaneurysm. Pseudoaneurysm may present at any time from hours to months after penetrating vascular injury [3] and a high index of suspicion needs to be maintained following penetrating injury in the vicinity of a major vessel, particularly in the presence of persisting symptoms [8]. Most pseudoaneurysms occur immediately following injury as a result of significant transmural arterial laceration. In a small group of patients with minor arterial wall injuries or intimal flaps these pseudoaneurysms may remain clinically undetected, progress slowly and present later with complications [9]. Thus, delayed neurological compromise may be the first indicator of a co-existing pseudoaneurysm as seen in case numbers 8 and 9. Rupture of a pseudoaneurysm into a closed osteo-fascial compartment following closed injury may present with clinical features of compartment syndrome. A fasciotomy in such situations may be life threatening. Clinical evaluation, although important, is not always accurate. Classic signs of arterial injury such as pulse deficit, bruit, arterial bleeding and expanding or pulsatile haematoma may be absent despite significant damage to the arterial wall. Many reports document the presence of
normal pulses distal to the major arterial bleeding [10–14]. This can be explained by the fact that the pulse pressure wave can be transmitted beyond an intimal flap, through soft, fresh clot or through collaterals [10]. Moreover, since there is only partial disruption of the vessel wall some flow continues across the site of the aneurysm resulting in a palpable though sometimes diminished distal pulse. False aneurysms can indeed be overlooked after trauma, especially in the pre-rupture phase. Continued surveillance of the site of injury is mandatory when the manifestations of vascular injury are delayed. Expansion of a formerly well-contained haematoma, persistence of swelling without evidence of resolution, pulsation and/or presence of a bruit, and above all occurrence of new nerve palsy in patients with a history Table 3 Procedures performed Operative procedure
Number of cases
Ligation Lateral suture Resection and (A) End-to-end suture (B) Vein graft (C) Synthetic graft Endoaneurysmorrhaphy Selective embolisation Amputation Spontaneous cure
2 3 1 1 0 1 2 2 1
776
A. Dhal et al. / Injury, Int. J. Care Injured 32 (2001) 771–778
case of the Ilizarov fixator these include perforation of the artery, vein or both [24,25]. Direct vascular injury with the Ilizarov technique may occur during the initial wire insertion procedure or as a result of the distraction process [25]. Vascular injury may also occur from indirect trauma to the vessel over time as a wire placed near an artery causes erosion from constant arterial pulsations against a fixed surface [18]. Jakim et al. [19] propose that axial micromovement of a transfixation wire against an arterial wall may be an aggravating factor in progressive arterial erosion leading to late pseudoaneurysm formation. The use of thin wires is
Fig. 5. Genesis of a pseudoaneurysm.
of penetrating injury are all indications for angiography. Arteriography is useful to document lesions and evaluate deeper pseudoaneurysms [15]. It is important in those instances where reconstruction is considered, and may help in the decision to reconstruct or ligate the involved artery. Non-invasive diagnosis of vascular lesions by duplex ultrasonography has also proven useful and is reported to be 98% accurate [16]. The management of arterial pseudoaneurysms depends on their location and size, and the presence or absence of infection [17]. Some pseudoaneurysms may simply be observed if they are B10 mm in size, are asymptomatic, and involve arteries of minor importance as evident from case number 1 which recovered ‘spontaneously’ (Figs. 6a,b and 7a,b). Larger aneurysms, those that become symptomatic, or those that involve major arteries in which occlusion would threaten severe ischaemic effects generally require intervention. These lesions may warrant surgery or may be treated by invasive radiological techniques to induce pseudoaneurysm thrombosis [17]. If left alone there is a risk of expansion and ultimate rupture, which may lead to exsanguination and death as in case number 13. Resection and reconstruction was the procedure of choice for large rents. Lateral suture was the preferred technique only in those cases where there was a small rent in a large-bore vessel. In the presence of gross infection and life threatening bleeding ligation/amputation was done as a salvage procedure. Orthopaedic surgeons throughout the world are increasingly using various types of external fixators. Thus there may be an increased incidence of iatrogenic vascular injury [18–22], the incidence of which is reported to be 1% [23]. Vascular complications associated with the use of any transfixing external fixators are usually attributed to improper pin insertion technique and imprecise familiarity with cross-sectional anatomy. In the
Fig. 6. (a) Angiogram of case number 1 showing pseudoaneurysm arising from the posterior tibial artery damaged by the butterfly segment. (b) ‘Spontaneous cure’ of the pseudoaneurysm.
A. Dhal et al. / Injury, Int. J. Care Injured 32 (2001) 771–778
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rendering it more prone to iatrogenic injury. It is recommended that half pins be used in this region instead of transfixing wires.
References
Fig. 7. (a) Angiogram of case number 3 showing a pseudoaneurysm arising from rthe internal iliac artery following pelvic disruption. (b) Completion angiogram after selective embolization showing cessation of leakage.
believed to reduce the incidence of vascular injury associated with external fixation, but should this complication be recognised at the time of surgery, it may be treated by removal of the wire and application of local pressure [25]. It is interesting to note that four out of five fixator related pseudoaneurysms in our series resulted as a complication of transfixing wire fixation. In retrospect, the placement of some of these wires did not conform to the ‘safe zones’ of wire placement. The procedure is technically demanding, requiring a sound knowledge of cross-sectional limb anatomy and related pre-operative pin placement planning. On critical analysis of such cases certain mistakes were noted which could have led to the vascular injury. The Schanz screw used in case number 7 protruded too far beyond the medial femoral cortex. Transfixing wires (cases 8, 11, 12) were drilled all the way instead of initial drilling till they pierced the medial cortex and subsequent hammering. Moreover, the vascular bundle is relatively less mobile and changes its position in relation to the femur at the junction of middle and distal one third of femur as it passes through the intermuscular septum,
[1] Zitsman JL. Pseudoaneurysm after penetrating trauma in children and adolescents. J Pediatr Surg 1998;33(10):1574 – 7. [2] Rao PLNG, Rao KM, Warrior PKR. Traumatic pseudoaneurysm of the brachial artery in children. J Pediatr 1983;50:85. [3] Kerr CD, Duffey TP. Traumatic false aneurysm of the radial artery. J Trauma 1988;28:1603. [4] Akira K, Kazuya T, Koichi S. Peroneal arteriovenous fistula and pseudoaneurysm formation after blunt trauma — a case report. Clin Orthop 1994;304:218 – 21. [5] Gilroy D, Saadia R, Hide G, Demetriades D. Penetrating injury to the gluteal region. J Trauma 1992;32(3):294 – 7. [6] Landreneau RJ, Snyder WH. Pelvic abscess or pseudoaneurysm: diagnostic and therapeutic dilemma following iliac artery trauma. Am J Surg 1992;163:197 – 201. [7] Dominguez R, de Santos LA. Traumatic pseudoaneurysm of the anterior tibial artery simulating soft tissue malignancy. Skeletal Radiol 1986;15:622 – 4. [8] Morrison WG. Pseudoaneurysm and penetrating trauma. Injury 1992;23(2):127 – 8. [9] Hansky B, Murray E, Minami K, Korfer R. Delayed brachial plexus paralysis due to subclavian pseudoaneurysm after clavicular fracture. Eur J Cardiothorac Surg 1993;7:497 – 8. [10] Perry M. Complications of missed arterial injuries. J Vasc Surg 1993;17:399 – 407. [11] Graham AN, Henderson SA, McCoy GF, et al. Delayed presentation of bilateral popliteal artery injury. Eur J Vasc Surg 1992;6:673 – 6. [12] Drapanas T, Hewitt RL, Weichert RF 3rd, et al. Civilian vascular injuries. A critical appraisal of three decades of management. Ann Surg 1970;172:351. [13] Holcomb GW, Meacham PW, Dean RH. Penetrating popliteal artery injuries in children. J Pediatr Surg 1988;23:859 –61. [14] Rosenbloom MS, Fellows BA. Chronic pseudoaneurysm of the popliteal artery after blunt trauma. J Vasc Surg 1989;10:187 – 9. [15] Norris CS, Zlotnick R, Silva WE, Wheeler HB. Traumatic pseudoaneurysm following blunt trauma. J Trauma 1986;26(5):480 – 2. [16] Byenoe RP, Miles WS, et al. Noninvasive diagnosis of vascular trauma by duplex ultrasonography. J Vasc Surg 1991;14:346 –52. [17] Ricotta JJ. False aneurysm and arteriovenous fistula. In: Cameron JL, editor. Current Surgical Therapy, 4th ed. St. Louis, MO: Mosby, 1992:681 – 4. [18] Waldhausen J, Mosca V, Johansen K, Schaller R. Delayed presentation of popliteal artery injury during Ilizarov limb lengthening. Orthopedics 1998;21(4):477 – 8. [19] Jakim I, Kastanos K, Sweet MBE. Delayed presentation of a vascular injury by an Ilizarov external fixation. Injury 1993;24:135 – 6. [20] Dujon D, La Hausse-Brown TP, O’Hare P. Pseudo-aneurysm of the lateral circumflex humeral artery following external fixation of a free fibular transfer. Injury 1995;26(8):551 – 2. [21] Pankovich AM, Shivaram MS, Lim L. Infected late false aneurysm of the deep femoral artery. Clin Orthop 1981;154:208 –11. [22] Vancabeke M, Heiderich B, Bellens B, Putz P. Pseudoaneurysm of the ulnar artery following use of an external fixator— a case report. Acta Orthop Scand 1999;70(5):522 – 3. [23] Paul MA, Patka P, van Heuzen EP, Koomem AR, Rauwerda J.
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Vascular injury from external fixation: case reports. J Trauma 1992;33:917. [24] Bhrens F. General theory and principles of external fixation.
Clin Orthop 1989;241:15. [25] Paley D. Problems, obstacles and complications of limb lengthening by the Ilizarov technique. Clin Orthop 1990;250:81 –104.
Encounters with pseudoaneurysms in orthopaedic practice Anil Dhal a,*, Manish Chadha a, Hitesh Lal a, Tejveer Singh a, Sanjay Tyagi b a
Department of Orthopaedics, Maulana Azad Medical College and associated Lok Nayak Hospital, Delhi 110002, India b Department of Cardiology, Maulana Azad Medical College and associated G.B. Pant Hospital, Delhi 110002, India Accepted 12 June 2001
Abstract Thirteen pseudoaneurysms are presented of which five were caused as a complication of pin/wire placement of external fixators (one conventional and four Ilizarov frames). The most common symptom was the presence of profuse persistent bleeding from either the wound or the pin/wire site. In nine patients the pseudoaneurysm was directly caused by a fracture or subsequent fracture stabilisation. Pre-operative evaluation included radiography, arteriography, Doppler and computed tomography (CT) angiography. Depending on the site and size of the pseudoaneurysm management consisted of either ligation, resection and end-to-end anastamosis/vein grafting, lateral suture, endoaneurysmorrhaphy or selective embolisation. A high index of suspicion needs to be maintained following penetrating injury in the vicinity of a major vessel, particularly in the presence of persisting symptoms. External fixators are widely used to treat complex orthopaedic problems. The procedure is technically demanding, requiring a sound knowledge of cross-sectional limb anatomy. Injudicious use may result in potentially life/limb threatening complication of pseudoaneurysm. © 2001 Elsevier Science Ltd. All rights reserved.
1. Introduction Pseudoaneurysms are associated with penetrating injuries resulting from a tangential laceration through all the three layers of the wall of an artery. In civilian practice stab wounds, industrial accidents and road traffic accidents with/without associated fractures are the usual causes. With the use of external fixators there is an inherent risk of pseudoaneurysm caused by the insertion of pins/wires, and the added trauma of distraction. We report our experience in treating 13 cases of false aneurysm of which a significant number were caused as a result of external fixation performed on the extremities.
2. Material and methods Thirteen patients with suspected post-traumatic peripheral pseudoaneurysms were admitted to the depart* Corresponding author. Present address: G-41 Lajpat Nagar III, New Delhi 110024, India. Tel.: + 91-11-683-6146; fax: +91-11-6918788. E-mail address: [email protected] (A. Dhal).
ment of Orthopaedic surgery between 1991 and 1999. Clinical suspicion was based on the presence of, 1. profuse persistent bleeding from either the wound or pin site; 2. progressive pulsatile swelling. A detailed history and physical examination was recorded for each patient at the time of admission to determine, 1. the mode of injury; 2. site of injury; 3. associated injuries and/or complications; 4. previous operative procedures if any. Besides routine investigations, pre-operative evaluation included plain radiographs, arteriography, Doppler and computed tomography (CT) angiography. Once the diagnosis was confirmed, patients underwent exploration and appropriate stabilisation of any associated fractures. Depending on the size and site of the pseudoaneurysm surgical management consisted of either ligation, resection and end to end anastamosis/vein grafting, lateral suture or endoaneurysmorrhaphy. In two patients selective embolisation was chosen since the pseudoaneurysms were involving non-critical blood vessels. One patient recovered spontaneously.
0020-1383/01/$ - see front matter © 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 1 ) 0 0 0 9 4 - 8
A. Dhal et al. / Injury, Int. J. Care Injured 32 (2001) 771–778
772
Table 1 Patient profile according to outcome (all were male) Serial number Age (years)
Artery
Etiology
Associated injuries Procedure
Outcome
Fracture tibia and fibula Nil Fracture pelvis
Healed Healed
1
32
Posterior tibial
Bone fragment
2 3
24 34
Popletial Internal iliac
Stab injury Fracture pelvis
4
20
Anterior tibial
Proximal osteotomy
5
52
Peroneal
Sprain ankle
Fracture tibia with bone loss Nil
6
18
Brachial
Scissors
Nil
7
34
External fixator
8
18
Profunda femoris Deep femoral
9
12
Deep femoral
10 11
28 30
Deep femoral Deep femoral
12
33
Deep femoral
13
26
Common femoral
Open fracture femur Ilizarov fixator Intercondylar fracture tibia Fracture femur fragment Fracture femur Fracture femur fragment Fracture femur Ilizarov fixator Open fracture femur Ilizarov fixator with Open fracture distal femoral osteotomy femur Bullet injury Nil
Most patients were operated upon under regional anaesthesia using indwelling epidural catheters. These were retained for 48 h post-operatively for sympathetic blockade. None of the patients were heparinised. Postoperatively the limb was nursed at body level. Vasodilators and low molecular weight dextran were used in all cases. Following the surgical procedure patients were assessed clinically as well as by post-operative arteriography and Doppler studies to document resolution of the pseudoaneurysm and the continuity of arterial flow across the repair site. The patients were followed up regularly and surgical procedures for associated injuries were undertaken as necessary.
Spontaneous cure Pulses+ Lateral suture Selective embolisation Ligation
Healed
EndoaneurysmorhHealed apphy Resection and Pulses+ end to end suture Selective Pulses+ embolisation Lateral suture Pre-operative foot drop, recovered Lateral suture Pulses+, preop footdrop recovered Ligation Pulses absent, limb survived Ligation Amputation for gangrene Amputation Resection and vein graft
Primary amputation for infection and bleeding Recurrence, died due to exsanguination
Most commonly the pseudoaneurysms were caused as a complication of pin placement of external fixators (case numbers 4, 7, 8, 11, 12). Bone fragments in severely comminuted/open fractures resulted in four pseudoaneurysms (case numbers 1, 3, 9, 10). Three resulted from penetrating injuries and one from blunt trauma with no fracture (Table 2). Of the 13 patients nine (69.2%) had associated fractures which either directly caused the pseudoaneurysm or subsequent fracture stabilisation led to the same. Two patients had pre-operative footdrop as a result of pressure over the adjacent nerve. Both recovered following management of the pseudoaneurysm by lateral suture.
3. Observations and results Thirteen patients with traumatic pseudoaneurysms of the peripheral vascular system were treated in the department of Orthopaedic Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital in an 8-year period (1991– 1999; Table 1). All were male patients with an average age of 27.8 years (range 12–52 years). The commonest vessel to be involved was the deep femoral artery (five cases) while the internal iliac, profunda femoris, common femoral, popliteal, posterior tibial, peroneal, anterior tibial and brachial arteries were involved in one case each.
Table 2 Aetiology of pseudoaneurysm formation Aetiology Penetrating injury (a) Bullet injury (b) Sharp object (c) Industrial accident Iatrogenic (a) Conventional AO fixator (b) Ilizarov(ring) fixator Fracture fragments Blunt injury
Number of cases
1 2 0 1 4 4 1
A. Dhal et al. / Injury, Int. J. Care Injured 32 (2001) 771–778
The commonest presenting symptom of the pseudoaneurysms was persistent profuse bleeding, inconsistent with the magnitude of injury, several days after trauma/ external fixation from either the wound sustained as a result of the trauma or from a pin site. It should be noted that five cases (38.5%) were caused as a direct result of external fixation. One of these cases was seen with a conventional AO type of external fixation performed for an open fracture of the femur. Persistent profuse bleeding was observed from one of the pin sites, though distal pulses were palpable. The external fixator was removed by the treating surgeon and referred to us with a suspected vascular injury. An angiogram revealed a false aneurysm of a branch of the profunda femoris artery, probably injured at the time of surgery by a drill bit/Schanz screw tip. Selective embolisation was successfully performed for the pseudoaneurysm as it involved a non-critical blood vessel (Fig. 1a and b). Distraction at the corticotomy site of an Ilizarov procedure caused a pseudoaneurysm in one of our cases. A 20-year-old male was operated for gap non-union of the tibia. An Ilizarov frame was applied with a proximal tibial corticotomy for bone transport. The post-operative period was uneventful, but after nearly 2 months of distraction the patient developed frequent breakdown of soft tissue at the corticotomy site associated with profuse bleeding, which continued despite stopping distraction. An angiogram revealed a pseudoaneurysm of the anterior tibial artery. It was felt that the arterial injury resulted from a misguided osteotome. The tear may have initially sealed off by a blood clot but subsequent distraction at the osteotomy site would have increased the size of the rent and the resultant leakage led to pseudoaneurysm formation. The wounds healed following exploration and ligation of the anterior tibial artery (Fig. 2a and b). The other three cases were seen in relation to Ilizarov fixator frames applied for open fractures of the femur (case numbers 11, 12) and an open intercondylar fracture of the tibia (case number 8). The patients presented with a similar history of persistent profuse bleeding from pin sites, inconsistent with the extent of their injuries. Angiography revealed pseudoaneurysms in close proximity to the transfixing wires. One of these patients (case number 12) had to undergo primary amputation as a life saving procedure in presence of gross infection and persistent, profuse, life-threatening bleeding (Fig. 3a and b). Case number 11 had a similar presentation of infection and bleeding and underwent ligation of the femoral artery in an attempt to save the limb but gangrene resulted since there was inadequate collateral circulation and subsequent amputation was performed. In the third patient, the offending wire was removed and lateral suture done resulting in a full recovery.
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Fig. 1. (a) Angiogram of case number 7 showing a false aneurysm arising from a branch of the profunda femoris artery. (b) Following selective embolisation.
In one patient ligation was performed for a pseudoaneurysm of the femoral artery (case number 10). Distal pulses were absent following surgery. However, the limb survived with good neuromuscular function due to the excellent collateral circulation. One patient with pseudoaneurysm of the common femoral artery sustained as a result of a bullet injury (case number 13) underwent exploration followed by resection and reconstruction using a saphenous vein graft. The immediate post-operative period was uneventful. During follow up in the out patient department recurrence of the pseudoaneurysm was noticed. Angiography revealed leakage from the proximal anastamosis with a patent vein graft (Fig. 4a–c). Immediate admission for investigations and reexploration was advised but the patient refused. Subsequently, the pseu-
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doaneurysm burst with profuse bleeding and the patient died as a result of exsanguination by the time he could reach the hospital. One patient recovered spontaneously while selective embolisation was performed in two cases since the pseudoaneurysm involved non-critical blood vessels.
Fig. 3. (a) Dissected specimen of the amputated limb of case number 12. (b) The wire is placed in the lumen of the deep femoral artery, which is continuous with the sac.
The procedures performed in our study are listed in Table 3.
4. Discussion
Fig. 2. (a) Case number 4 presented with frequent breakdown of soft-tissue cover and profuse bleeding from the corticotomy site, 2 months following application of Ilizarov fixator for gap non-union tibia. (b) Angiogram of the patient revealed a pseudoaneurysm of the anterior tibial artery.
Traumatic pseudoaneurysms follow incomplete disruption of an artery and result in leakage of blood into the surrounding tissues. The uninjured portion of the arterial wall prevents the vessel from contracting leading to unbridled extravasation, which in due course organises and develops a fibrous capsule [1]. However, turbulent blood flow continues in the central region (Fig. 5). The classical presentation is that of an enlarging pulsatile swelling. A systolic bruit may be audible and a thrill may be present. Distal pulsations are usually present. Distal arterial insufficiency is therefore rare [2]. Aneurysms may mimic soft-tissue masses including abscesses, neoplasms or ganglions [3–7]. The inflammation that results subsequent to organisation of the haematoma may masquerade as an infection because local heat and tenderness are usually present. If mis-
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Fig. 4. (a) Pseudoaneurysm arising from the common femoral artery caused as a result of a gunshot injury. (b) Vascular reconstruction using saphenous vein graft after resection of the pseudoaneurysm. (c) Six weeks post-operative angiogram showing recurrence of the pseudoaneurysm at the proximal anastamosis site with a patent vein graft.
taken for an abscess, inadvertent incision and drainage will cause a major problem [1]. Hence, it is advisable to aspirate all abscesses before incision. Alertness on the part of resident doctors was instrumental in preventing such a catastrophy in two of our cases (case numbers 9, 13). Incision and drainage was abandoned when aspiration in theatre yielded blood and a subsequent angiogram and Doppler study revealed a pseudoaneurysm. Pseudoaneurysm may present at any time from hours to months after penetrating vascular injury [3] and a high index of suspicion needs to be maintained following penetrating injury in the vicinity of a major vessel, particularly in the presence of persisting symptoms [8]. Most pseudoaneurysms occur immediately following injury as a result of significant transmural arterial laceration. In a small group of patients with minor arterial wall injuries or intimal flaps these pseudoaneurysms may remain clinically undetected, progress slowly and present later with complications [9]. Thus, delayed neurological compromise may be the first indicator of a co-existing pseudoaneurysm as seen in case numbers 8 and 9. Rupture of a pseudoaneurysm into a closed osteo-fascial compartment following closed injury may present with clinical features of compartment syndrome. A fasciotomy in such situations may be life threatening. Clinical evaluation, although important, is not always accurate. Classic signs of arterial injury such as pulse deficit, bruit, arterial bleeding and expanding or pulsatile haematoma may be absent despite significant damage to the arterial wall. Many reports document the presence of
normal pulses distal to the major arterial bleeding [10–14]. This can be explained by the fact that the pulse pressure wave can be transmitted beyond an intimal flap, through soft, fresh clot or through collaterals [10]. Moreover, since there is only partial disruption of the vessel wall some flow continues across the site of the aneurysm resulting in a palpable though sometimes diminished distal pulse. False aneurysms can indeed be overlooked after trauma, especially in the pre-rupture phase. Continued surveillance of the site of injury is mandatory when the manifestations of vascular injury are delayed. Expansion of a formerly well-contained haematoma, persistence of swelling without evidence of resolution, pulsation and/or presence of a bruit, and above all occurrence of new nerve palsy in patients with a history Table 3 Procedures performed Operative procedure
Number of cases
Ligation Lateral suture Resection and (A) End-to-end suture (B) Vein graft (C) Synthetic graft Endoaneurysmorrhaphy Selective embolisation Amputation Spontaneous cure
2 3 1 1 0 1 2 2 1
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case of the Ilizarov fixator these include perforation of the artery, vein or both [24,25]. Direct vascular injury with the Ilizarov technique may occur during the initial wire insertion procedure or as a result of the distraction process [25]. Vascular injury may also occur from indirect trauma to the vessel over time as a wire placed near an artery causes erosion from constant arterial pulsations against a fixed surface [18]. Jakim et al. [19] propose that axial micromovement of a transfixation wire against an arterial wall may be an aggravating factor in progressive arterial erosion leading to late pseudoaneurysm formation. The use of thin wires is
Fig. 5. Genesis of a pseudoaneurysm.
of penetrating injury are all indications for angiography. Arteriography is useful to document lesions and evaluate deeper pseudoaneurysms [15]. It is important in those instances where reconstruction is considered, and may help in the decision to reconstruct or ligate the involved artery. Non-invasive diagnosis of vascular lesions by duplex ultrasonography has also proven useful and is reported to be 98% accurate [16]. The management of arterial pseudoaneurysms depends on their location and size, and the presence or absence of infection [17]. Some pseudoaneurysms may simply be observed if they are B10 mm in size, are asymptomatic, and involve arteries of minor importance as evident from case number 1 which recovered ‘spontaneously’ (Figs. 6a,b and 7a,b). Larger aneurysms, those that become symptomatic, or those that involve major arteries in which occlusion would threaten severe ischaemic effects generally require intervention. These lesions may warrant surgery or may be treated by invasive radiological techniques to induce pseudoaneurysm thrombosis [17]. If left alone there is a risk of expansion and ultimate rupture, which may lead to exsanguination and death as in case number 13. Resection and reconstruction was the procedure of choice for large rents. Lateral suture was the preferred technique only in those cases where there was a small rent in a large-bore vessel. In the presence of gross infection and life threatening bleeding ligation/amputation was done as a salvage procedure. Orthopaedic surgeons throughout the world are increasingly using various types of external fixators. Thus there may be an increased incidence of iatrogenic vascular injury [18–22], the incidence of which is reported to be 1% [23]. Vascular complications associated with the use of any transfixing external fixators are usually attributed to improper pin insertion technique and imprecise familiarity with cross-sectional anatomy. In the
Fig. 6. (a) Angiogram of case number 1 showing pseudoaneurysm arising from the posterior tibial artery damaged by the butterfly segment. (b) ‘Spontaneous cure’ of the pseudoaneurysm.
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rendering it more prone to iatrogenic injury. It is recommended that half pins be used in this region instead of transfixing wires.
References
Fig. 7. (a) Angiogram of case number 3 showing a pseudoaneurysm arising from rthe internal iliac artery following pelvic disruption. (b) Completion angiogram after selective embolization showing cessation of leakage.
believed to reduce the incidence of vascular injury associated with external fixation, but should this complication be recognised at the time of surgery, it may be treated by removal of the wire and application of local pressure [25]. It is interesting to note that four out of five fixator related pseudoaneurysms in our series resulted as a complication of transfixing wire fixation. In retrospect, the placement of some of these wires did not conform to the ‘safe zones’ of wire placement. The procedure is technically demanding, requiring a sound knowledge of cross-sectional limb anatomy and related pre-operative pin placement planning. On critical analysis of such cases certain mistakes were noted which could have led to the vascular injury. The Schanz screw used in case number 7 protruded too far beyond the medial femoral cortex. Transfixing wires (cases 8, 11, 12) were drilled all the way instead of initial drilling till they pierced the medial cortex and subsequent hammering. Moreover, the vascular bundle is relatively less mobile and changes its position in relation to the femur at the junction of middle and distal one third of femur as it passes through the intermuscular septum,
[1] Zitsman JL. Pseudoaneurysm after penetrating trauma in children and adolescents. J Pediatr Surg 1998;33(10):1574 – 7. [2] Rao PLNG, Rao KM, Warrior PKR. Traumatic pseudoaneurysm of the brachial artery in children. J Pediatr 1983;50:85. [3] Kerr CD, Duffey TP. Traumatic false aneurysm of the radial artery. J Trauma 1988;28:1603. [4] Akira K, Kazuya T, Koichi S. Peroneal arteriovenous fistula and pseudoaneurysm formation after blunt trauma — a case report. Clin Orthop 1994;304:218 – 21. [5] Gilroy D, Saadia R, Hide G, Demetriades D. Penetrating injury to the gluteal region. J Trauma 1992;32(3):294 – 7. [6] Landreneau RJ, Snyder WH. Pelvic abscess or pseudoaneurysm: diagnostic and therapeutic dilemma following iliac artery trauma. Am J Surg 1992;163:197 – 201. [7] Dominguez R, de Santos LA. Traumatic pseudoaneurysm of the anterior tibial artery simulating soft tissue malignancy. Skeletal Radiol 1986;15:622 – 4. [8] Morrison WG. Pseudoaneurysm and penetrating trauma. Injury 1992;23(2):127 – 8. [9] Hansky B, Murray E, Minami K, Korfer R. Delayed brachial plexus paralysis due to subclavian pseudoaneurysm after clavicular fracture. Eur J Cardiothorac Surg 1993;7:497 – 8. [10] Perry M. Complications of missed arterial injuries. J Vasc Surg 1993;17:399 – 407. [11] Graham AN, Henderson SA, McCoy GF, et al. Delayed presentation of bilateral popliteal artery injury. Eur J Vasc Surg 1992;6:673 – 6. [12] Drapanas T, Hewitt RL, Weichert RF 3rd, et al. Civilian vascular injuries. A critical appraisal of three decades of management. Ann Surg 1970;172:351. [13] Holcomb GW, Meacham PW, Dean RH. Penetrating popliteal artery injuries in children. J Pediatr Surg 1988;23:859 –61. [14] Rosenbloom MS, Fellows BA. Chronic pseudoaneurysm of the popliteal artery after blunt trauma. J Vasc Surg 1989;10:187 – 9. [15] Norris CS, Zlotnick R, Silva WE, Wheeler HB. Traumatic pseudoaneurysm following blunt trauma. J Trauma 1986;26(5):480 – 2. [16] Byenoe RP, Miles WS, et al. Noninvasive diagnosis of vascular trauma by duplex ultrasonography. J Vasc Surg 1991;14:346 –52. [17] Ricotta JJ. False aneurysm and arteriovenous fistula. In: Cameron JL, editor. Current Surgical Therapy, 4th ed. St. Louis, MO: Mosby, 1992:681 – 4. [18] Waldhausen J, Mosca V, Johansen K, Schaller R. Delayed presentation of popliteal artery injury during Ilizarov limb lengthening. Orthopedics 1998;21(4):477 – 8. [19] Jakim I, Kastanos K, Sweet MBE. Delayed presentation of a vascular injury by an Ilizarov external fixation. Injury 1993;24:135 – 6. [20] Dujon D, La Hausse-Brown TP, O’Hare P. Pseudo-aneurysm of the lateral circumflex humeral artery following external fixation of a free fibular transfer. Injury 1995;26(8):551 – 2. [21] Pankovich AM, Shivaram MS, Lim L. Infected late false aneurysm of the deep femoral artery. Clin Orthop 1981;154:208 –11. [22] Vancabeke M, Heiderich B, Bellens B, Putz P. Pseudoaneurysm of the ulnar artery following use of an external fixator— a case report. Acta Orthop Scand 1999;70(5):522 – 3. [23] Paul MA, Patka P, van Heuzen EP, Koomem AR, Rauwerda J.
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A. Dhal et al. / Injury, Int. J. Care Injured 32 (2001) 771–778
Vascular injury from external fixation: case reports. J Trauma 1992;33:917. [24] Bhrens F. General theory and principles of external fixation.
Clin Orthop 1989;241:15. [25] Paley D. Problems, obstacles and complications of limb lengthening by the Ilizarov technique. Clin Orthop 1990;250:81 –104.