Eur J VascSurg 6, 673-676(1992)
CASE REPORT Delayed Presentation of Bilateral Popliteal Artery Injury A. N. J. Graham, ~ S. A. Henderson, 2 G. F. McCoy, 2 G. G. C o o p e r ~ and J. M. Hood I
1Vascular Surgery Unit and 2Fracture Clinic, The Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland We describe a patient who developed serious vascular complications following gunshot wounds to both poplitealfossae. There was minimal evidence of vascular injury on presentation to hospital, in particular ankle systolic pressures were normal. Five days following the initial injuries he was found to have a false aneurysm of the popliteal artery in his right leg and an arteriovenous fistula affecting the popliteal vessels of his left leg. The roles of arteriography and Doppler pressure studies in assessment of possible peripheral vascular injury following penetrating trauma are discussed. It is emphasised that a high index of suspicion and careful clinical review is essential if vascular injuries and their complications are not to be missed. Key Words: Penetrating wounds; Vascular injuries; Delayed diagnosis.
Introduction
Case History
In patients with penetrating injuries of the popliteal region, suspicion of arterial injury is based on the findings of clinical examination. While some authors contend that careful evaluation will detect abnormalities in all patients with major arterial injuries, 1 others have advocated the routine use of arteriography when there is a wound in the proximity of the popliteal artery. 2-4 The signs of arterial injuries have been classified as "hard" (distal ischaemia or pulse deficit, a bruit, expanding haematoma, arterial bleeding) and "soft" [stable haematoma, adjacent nerve injury, unexplained hypotension (less than 90 mmHg systolic) or the proximity of the penetrating w o u n d to underlying major blood vessels]. In the presence of "hard" signs the indications for surgical exploration are clear. In those with "soft" signs, however, the decision is more difficult with a risk that arterial injury may be overlooked. There has been recent interest in using Doppler ankle pressures to select patients for arteriography, 4"5 although there have been no reports as to its effectiveness. We describe a patient with "soft" signs of arterial injury and normal systolic pressures at the ankles who developed significant complications of popliteal artery injury in both legs.
A 26-year-old security guard was abducted by a terrorist organisation. He was forced to lie prone and was shot from close range in both popliteal fossae with a low velocity hand gun. There were bullet entry wounds in both popliteal fossae with exit wounds above the patellae. There were normal popliteal and pedal pulses bilaterally. No bruits were heard. His brachial arterial pressure was 90mmHg. His right posterior tibial arterial pressure was 100mmHg and left posterior tibial arterial pressure was 105mmHg (ankle-brachial pressure indices 1.11 and 1.17, respectively). Sensation was diminished on the plantar aspect of the right foot. Radiographs showed that the bullets had passed through the lower ends of both femora (Fig. 1). Wound debridement was carried out promptly under general anaesthesia, during which bleeding occurred from the popliteal w o u n d on the right side. As this was easily controlled by pressure no further action was taken. Three days later, the patient complained of a painful, swollen right calf. A venogram showed extensive thrombus in the deep veins of the right leg and distortion of the distal 5-6 cm of the femoral vein were consistent with external compression. Intravenous (i.v.) heparin therapy was commenced. On the fifth postoperative day a pulsatile mass was noted in the right antero-medial thigh deep to the exit wound. Digital subtraction angiography demonstrated a 4 cm diameter false aneurysm of the right
Please address all correspondence to: A. N. J. Graham, Surgical Registrar, BelfastCity Hospital, BT9 7AB,Northern Ireland. 0950-821X/92/060673+04$08.00/0© 1992Grune & Stratton Ltd.
674
A.N. J, Graham et aL
Fig. 1. Bullet track through lower end of right femur.
popliteal artery and an arterio-venous fistula between the left popliteal artery and vein (Fig. 2). The false aneurysm was repaired by excision of the affected segment of the artery with restoration of continuity by an interposition vein graft. The arteriovenous fistula was repaired by vein patch angioplasty of the popliteal artery and direct suture of the popliteal vein. Both procedures were performed via a standard medial approach. There were no postoperative complications.
Discussion
Penetrating injury to the popliteal fossa inflicted by a low velocity hand gun has been the most common cause of arterial injury in our hospital for almost 20 years. Despite this pattern of injury, administered as a form of punishment by a number of paramilitary groups, the popliteal vessels are not injured in the majority of victims. The general approach to the management of popliteal vessel injuries in Belfast has previously been described, 6"7 i.e. prompt surgical exploration of the popliteal vessels when clinical examination has raised the suspicion of arterial injury. Arteriography is used sparingly to evaluate patients with equivocal signs of arterial injury, late Eur J VascSurg Vol 6, November1992
referrals from other centres or failure of a previous vascular repair. With this approach an amputation rate of 5.1% has been documented at our hospital, the lowest reported for this type of injury, s The frequency with which vascular injuries are missed at initial evaluation has not been clearly defined. However, it is known that between 5-8% of arterial injuries present with either a false aneurysm or an arteriovenous fistula. 9 In 9-25% 1"2° of arterial injuries, the distal pulses are normal, thus causing inexperienced clinicians to ignore the possibility of vascular trauma. In an attempt to reduce the incidence of missed vascular injuries following penetrating trauma, several different management policies have been advocated. Routine surgical exploration of all wounds in the proximity of a major artery has been proposed, ~1but was associated with a negative exploration rate of 64%, a morbidity of 5% and mortality of 0.04% in one major study. ~2 Surgical exploration may also miss significant arterial injuries. 23 The routine use of arteriography when there is proximity of the wound to vascular structures has been advocated. 2-4 Recent reports, 2"5 however, have questioned the necessity of this as many of the injuries detected were insignificant and the procedure itself had complications. The low detection rate of 6.7-12% 3,5 has discouraged us from performing
Bilateral Popliteal Artery Injury
675
Fig. 2. Digital subtraction arteriogram of popliteal vessels. (a) False aneurysm of right popliteaI artery; (b) arterio-venous fistula between left popliteaI vessels.
routine arteriography for proximity wounds in the absence of other signs. Although there has been interest in the use of Doppler pulse pressures to identify patients with limb injuries who should have arteriography, the predictive efficiency of this test has not been defined. Our patient's case history illustrates that significant complications may develop despite normal findings at presentation. Serial measurements may be more useful although we did not perform them. In retrospect, the bleeding observed at w o u n d debridement and the distortion of venous anatomy at venography might have led us to diagnose arterial injury at an earlier stage. The heparin used to treat our patient's femoro-popliteal venous thrombosis may have played a role in the presentation of the arterial complications. Patients on anticoagulant therapy at the time of diagnostic arterial puncture have been found to be at a four-fold risk of developing iatrogenic arterial complications. 14 Our patient, however, was not anticoagulated until three days after injury. In our opinion, a high index of suspicion, regular
re-examination and selective use of arteriography are important principles in the management of patients with penetrating wounds in the proximity of major arteries. Doppler derived pedal artery pressures may be a helpful additional test in the lower limb but may lack sensitivity for arterial injury.
References 1 Rose SC, MooR5 EE. Trauma angiography: the use of clinical findings to improve patient selection and case preparation. J Trauma 1988; 28: 240-245. 2 SNYDERWH, THALER, BRIDGESRA, GERLOCKAJ,PERRYMO, FRY WJ. The validity of normal arteriography in penetrating trauma. Arch Surg 1978; 11: 424-428. 3 MENZOIANJO, DOYLEJE, LOGERFOFW, CANTELMON, WEITZMAN AF, SEQUIERAJC. Evaluation and management of vascular injuries of the extremities. Arch Surg 1983; 118: 93-95. 4 FELICIANODV, CRUSE PA, BURCH JM, BITONDO CG. Delayed diagnosis of arterial injuries. Am J Surg 1987; 154: 579-584. 5 REID JDS, WEIGELT JA, THAL ER, FRANCIS H. Assessment of proximity of a wound to major vascular structures as an indication for arteriography. Arch Surg 1988; 123: 942-946. Eur J Vasc Surg Vol 6, November 1992
676
A.N. J, Graham et aL
60'REILLY MJG, HOOD JM, LIVINGSTONRH, IRWINJWS. Penetrating injuries of the popliteal artery. Br J Surg 1978; 65: 789-792. 7 BARROSD'SA AAB, HASSARD TH, LIVINGSTONRH, IRWIN JWS. Missile-induced vascular trauma. Injury 1980; 12: 13-20. 8 BARROS D'SA AAB. A decade of missile induced vascular trauma. Ann R Coll Surg Engl 1982; 64: 37-44. 9 RICH NM, HOBSON RW, COLLINS GJ. Traumatic arteriovenous fistulas and false aneurysms: a review of 588 lesions. Surgery 1975; 78: 817-828. 10 TURCOTTE JK, TOWNE JB, BERNHARD VM. Is arteriography necessary in the management of vascular trauma of the extremities? Surgery 1978; 84: 557-562.
Eur J Vasc Surg Vol 6, November 1992
11 PERRYMO, THAL ER, SHIRES GT. Management of arterial injuries. Ann Surg 1971; 173: 403-408. 12 SIRINEK KR, LEVINE BA, GASKILEHV, ROOT HD. Reassessment of the role of routine operative exploration in vascular trauma. ] Trauma 1981; 21: 339-344. 13 RICHARDSON JD, VITALE GC, FLINT LM. Penetrating arterial trauma. Analysis of missed vascular injuries. Arch Surg 1987; 122: 678-683. 14 MORTENSENJD. Clinical sequelae from arterial needle puncture, cannulation and incision. Circulation 1967; 35: 1118-1123.
Accepted 2 March 1991
CASE REPORT Delayed Presentation of Bilateral Popliteal Artery Injury A. N. J. Graham, ~ S. A. Henderson, 2 G. F. McCoy, 2 G. G. C o o p e r ~ and J. M. Hood I
1Vascular Surgery Unit and 2Fracture Clinic, The Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland We describe a patient who developed serious vascular complications following gunshot wounds to both poplitealfossae. There was minimal evidence of vascular injury on presentation to hospital, in particular ankle systolic pressures were normal. Five days following the initial injuries he was found to have a false aneurysm of the popliteal artery in his right leg and an arteriovenous fistula affecting the popliteal vessels of his left leg. The roles of arteriography and Doppler pressure studies in assessment of possible peripheral vascular injury following penetrating trauma are discussed. It is emphasised that a high index of suspicion and careful clinical review is essential if vascular injuries and their complications are not to be missed. Key Words: Penetrating wounds; Vascular injuries; Delayed diagnosis.
Introduction
Case History
In patients with penetrating injuries of the popliteal region, suspicion of arterial injury is based on the findings of clinical examination. While some authors contend that careful evaluation will detect abnormalities in all patients with major arterial injuries, 1 others have advocated the routine use of arteriography when there is a wound in the proximity of the popliteal artery. 2-4 The signs of arterial injuries have been classified as "hard" (distal ischaemia or pulse deficit, a bruit, expanding haematoma, arterial bleeding) and "soft" [stable haematoma, adjacent nerve injury, unexplained hypotension (less than 90 mmHg systolic) or the proximity of the penetrating w o u n d to underlying major blood vessels]. In the presence of "hard" signs the indications for surgical exploration are clear. In those with "soft" signs, however, the decision is more difficult with a risk that arterial injury may be overlooked. There has been recent interest in using Doppler ankle pressures to select patients for arteriography, 4"5 although there have been no reports as to its effectiveness. We describe a patient with "soft" signs of arterial injury and normal systolic pressures at the ankles who developed significant complications of popliteal artery injury in both legs.
A 26-year-old security guard was abducted by a terrorist organisation. He was forced to lie prone and was shot from close range in both popliteal fossae with a low velocity hand gun. There were bullet entry wounds in both popliteal fossae with exit wounds above the patellae. There were normal popliteal and pedal pulses bilaterally. No bruits were heard. His brachial arterial pressure was 90mmHg. His right posterior tibial arterial pressure was 100mmHg and left posterior tibial arterial pressure was 105mmHg (ankle-brachial pressure indices 1.11 and 1.17, respectively). Sensation was diminished on the plantar aspect of the right foot. Radiographs showed that the bullets had passed through the lower ends of both femora (Fig. 1). Wound debridement was carried out promptly under general anaesthesia, during which bleeding occurred from the popliteal w o u n d on the right side. As this was easily controlled by pressure no further action was taken. Three days later, the patient complained of a painful, swollen right calf. A venogram showed extensive thrombus in the deep veins of the right leg and distortion of the distal 5-6 cm of the femoral vein were consistent with external compression. Intravenous (i.v.) heparin therapy was commenced. On the fifth postoperative day a pulsatile mass was noted in the right antero-medial thigh deep to the exit wound. Digital subtraction angiography demonstrated a 4 cm diameter false aneurysm of the right
Please address all correspondence to: A. N. J. Graham, Surgical Registrar, BelfastCity Hospital, BT9 7AB,Northern Ireland. 0950-821X/92/060673+04$08.00/0© 1992Grune & Stratton Ltd.
674
A.N. J, Graham et aL
Fig. 1. Bullet track through lower end of right femur.
popliteal artery and an arterio-venous fistula between the left popliteal artery and vein (Fig. 2). The false aneurysm was repaired by excision of the affected segment of the artery with restoration of continuity by an interposition vein graft. The arteriovenous fistula was repaired by vein patch angioplasty of the popliteal artery and direct suture of the popliteal vein. Both procedures were performed via a standard medial approach. There were no postoperative complications.
Discussion
Penetrating injury to the popliteal fossa inflicted by a low velocity hand gun has been the most common cause of arterial injury in our hospital for almost 20 years. Despite this pattern of injury, administered as a form of punishment by a number of paramilitary groups, the popliteal vessels are not injured in the majority of victims. The general approach to the management of popliteal vessel injuries in Belfast has previously been described, 6"7 i.e. prompt surgical exploration of the popliteal vessels when clinical examination has raised the suspicion of arterial injury. Arteriography is used sparingly to evaluate patients with equivocal signs of arterial injury, late Eur J VascSurg Vol 6, November1992
referrals from other centres or failure of a previous vascular repair. With this approach an amputation rate of 5.1% has been documented at our hospital, the lowest reported for this type of injury, s The frequency with which vascular injuries are missed at initial evaluation has not been clearly defined. However, it is known that between 5-8% of arterial injuries present with either a false aneurysm or an arteriovenous fistula. 9 In 9-25% 1"2° of arterial injuries, the distal pulses are normal, thus causing inexperienced clinicians to ignore the possibility of vascular trauma. In an attempt to reduce the incidence of missed vascular injuries following penetrating trauma, several different management policies have been advocated. Routine surgical exploration of all wounds in the proximity of a major artery has been proposed, ~1but was associated with a negative exploration rate of 64%, a morbidity of 5% and mortality of 0.04% in one major study. ~2 Surgical exploration may also miss significant arterial injuries. 23 The routine use of arteriography when there is proximity of the wound to vascular structures has been advocated. 2-4 Recent reports, 2"5 however, have questioned the necessity of this as many of the injuries detected were insignificant and the procedure itself had complications. The low detection rate of 6.7-12% 3,5 has discouraged us from performing
Bilateral Popliteal Artery Injury
675
Fig. 2. Digital subtraction arteriogram of popliteal vessels. (a) False aneurysm of right popliteaI artery; (b) arterio-venous fistula between left popliteaI vessels.
routine arteriography for proximity wounds in the absence of other signs. Although there has been interest in the use of Doppler pulse pressures to identify patients with limb injuries who should have arteriography, the predictive efficiency of this test has not been defined. Our patient's case history illustrates that significant complications may develop despite normal findings at presentation. Serial measurements may be more useful although we did not perform them. In retrospect, the bleeding observed at w o u n d debridement and the distortion of venous anatomy at venography might have led us to diagnose arterial injury at an earlier stage. The heparin used to treat our patient's femoro-popliteal venous thrombosis may have played a role in the presentation of the arterial complications. Patients on anticoagulant therapy at the time of diagnostic arterial puncture have been found to be at a four-fold risk of developing iatrogenic arterial complications. 14 Our patient, however, was not anticoagulated until three days after injury. In our opinion, a high index of suspicion, regular
re-examination and selective use of arteriography are important principles in the management of patients with penetrating wounds in the proximity of major arteries. Doppler derived pedal artery pressures may be a helpful additional test in the lower limb but may lack sensitivity for arterial injury.
References 1 Rose SC, MooR5 EE. Trauma angiography: the use of clinical findings to improve patient selection and case preparation. J Trauma 1988; 28: 240-245. 2 SNYDERWH, THALER, BRIDGESRA, GERLOCKAJ,PERRYMO, FRY WJ. The validity of normal arteriography in penetrating trauma. Arch Surg 1978; 11: 424-428. 3 MENZOIANJO, DOYLEJE, LOGERFOFW, CANTELMON, WEITZMAN AF, SEQUIERAJC. Evaluation and management of vascular injuries of the extremities. Arch Surg 1983; 118: 93-95. 4 FELICIANODV, CRUSE PA, BURCH JM, BITONDO CG. Delayed diagnosis of arterial injuries. Am J Surg 1987; 154: 579-584. 5 REID JDS, WEIGELT JA, THAL ER, FRANCIS H. Assessment of proximity of a wound to major vascular structures as an indication for arteriography. Arch Surg 1988; 123: 942-946. Eur J Vasc Surg Vol 6, November 1992
676
A.N. J, Graham et aL
60'REILLY MJG, HOOD JM, LIVINGSTONRH, IRWINJWS. Penetrating injuries of the popliteal artery. Br J Surg 1978; 65: 789-792. 7 BARROSD'SA AAB, HASSARD TH, LIVINGSTONRH, IRWIN JWS. Missile-induced vascular trauma. Injury 1980; 12: 13-20. 8 BARROS D'SA AAB. A decade of missile induced vascular trauma. Ann R Coll Surg Engl 1982; 64: 37-44. 9 RICH NM, HOBSON RW, COLLINS GJ. Traumatic arteriovenous fistulas and false aneurysms: a review of 588 lesions. Surgery 1975; 78: 817-828. 10 TURCOTTE JK, TOWNE JB, BERNHARD VM. Is arteriography necessary in the management of vascular trauma of the extremities? Surgery 1978; 84: 557-562.
Eur J Vasc Surg Vol 6, November 1992
11 PERRYMO, THAL ER, SHIRES GT. Management of arterial injuries. Ann Surg 1971; 173: 403-408. 12 SIRINEK KR, LEVINE BA, GASKILEHV, ROOT HD. Reassessment of the role of routine operative exploration in vascular trauma. ] Trauma 1981; 21: 339-344. 13 RICHARDSON JD, VITALE GC, FLINT LM. Penetrating arterial trauma. Analysis of missed vascular injuries. Arch Surg 1987; 122: 678-683. 14 MORTENSENJD. Clinical sequelae from arterial needle puncture, cannulation and incision. Circulation 1967; 35: 1118-1123.
Accepted 2 March 1991
