Surgical Treatment of Popliteal Artery Injuries David M. Conkle, MD; Robert E. Richie, MD; John L. Sawyers, MD; H. William Scott, Jr, MD

\s=b\ Twenty-seven patients with injury to the popliteal artery and associated structures were operated on during the past 15 years. There were no operative or hospital deaths. The limb salvage rate was 56%; the amputation rate was 44%. Those patients with penetrating injuries were found to have a much better salvage rate (85%) than those with blunt trauma (29%). Preoperative arteriography and immediate repair of the popliteal artery by either end-to-end anastomosis or a vein graft is advocated for these patients. Popliteal vein injuries should be repaired when possible by lateral suture or end-to-end anastomosis. Fasciotomy is advocated on a selected basis.

(Arch Surg 110:1351-1354, 1975)

been

increasingly refined. However, the failure rate with popliteal artery repairs has remained high. Rich and col¬ leagues" reviewed the Vietnam experience and found an amputation rate of 32%. The civilian experience with this injury7 has been comparable except for the reports of Eger et als and Hermreck et al," who reported amputation rates of 10% and 16.6%, respectively, following popliteal artery repair. With the above reports as a stimulus, the experience at the Vanderbilt University Affiliated Hospitals was re¬ attempt to evaluate our results and define an acceptable approach in this injury's management.

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an

SUBJECTS

surgical management of popliteal artery injuries has changed greatly in the last 30 years. Prior to and during World War II, the primary treatment for this in¬ jury was ligation.1·2 This mode of treatment was as¬ sociated with an amputation rate of approximately 70%. During the Korean conflict the techniques of arterial re¬ construction utilizing lateral suturing, end-to-end anasto¬ mosis, and vein graft interposition were introduced.35 Hughes' report,7 summarizing the experience of arterial repair in Korea, made reference to 68 popliteal artery re¬ constructions. The amputation rate was 32.4%. Since the Korean conflict, the techniques of arterial repair have

The

Accepted for publication June 27, 1975. From the Department of Surgery, Vanderbilt Medical Center (Dr Conkle), Department of Surgery, Nashville Veterans Administration Hospital (Dr Richie), Department of Surgery, Nashville Metropolitan General Hospital (Dr Sawyers), and Department of Surgery, Vanderbilt University Hospital (Dr Scott), Nashville, Tenn. Read before the 23rd scientific meeting of the International Cardiovascular Society, Boston, June 19, 1975. Reprint requests to Nashville Metropolitan General Hospital, Nashville, TN 37210 (Dr Sawyers).

Twenty-seven patients with injuries to the popliteal artery and associated structures have been treated at the Vanderbilt Univer¬ sity Affiliated Hospitals since Jan 1, 1959. There were 22 males and five females. Their ages ranged from 11 to 72 years, with the average age being 33 years. The types of injury sustained were penetrating wounds (gunshot wounds [11] and lacerations [2]) in 13 patients and blunt trauma in 14 patients. Associated injuries were found in 26 of the 27 patients. Nine¬ teen patients had injured the peroneal or sciatic nerve. Twenty patients had an injury of the popliteal vein. Eight patients had concomitant fractures of the femur, tibia, or fibula and five had dislocation of the knee. Four patients had massive soft tissue in¬

jury. Preoperative arteriography was obtained in 19 patients (Fig¬ ure). In all 19 patients, the location of the injury was defined and in three patients an unexpected arteriovenous fistula was defined. Operative exploration was carried out in all 27 patients. The time interval from accident to operative exploration was less than ten hours in 25 patients. Two patients were referred to Vanderbilt Hospital after three days of ischemia. There were no operative or hospital deaths. The popliteal space was approached through a medial incision in 22 patients and a posterior incision in five pa-

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Preoperative (left) and postoperative (right) arteriograms in patient with popliteal artery disruption secondary to knee dislocation. Popliteal artery was repaired with end-to-end anastomosis.

tients. The

operations performed

were as

follows:

saphenous vein

ten patients; end-to-end anastomosis, nine patients; lateral suture, two patients; thrombectomy, two patients; bovine graft,

graft,

patient; Teflon graft, one patient; ligation of popliteal artery, patient; and above-knee amputation, one patient. Successful salvage of the leg was accomplished in 15 of the 27 patients (56%); 12 patients (44%) required amputation. Eleven of the 13 patients (85%) who received a penetrating wound had a successful recon¬ struction. However, only four of the 14 patients (29%) with blunt trauma had their leg salvaged. When associated injuries were correlated with successful or un¬ successful reconstruction, the presence of long bone fractures and knee dislocation secondary to blunt trauma were both associated with a low success rate (0 of eight and three of five patients, re¬ spectively). None of the legs of the four patients with massive soft tissue injury were salvaged. Nine of the 20 popliteal vein injuries were repaired, and seven of these patients had their limb sal¬ vaged.

one

one

COMMENT

Past

experience has

shown that

injury of the popliteal

artery often results in loss of the involved limb.1'5-6 The ex¬

perience in amputation

our

hospitals confirms this, with the overall popliteal artery injuries being 44%.

rate for

When each case was examined, several factors were ap¬ parent that helped better our understanding of both the successful and unsuccessful reconstructions. The lag time between injury and reestablishment of flow must be kept at a minimum. This point has been dis¬ cussed in clinical reviews410 as well as investigated in the laboratory." The exact interval is probably variable and would appear to be related to available collaterals. In our series all operations were performed within ten hours of the injury, except for two patients who had a three-day interval between their injury and reestablishment of blood flow. Both of these patients had successful reanastomoses but required amputation for infection and

myonecrosis.

The type of wound affects the salvage rate. In those pa¬ tients who had a penetrating injury, the salvage rate was 85%. In those who received blunt trauma to the popliteal region, the limb salvage rate was only 29%. These patients with blunt trauma had more extensive injuries with asso¬ ciated long bone fractures, knee dislocations, and massive soft tissue injury. Thus, the extent of the injury appears to be a major determinant in limb salvage. In patients

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with blunt trauma the fractures should be stabilized ex¬ ternally. The wound should be debrided extensively until all remaining soft tissue is assuredly viable. Anastomoses or graft coverage should be with muscle whenever pos¬ sible, but subcutaneous tissue, skin grafts, or biologic dressings can also be employed. In examining each operation performed, we found that 13 of the 15 successful salvage procedures employed a saphenous vein graft or an end-to-end anastomosis. Lesser operations, such as lateral suturing and throm¬ bectomy, should be used sparingly. Care must be taken in patients whose vessel appears intact and occluded with thrombus. These vessels will almost certainly have intimai damage that will prohibit a successful thrombectomy. In transected vessels the ends should be free of gross injury

and end-to-end anastomoses should be performed only if no tension is present. In all other cases a reversed saphenous vein from the noninvolved leg should be used. If soft tissue injury prohibits adequate coverage of an end-toend anastomosis, a saphenous vein graft can be routed through viable tissue and thus avoid the injured area. Al¬ though only nine of the 20 popliteal vein injuries were re¬ paired, we agree with the current beliefs12 that the vein should be repaired whenever possible. Sullivan et al12 have shown that extremity stasis and edema are reduced fol¬ lowing popliteal vein repair and that limb salvage is im¬ proved. Although only employed in four patients, fasc¬ iotomy should play a role in the management of those patients who develop decreased perfusion as a result of anterior compartment compression.

References 1. DeBakey ME, Simeone FA: Battle injuries of the arteries in World War II: An analysis of 2,471 cases. Ann Surg 123:534-579, 1944. 2. Makins GH: On Gunshot Wounds to the Blood Vessels. Bristol, England, John Wright and Son Ltd, 1919. 3. Spencer FG, Grewe RV: The management of acute arterial injuries in battle casualties. Ann Surg 141:304-313, 1955. 4. Jahnke EJ Jr, Howard JM: Primary repair of major arterial injuries. Arch Surg 66:646-649, 1953. 5. Hughes CW: Arterial repair during the Korean War. Ann Surg 147:555-561, 1958. 6. Rich NM, Baugh JA, Hughes CW: Popliteal artery injuries in Vietnam. Am J Surg 118:531-534, 1969. 7. Drapanas T, Hewitt RL, Weichert RF, et al: Civilian vascular injuries.

Ann Surg 172:351-360, 1970. 8. Eger M, Golcman L, Schmidt

B, et al: Problems in the management of

popliteal artery injuries. Surg Gynecol Obstet 134:921-926, 1972. 9. Hermreck AS, Sifers TM, Reckling FW, et al: Traumatic vascular injuries. Am J Surg 128:813-817, 1974. 10. Eger M, Huler T, Hirsh M: Popliteal artery occlusion associated with dislocation of the knee joint. Br J Surg 57:315-317, 1970. 11. Miller HH, Welch CS: Quantitative studies of the time factor in arterial injuries. Ann Surg 130:428-438, 1949. 12. Sullivan WG, Thornton FH, Baker LH, et al: Early influence of popliteal vein repair in the treatment of popliteal vessel injuries. Am J Surg 122:528-531, 1971.

Discussion Dr Levine: Jackson, Miss: I enjoyed hearing the results of the authors' experience with this challenging injury. An amputation rate of 34% was obtained in 21 popliteal artery injuries treated at the University of Mississippi Medical Center. These included ten bullet wounds, four shotgun wounds, three dislocation of the knee, three blunt injuries to the popliteal fossa, and one stab wound. As in the present study, major factors influencing amputation were delays of diagnosis of injury and the extent of vein, soft tis¬ sue, muscle, bone, and nerve injury. In our series we found that if the injury was repaired within 12 to 14 hours of its occurrence, the amputation rate was similar to that in those repaired in six hours. We have had to amputate on two occasions because of problems with extensive necrosis, in spite of patent grafts and fasciotomies, because of secondary metabolic sequels or muscle loss. In a patient, who has sustained severe myonecroses in his ante¬ rior compartment we would like to ask the authors if they have any criterion for evaluating patients preoperatively. We have been feeling the calf carefully, and if there is a high degree of muscle rigor with an anesthetic paralyzed foot, we would seriously consider a primary amputation. Norman M. Rich, MD, Washington, DC: I agree with the au¬ thors' thoughts. Many of you may remember that three years ago we analyzed 125 patients who had popliteal vascular trauma that ended in amputation. An analysis of our material was similar to what the authors presented. My main comment at this time is to emphasize that popliteal vascular trauma remains a problem. The authors noted that there are two studies where the amputation rate is quite low, but one is a series of only ten patients. We are talking about a problem, not about the patients who do well. In my own practice, the number of ligation procedures that in-

volved trauma of the popliteal artery, delayed recognition, failure of repair, and amputation, far exceeds any other problem that I have been asked to comment on in vascular surgery. I congratulate the authors, not only for a good presentation, but for again emphasizing a major problem area. Kenneth L. Mattox, Houston: Among 65 patients with poplit¬ eal artery injuries admitted to Houston's Ben Taub Hospital, 82% of whom had preoperative arteriography, there was an overall amputation rate of 23.5% and a mortality, basically from associ¬ ated thoracic and abdominal injuries, of 6.9%. We commend Dr Richie and his associates on successful poplit¬ eal artery reconstruction in 60% of the patients with intimai dis¬ section of the popliteal artery from posterior dislocation of the knee. This represents about 20% of those successfully managed in the literature. In two similar successful cases, we learned that one must per¬ form the conduit prosthetic anastomosis at the distal popliteal ar¬ tery quite near the takeoff from the anterior tibial artery. Should balloon catheters be used in these arterial stretch, Chinese finger trap, type injuries, the catheter should be passed quite gently along an already traumatized intima. One question haunts the surgeon evaluating vascular trauma and I pose it to the authors based on their experience. Does the importance of popliteal venous continuity in the patient with trauma to the popliteal fossa indicate that phlebography should now be proposed as a routine evaluation? When arteriography re¬ sults are normal, what operative procedure, if any, should be per¬ formed on the isolated popliteal vein injury, such as venous repair, ligation, fasciotomy, or merely continued observation? Frank C. Spencer, MD, New York: I would like to ask two questions. The amputation rate reported by Dr Richie in this

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struction. Patients operated on after irreversible muscle necrosis has oc¬ curred can be recognized in retrospect, for gangrene progresses despite adequacy of vascular repair, but little can be done to im¬

gard to his criteria for evaluation of myonecrosis, I agree this is a very difficult problem. In examining the patients preoperatively, we have looked at the degree of tissue damage, but have at¬ tempted to revascularize all of our patients. We believe that exter¬ nal stabilization in the massively injured extremity is important because it allows very close postoperative observation. In answer to Dr Mattox, popliteal venous continuity is some¬ thing that we have been hearing about of late. We do believe that it is important to reestablish venous flow when at all possible. As far as phlebography is concerned, we have not done this at our in¬

a particularly elusive one. The most common failure, however, is a failure of vascular re¬ construction because of the combined problem of arterial injury, venous injury, and soft tissue injury. I seriously wonder if at¬ tempts at primary repair should not be abandoned with such mas¬ sive injuries, and instead an extra-anatomic bypass performed from the femoral artery proximally to one of the arteries in the midleg distally. The soft tissue injury could then be debrided and vascular reconstruction performed later. What should be done with the popliteal vein injury is uncertain, but if repair is feasible it certainly should be done. Attempts at primary repair usually fail for one or two reasons. If the soft tissues are radically debrided, there is inadequate re¬ maining tissue to cover the site of vascular reconstruction; so, sec¬ ondary hemorrhage and thrombosis occur. However, if radical debridement is not done, infection commonly supervenes with the same end result. This dilemma has been reported again and again; so I seriously wonder if a new approach is not needed ahd I would appreciate Dr Richie's comments about this. All of us appreciate his contribution of bringing this basically unsolved problem to our attention. With all of the bright investi¬ gators in this room, our goal should be to reduce the amputation rate to the range of 10% within the next three to four years. Dr Conkle: In listening to Dr Levine's data, I think his patient population compares somewhat with ours, except that the number of blunt trauma patients in his series was somewhat smaller. I would think that those patients with massive blunt trauma in his series contributed to the large majority of his amputations. In re-

stitution. In answer to Dr Spencer, when we examined our failures, two patients had failures secondary to penetrating trauma. One pa¬ tient had a thrombectomy in a limb that had been caught in a corn picker. This thrombectomy was carried out on three different oc¬ casions and finally flow was reestablished. However, the patient went on to lose his limb. The other patient had a shotgun wound to the popliteal artery. There were multiple pellet perforations, and these were closed with lateral sutures. This patient had inade¬ quate flow immediately following the operation and went on to lose his limb. In the ten patients with blunt trauma who failed, six had no ob¬ jective reestablishment of flow following operation, eight had long bone fractures, two had knee dislocations, and four of these pa¬ tients had massive soft tissue injury. So, the failures in our series were primarily due to two causes: (1) massive trauma and (2) the inability to reestablish flow follow¬ ing the operative procedure. As far as grafting around the area of blunt trauma, we have had the opportunity to do this in one patient who had severed his leg above the knee, except for some soft tissue and muscle continuity of the medial aspect of his thigh. We initially attempted to do a saphenous vein graft in that area, stabilized the extremity, and covered the graft with existing muscle. The patient went on to have infection and bleeding at this site. We went back and rerouted the saphenous vein graft through the subcutaneous tissue, which remained viable. However, the patient went on to lose his limb. There have been several recent reports in which this has been attempted and it certainly merits further investigation.

analysis

is typical of the unsolved problem with severe of the popliteal artery, for the amputation rate has remained near 30% for the last 15 to 20 years. I would like to know if the amputations in this group were due to operating too late after the injury, at a time when muscle necrosis was irreversible, or whether the failures were due to ineffective vascular recon¬

careful

injuries

prove the care of such patients, except to hope that the operation can be done earlier. The decision for primary amputation in such

patients is

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Surgical treatment of popliteal artery injuries.

Twenty-seven patients with injury to the popliteal artery and associated structures were operated on during the past 15 years. There was no operative ...
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