Popliteal artery war injuries

Popliteal artery war injuries

ELSEVIER SCIENCE! PII: S0967-2109(96)00067.1 Cardiovascular Surgery, Vol. 5, No, 1, pp.37-41, 1997 Q 1997The lntemationd Societyfor CardiovascularSu...

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ELSEVIER SCIENCE!

PII: S0967-2109(96)00067.1

Cardiovascular Surgery, Vol. 5, No, 1, pp.37-41, 1997 Q 1997The lntemationd Societyfor CardiovascularSurge~ Publishedby Elsevier ScienceLtd. Printed in Great Britain 0967-2109/97$17.(XI+ 0,00

Poplitealarterywar injuries L.Davidovi6, S. Lotina,D. Kostit,D.Velimirovit, P. Dukit,1.~inara,M.Vrane5 and M.Markovit The Institutefor Cardiovascular Diseases,MedicalCentreof Serbia, 8, DrKoste Todorovika, 11000 Belgrade,Yugoslavia The earlypostoperativeresultsof 44 surgicallytreatedpoplitealarterialinjuriesfrom the Yugoslavcivilwararereported.Ofthesepatients,41 (93%)weremalesandthree(7%) were females,averageagewas28 (range6-45) years.Twentypatients(4!3%)hadgunshotwounds and 24 (SS%)explosivewounds.Twelve(280A)sufferedisolatedvasculardamage,while32 (72%) sufferedconcomitantbonefractures.Isolatedarteriallesionswerefoundin 24 (SS%) cases,andconcomitantarterialandvenouslesionsin 20 (4!?10A). Twenty-four(!3!3%)hadprimaryreconstructions afterhaemostasisin the initialwar hospital,and 20 (4!3%)secondary reconstructions after inadequateprimaryreconstructionin a regionalwar hospital.Artery proceduresincluded19 reversesaphenousveingraft interpositions, 10 reversesaphenous veinbypasses,12 ‘insitu’ saphenousveinbypassesandfivelateralsubcutaneoussaphenous veinbypasses.Theearlygraftpateneyratewas 100%,and limbsalvage72%. Majoramputationwasperformedin28%.Concomitant bonefractures,secondaryreconstructions, secondary hemorrhage from an infectedgraft, and explosionwoundssignificantly increasedthe amputationrate(P< 0.01). Elevenamputations wereperformedafteran anatomic,andonly one afteran extra-anatomic reconstruction (P <0.01 ). Theauthorsrecommendan in situ or lateralsubcutaneousreconstruction in casesof complicatedpoplitealarteryinjuries,suchas concomitantbone fracturesaccompaniedby massivesoft tissuedamage,and this type of reconstruction shouldalsobe usedif infectionis presentor the procedureis delayed.01997 The International Societyfor Cardiovascular Surgery. Keywords:popliteal artery, war injury

An analysisof vasculartraumareportedduringwars during the presentcenturyshows a high incidence of popliteal arteryinjuries.Makinsl reported that 12.1’%0of all vascularinjurieswere to the popliteal arteryin theFirstWorldWar,DeBakeyandSirneone2 noted 20.9°/0from the Second World War, Hughes3 reported25.9Y0from the Koreanconflict, and Rich and Spencer4reported21.7°/0fromtheVietnamwar. Major amputationis veryoften the outcome after inadequatelytreatedpoplitealarterytrauma.Giordanegoet aZ.5reportedthat25-40Y0of poplitealartery injuriesresultedin amputation,while Sfeirand col-

Correspondence to: Dr L. Davidovk

CARDIOVASCULAR SURGERY FEBRUARY1997 VOL5 NO 1

leaguesGreported 11.9°/0 amputation from the Lebanon and Radonic et aZ.730.8’XO from Croatia. The aims of the presentstudyare to presentthe earlypostoperativeintra-hospitalresultsof popliteal arteryinjuriestreatedsurgicallyduringthe Yugoslav civil war, and to presenta new operativetechnique which was consideredto have helped preventmore major amputations.

Patients and methods BetweenDecember 1991 and November 1994, 137 war-woundedfrom theYugoslavcivilwarwereoperatedon at the Institutefor CardiovascularDiseases, Belgrade.Some 44 (30.5Yo)had a poplitealartery injury, 40 (91’XO)being soldiers, and four (9’%0) civilians.The averageagewas28 (range6–45) years; 37

Popliteal arterywar iqjuries:L. Davidovitet al. Table 1 Characteristicsof popliteal artery injuries Type of injury

No. of wounds

Gunshotwounds Explosivewounds Total

20 (45) 24 (55) 44 (loo)

Vascularlesiononly Bonefracture Total

12 (2B) 32 (72 44

Artery Artery + vein Total

20 (45) 44 (loo)

(loo)

24 (55)

Valuesin parenthesesare percentages.

41 (93VO)were males and three (7’Yo)females. Twenty (45Yo)had gunshotwounds and 24 (55%) explosivewounds. An isolatedvascularlesion was found in 12 cases(28’Yo),whilea concomitantlesion (bone, nervesor soft tissue)was found in 32 cases (72%). Thirty-two (72%) of the wounded had a bone fracture(20 tibialplateaufracturesand 12fracturesof the femur). Tibial nerveinjurywas present in 10 cases (200/0).Massive SOI?tissue damage or completetissueloss was seenin all 24 patientswith explosiveinjuries.Isolatedpopliteal arteryinjuries were found in 24 cases (55’Yo)and an associated venous injury in 20 cases (45Yo). Four of the wounded had a post-traumaticarteriovenousfistula,and two had a pseudoaneurysmof thepopliteal artery(Table 1; Fzjyzres1 and 2). The wounded comprised two groups. Group 1 included 24 (55°/0)wounded who had had urgent surgeryto preventbleeding (arterialandlor venous ligatures)undertakenat the initialwarhospitalnear to the battlefield. Group 2 included 20 (45’XO)

Figure 1

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Pseudoaneurysms of the popliteai artery

wounded who had undergonesome form of reconstruction carried out in a regional war hospital. Group 1 had ischaemic limbs and group 2 had ischaemiain 10 cases and secondaryhemorrhage from an infected graft in 10 cases. Preoperative Doppler sonographyand angiographicexamination were performed in all 24 cases from group 1 (primaryreconstruction)and in the 10 cases from group 2 who had signs of ischaemia (secondary reconstruction).Ten patientsfrom group 2 who were haemorrhagingwere operated on urgently, withoutany preoperativediagnosticprocedures. Reconstructionwas performedjust aftersystematic heparinization.Patientswere given antibiotics duringthe operationand a cephalosporinwas combined with an aminoglycosideantibioticfor 5 days aftersurgery. Furtherantibioticprotectionwasgivendepending on thepresenceor absenceof infection,and the culture and sensitivityof the organism. The reconstructiveproceduresare presentedin Table 2. In 19 cases a reversedipsi- or contralaterallong saphenousvein graft with end-to-end anastomosis betweenthe poplitealarteryand the graftswasused CARDIOVASCLMR SURGERY FEBRUARY1997 VOL S NO 1

Popliteal artery war injuries: L. Davidovit et al. Table Z Surgicalprocedures Procedure

Arterial

Ligature Graft interposition Bypass In situ bypass Lateralsubcutaneous Total

Venous

10 19

5 5

10 10



5



44

20

in the anatomicposition(poplitealspace) (shownas graftinterpositionin Table 2). In 10 cases a reversed ipsi- or contralateral saphenousvein graftwas used with two end-to-side anastomoses(betweenthe poplitealarteryandgraft) in the anatomicposition(poplitealspace) (shownas bypassin Table 2). Extra-anatomicbypass procedures were performed in 17 cases with concomitantbone fractures accompaniedby massivesoft tissuedamage,as well as cases with infection and in patientshavinglate secondaryreconstructionwith an occluded primary implantedgraft or a reconstructedartery.Twelve caseshad aninsitubypass(valvulotomizedipsilateral long saphenousvein) from the superficialfemoralto the posteriortibialartery.This procedurewas only used in caseswhere the skin and soft tissueabove the saphenousveinremainedintact.In the otherfive cases,an extra-anatomiclateralsubcutaneousbypass from the superficialfemoral arteryto the anterior tibialarterywas performedand the saphenousvein was taken from the contralateralleg. There were some caseswherethe skin and subcutaneoustissue above the ipsilateralsaphenousvein was deficient. All 32 caseswith bone fractureshad an external fixator applied. In 24 cases this was performed before any vascularreconstructionin the temporary initialwarhospital,whilein eightcasesit wascarried Table 3

Figure 3 The ‘insitu’ bwassfrom the superficialfemoralto the posterior tifial artery in caseof e;plosive injury of ”the popliteal artery

out at the authors’ institutejust before vascular reconstruction. Fifieen (34’Yo)of the presentpatientswere operated on at a very late stage, more than 6 h after injury.The averagetimefor the primaryreconstruction was 1 day (range 12 hours to 2 days), and for the secondaryreconstruction,3 (range 1–30) days.

Amputation rates

Surgerydetails

No. of wounds

No. of amputations

P

Gunshotwounds Explosivewounds Concomitantbone fracture Yes No La@operations Yes No Primary reconstruction Secondaryreconstruction Anatomicreconstruction Extra-anatomicreconstruction

20 24

2 (lo) 10 (41)

<0.01

32 12

12 (40)

15 29 24

12 (80)

20 24 15

10 (50) 11 (34) 1 (6)

o (o) o (o) 2 (8)

<0.01 <0.01 <0.01 <0.01

Valuesin parenthesesare percentages.

CARDIOVASCULAR SURGERY FEBRUARY1997 VOL 5 NO 1

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Popliteal artery war injuries:

L. Davidovit et al. and concomitant bone fractures; (ii) two amputationswerecarriedout afiera primary,and 10 after a secondaryreconstruction(P< 0.01); (iii) 11 amputations were performed after an anatomical (reversedlong saphenousvein graftinterpositionor bypasswithreversedsaphenouslong vein), and one after an extra-anatomicalreconstruction (in situ bypass or lateral subcutaneous reversed long saphenousveinbypass)(P< 0.01); and (iv) two amputationswereperformedfollowinggunshotwounds and 10 afterexplosivewounds (P< 0.01) (Table 3). Graft infection with secondaryhemorrhage occurred in 14 cases (31Yo). In 12 cases major amputationhad to be performed,and in two other casesan infectedzrafthad to be removed.so thata new extra-anatom~c bypasshad to be carried out. Those werebypassesfrom the superficialfemoralto the anterior tibial artery with the contralateral saphenousvein.

Discussion

Figure 4 The extra-anatomicbypassfrom the superficialfemoral to the anterior tibial artery asa reoperation.Duringthe primary operationa graft interposition was completeddue to a gunshot injury. The secondaryhemorrhage causedby an infected graft was a reasonfor the secondary extra-anatomicoperation

All of thesecasesdevelopeda late revascularization syndrome (compartmentsyndromeassociatedwith typicalmetabolicchanges).Fasciotomieswere performed in thesecasesjust afterthe reconstructions, followed by necrectomy of the non-vital muscles. These cases were also treatedmedicallyto prevent renalfailure. Graftpatencywas examinedphysicallyby palpating the pedalpulses,as well as usingDoppler sonography. Only the earlypostoperativeintra-hospital resultsare presentedin this report.

Results No patient died during operation in the cases treated. The early graft patency rate was 100Yo, while limb salvageratewas 72°/0. Major amputations(above or below the knee) were carriedout in 12 cases (28Yo).Analysisof the amputeesshowed that: (i) the wounded who had amputationshad late revascularizationsyndrome

The high amputationratewhich occurs afterpopliteal arteryinjuryis usuallythe resultof prolonged distalischaemiaor secondaryhemorrhage caused by an infection. Infection after reconstructioncan arisefrom concomitantbone fractures,massivesoft tissue damage,or tunneling of the vasculargrafts througha contaminatedanatomicalpoplitealspace. The amputationrate afterpoplitealarterydamage increasesin cases where the surgeryis late, or the poplitealarterydamageincreasesin caseswherethe surgeryis late or the operationis a secondaryprocedure. Some authorspoint out thatlate surgeryis a bad prognosticfactor. In the study by RadoniLet al.7 of 26 popliteal arterywar injuries,the averagetime between the traumaoccurring and subsequentsurgerywas 9.8 (range2-30) h, with an amputationrateof 30.8%. Sfeir and colleagues in the Lebanon also reported late surgeryto the damagedpoplitealarteryto be a bad prognosticfactor.In 65Y0of the casesreported by Gosselinand co-workers8,amputationhad to be performedwhenthe initialoperationwascarriedout 12 or more hours afterinjury. The presentdata show the averagetime to be 1 day (range12 hoursto 2 days)betweentraumaand primaryreconstructionand 3 (range 1–30) daysfor secondaryreconstruction.All presentcasesof amputationhad concomitantbone fractures.In mostcases of secondaryreconstmction(10–12), and explosive wounds (10 of 24), amputation was eventually required. It is impossible to influence the nature of the trauma(e.g. concomitantlesion) or the time of the operation;however, it is possible to influence the graft position. Consequently, the authors have changed to extra-anatomicoperationsafier unsucCARDIOVASCULAR SURGERY FEBRUARY1997 VOLS NO 1

Poplitealartery war i~”uries:L. Davidovk et al.

cessful primary anatomic operations,especiallyin caseswithinfectedgraftsandconcomitantbone fracturesaccompaniedby massivesofi tissuedamage. Two approacheswere attempted.First,if an ipsilateralsaphenousvein was patent,and the skin as well as the sofi tissueabove the vein was not damaged,an ‘in situ’bypass(withvalvulotomizedipsilaterallong saphenousvein) from the superficialfemoral to the posterior tibial artery was performed (Fi@we3). Second, if an ipsilateralsaphenousvein was not patent,or if the skinand soft tissueabove the vein were damaged, an extra-anatomicbypass from the superficialfemoral to the anteriortibial arterywas placed laterallysubcutaneously,using a contralateralreversedsaphenousvein (Figure4). Of 17 extra-anatomicbypasses (in situ and lateral subcutaneous),only one graftinfectionoccurredand one amputationrequired. The poplitealvein wasreconstructed,when possible. In 10 of the presentcases(50°/0)reconstruction was carriedout an in 10 cases(50°/0)a ligaturewas applied,as a resultof and infectionin the popliteal space.In a seriesof 79 lower-extremity venousinjuries, Yelon and Scaka9had to carryout 48 ligatures and 31 reconstructions;some 86°/0of the patients treatedby ligationwere completelyfree of oedema at discharge.

CARDIOVASCULAR SURGERY FEBRUARY1997 VOL 5 NO 1

The present authors therefore recommend extra-anatomic reconstruction (in situ or lateral subcutaneous)of the injuredpoplitealarteryin complicated cases such as concomitantbone fractures accompaniedby massivesoft tissue damage or in cases of infection or in late secondaryreconstructions.

References 1. Makins GH. Gunshot Injuriesof the Blood Vessels.John Wright and Sons Ltd, Bristol, UK, 1919. 2. DeBakey ME, Simeone FA. Battle injuries of arteriesin World War II: an analysisof 2471 cases.Arm Surg 1946; 123: 534. 3. Hughes CW. Acute vasculartrauma in the Korean War. Casualties:an analysisof 180 cases. SurgGynecolObstet 1854; 99: 91. 4. Rich NM, Spencer FC, eds. Vascular Trauma.W.B. Saunders Corp, Philadelphia,London, Toronto, 1979. 5. Giordanego F, Felist R, Cugnasca M, Giufida GF. Traumatic lesions of the popliteal artery.Minerua Chir 1989; 44: 1207–11. 6. SfeirRE, Khoury GS, Haddad FF etal. The injuryto thepopliteal vessels: the Lebanese War experience. World 3 Swg 1992; 16: 11569. 7. Radoni6 V, Baric D, PetricevicA et al. Military injuries of the poplitealvesselsin Croatia.~ GmiiozxzscSurg 1994; 35: 27–32. 8. Gosselin RA, SiebergCJ, Coupland R, AgerskovK. Outcome of arterialrepairsin 23 consecutivepatientsat the ICRC-Peshawar hospital for war wounded. 3 Trauma 1993; 34: 373–6. 9. Yelon JA, ScakaTM. Venous injuriesof the lowerextremitiesand pelvis: repairversusligation.3 Trauma 1992; 33: 523–6. Paper accepted 14 August 1996

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