Superficial Femoral Artery Injury Research Articles

Medial Femoral Condyle Free Flap: A Systematic Review and Proportional Meta-analysis of Applications and Surgical Outcomes

Background: Recalcitrant bone nonunion and osseous defect treatment is challenging and often requires vascularized bone transfer. The medial femoral condyle flap has become an increasingly popular option for reconstruction. The study aims at reviewing its different applications and synthesizing its surgical outcomes. Method: A systematic review including all studies assessing surgical outcomes of free medial femoral condyle flap for bone reconstruction in adults was conducted on January 31, 2023. Flap failure and postoperative complications were synthesized with a proportional meta-analysis. Results: Forty articles describing bony reconstruction in the head and neck, upper limb, and lower limb areas were selected. Indications ranged from bony nonunion and bone defects to avascular bone necrosis. Multiple flaps were raised as either pure periosteal, cortico-periosteal, cortico-cancellous-periosteal, or cortico-chondro-periosteal. A minority of composite flaps were reported. Overall failure rate was 1% [95% confidence interval (CI), 0.00–0.08] in head & neck applications, 4% in the lower limb (95% CI, 0.00–0.16), 2% in the upper limb (95% CI, 0.00–0.06), and 1% in articles analyzing various locations simultaneously (95% CI, 0.00–0.04). Overall donor site complication rate was 4% (95% CI, 0.01–0.06). Major reported complications were: femoral fractures (n = 3), superficial femoral artery injury (n = 1), medial collateral ligament injury (n = 1), and septic shock due to pace-maker colonization (n = 1). Conclusion: The medial femoral condyle flap is a versatile option for bone reconstruction with high success rates and low donor site morbidity.

Superficial Femoral Artery Pseudoaneurysm Post-Subtrochanteric Femur Fracture

Superficial femoral artery injury due to bone fragment of femoral fracture is often overlooked as it occurs only in rare cases of femoral fractures and the onset of symptoms usually happen weeks or even months later. The deep femoral artery, in fact, is more susceptible to injuries associated with femoral fractures. Moreover, a preexisting calcification lesion of the arterial wall might enhance the chance of such arterial injury, a condition that we noticed in the case we are reporting. We will illustrate a rare case of calcified superficial femoral artery injury complicating subtrochanteric femur fracture.

Surgical Approach of an Infected Saphenofemoral Looped PTFE Graft Arteriovenous Fistula and Arterial Reconstruction with Cryopreserved Allograft

Introduction: Autologous arteriovenous fistula is still the most popular vascular access for hemodialysis [1]. There have been few reports of saphenofemoral arteriovenous fistulas over the last 10 to 20 years because of suggestions of high morbidity, poor patencies and needling difficulties [2]. Some disadvantages of using this access are the necessity for a more extensive and deeper dissection using larger vessels and greater susceptibility to infection and steal syndrome [3, 4]. Attention should be paid to the patient's vasculature before surgery, through the "maturation" phase and chronic use [5]. Case report: A 72-year-old female with a history of arterial hypertension, diabetes mellitus and chronic renal failure requiring three-weekly hemodialysis, with a 4-day history of a painful and hot mass in the right thigh, fever, and hemoglobin decline. Physical examination: hematoma at the right inguinal region, presence of a tourniquet, femoral pulse 2/2 and not assessable distal pulses due to edema; coldness, and increased capillary refill. Aortoiliac and lower limb angiotomography showed: ruptured pseudoaneurysm of the right common femoral artery, ipsilateral superficial femoral artery injury and prosthetic femoral arteriovenous fistula infection. Open emergency approach through an infra-inguinal longitudinal incision was performed, draining a large hematoma and pus, finding an infected prosthetic PTFE graft from a saphenofemoral loop fistula with injury of the right superficial femoral artery and active bleeding at the site, plus dehiscence of saphenous anastomosis. Thrombectomy of the superficial and common femoral artery, en bloc arteriotomy of the right superficial femoral artery and arterial reconstruction with a cryopreserved arterial allograft with end-to-end anastomosis was performed. A Vacuum Assisted Therapy (VAC® ) system was created to cover the surgical site. Patient deceased from hypovolemic shock. Conclusions Unusual site AVFs (i.e., saphenofemoral loop graft AVFs) should be carefully followed-up to reduce the risk of complications and raise the awareness to diminish associated morbidity and mortality. An arterial cryopreserved allograft may be used for arterial reconstruction in the setting of an infected wound. The goal must be to spread more knowledge in this critical area of medicine that is importantly affecting medical costs of renal replacement therapies and patients' quality of life and survival rates.

Outcomes of Revascularization and Factors Associated With Major Amputation in Patients With Lower Limb Arterial Injury: A Single-Center Retrospective Analysis.

ObjectiveTo identify the amputation rates and causative factors for failed revascularization leading to amputation in patients undergoing primary limb salvage procedures for lower-extremity vascular injuries.MethodsThis retrospective study was conducted at the vascular surgery department, Shaheed Mohtarma Benazir Bhutto (SMBB) Institute of Trauma, Karachi, Pakistan. The data were collected from hospital record using the non-probability sampling technique. Patients aged 17-70 years, undergoing primary revascularization during April 2016 to March 2021, were included in the study. Patients with crush injuries/non-salvageable limbs underwent primary amputation, isolated deep femoral artery or crural arteries (non-limb threatening) injuries, and non-traumatic injuries like intravenous drug-induced or iatrogenic injuries were excluded. The data analysis is done using SPSS Version 20.0 (IBM Corp., Armonk, NY, USA). A P-value of <0.05 was considered as significant.ResultsThis study includes 56 patients of mean age 30.82 ± 9.29 years with male gender four times more affected than their counterpart. About 32% of patients were smokers, while 58% of patients had no co-morbidities. All patients presented with a mean time of 7.66 ± 1.69 hours of injury with an average of 1.14 arterial segments involved. The most frequent artery involved was popliteal artery (both above and below the knee), followed by superficial femoral artery injury constituting 50% and 26%, respectively, with arterial laceration and transection being common findings on exploration. Out of 56 patients, 27 (48.2%) had open fractures, 21 (37.5% ) closed fractures, and eight patients (14.3 % ) presented with dislocation as associated injuries. Following the procedure, secondary amputation was recorded in 18 (32.1%) patients. Thrombosis and infection were the leading causes of revascularization failure. Type of injury, segment of arterial injury, and associated bony injuries were associated with limb amputation.ConclusionType and site of injury along with concomitant bony injuries are associated with major amputations after revascularization in lower-extremity arterial injuries.

Endovascular versus open repair of isolated superficial femoral and popliteal artery injuries

ObjectiveDespite the increasing use of endovascular therapy for traumatic arterial injuries, little is known about the outcomes of endovascular repair of superficial femoral artery (SFA) and popliteal artery (PA) injuries. In the present study, we compared the characteristics and outcomes of endovascular vs open repair of traumatic SFA and PA injuries. MethodsWe performed a retrospective National Trauma Data Bank analysis of trauma patients with a blunt or penetrating injury of the SFA and/or PA who had undergone endovascular or open repair from 2007 to 2014. Multivariate logistic regression was used to compare the outcomes, with propensity score matching used for sensitivity analysis. ResultsThe incidence of SFA and PA injuries was 0.2%, with an overall increase in the annual use of endovascular stent repair from 3.2% in 2007 to 7.6% in 2014 (P = .002). A total of 2,873 patients with an isolated SFA and/or PA injury were included in the present study, of whom 163 (5.7%) had undergone endovascular repair. SFA injuries were more frequently treated with endovascular repair (70% vs 27%) and PA injuries were more often associated with open repair (41.1% vs 54.7%). Open repair was more frequently associated with a concomitant femur fracture or knee dislocation (30.7% vs 38.8%; P = .039). Endovascular repair was not associated with worse in-hospital amputation-free survival (AFS) compared with open repair on univariate analysis (91.1% vs 89.7%; P = .573) or multivariate logistic regression (odds ratio [OR], 1.053; 95% confidence interval [CI], 0.551-2.012; P = .876). Propensity score matching revealed that in-hospital mortality was higher (OR, 3.69; 95% CI, 1.37-9.82; P = .01) and fasciotomy was lower (OR, 0.23; 95% CI, 0.14-0.37; P < .001) in the endovascular repair group, with no significant differences in AFS (OR, 0.86; 95% CI, 0.48-1.67; P = .65). ConclusionsEndovascular repair of SFA and PA injuries has in-hospital AFS comparable to that for open repair, supporting the increasing use of endovascular repair for traumatic SFA and PA injuries in appropriately selected cases. Given the unexpected finding of increased in-hospital mortality after endovascular repair, further studies are necessary to determine the appropriate patient selection and the durability of endovascular repair.

Evaluation of the efficacy of commercial and noncommercial tourniquets for extremity hemorrhage control in a perfused cadaver model.

Tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage; however, the optimal tourniquet type and effectiveness of noncommercial devices remain unclear. Our aim was to evaluate the efficacy of five tourniquets in a perfused-cadaver model. This prospective study used a perfused-cadaver model with standardized superficial femoral artery injury bleeding at 700 mL/min. Five tourniquets were tested: combat application tourniquet; rapid application tourniquet system; Stretch, Wrap, And Tuck Tourniquet; an improvised triangle bandage windlass; and a leather belt. Forty-eight medical students underwent a practical hands-on demonstration of each tourniquet. Using a random number generator, they placed the tourniquets on the bleeding cadaver in random order. Time to hemostasis, time to secure devices, estimated blood loss, and difficulty rating were assessed. A one-way repeated measures analysis of variance was used to compare efficacy between the tourniquets in achieving the outcomes. The mean ± SD participant age was 25 ± 2.6 years, and 29 (60%) were male. All but one tourniquet was able to stop bleeding, but the rapid application tourniquet system had a 4% failure rate. Time to hemostasis and estimated blood loss did not differ significantly (p > 0.05). Stretch, Wrap, And Tuck Tourniquet required the longest time to be secured (47.8 ± 17.0 seconds), whereas the belt was the fastest (15.2 ± 6.5 seconds; p < 0.001). The improvised windlass was rated easiest to learn and apply, with 22 participants (46%) assigning a score of 1. Four of five tourniquets evaluated, including both noncommercial devices, effectively achieved hemostasis. A standard leather belt was the fastest to place and was able to stop the bleeding. However, it required continuous pressure to maintain hemostasis. The improvised windlass was as effective as the commercial devices and was the easiest to apply. In an emergency setting where commercial devices are not available, improvised tourniquets may be an effective bridge to definitive care.

Limb-Salvage Outcomes of Arterial Repair Beyond Time Limit at Different Lower-Extremity Injury Sites.

BackgroundThe purpose of this study was to analyze the outcomes of revascularization exceeding 12 h after arterial injury at different sites of the lower extremity.Materal/MethodsFrom January 2009 to April 2017, 58 patients with 58 lower-limb arterial injuries who underwent revascularization over 12 h after trauma were included in our study. Outcomes measured, including mortality, amputation, complications, and other parameters (gait, length discrepancy, the range of movement of the knee and ankle joint, and muscle wasting) were analyzed.ResultsExternal iliac artery injury (EIAI) or femoral artery injury (FAI) was affected in 4 patients, superficial femoral artery injury (SFAI) in 18, and popliteal artery injury (PAI) (including proximal gastrocnemius muscle vascular (PGMV) and proximal gastrocnemius muscle vascular [PGMV]) in 36. The median time of arterial injury was 72 h (interquartile range, 59.5). No mortality was found. Amputations were performed in 16 patients due to non-viable limbs, progressing infection, or muscle necrosis. All patients were followed up (median, 52 months; interquartile range, 5.5). Of the 42 limb-salvage patients, most had a limp, muscle wasting, or ankle and knee dysfunctions, and 26 patients with knee or ankle dysfunction underwent secondary surgery.ConclusionsAlthough limited recanalization of blood vessels may lead to limb complications or amputations over time, the high success rate of limb salvage still merits the surgeon’s best efforts.

Endovascular repair is a feasible option for superficial femoral artery injuries: a comparative effectiveness analysis.

To compare outcomes between open (OR) and endovascular repair following superficial femoral artery (SFA) injuries. This is a cross-sectional study querying the 2012-2014 National Inpatient Sample for SFA injuries. Patients were grouped into OR and stent-graft placement (SGP). Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), fasciotomy and amputation rate, and cost. Wilcoxon rank-sum, Kruskal-Wallis, Chi-squared test with Bonferroni adjustment were used as appropriate; p < 0.05 was significant. 255 Patients were identified. Mean age was 34.6years and majority were males. OR was performed in 82.7%. Overall mortality rate was 3.7%. Median HLOS was 8days. Fasciotomies were performed in 31% and lower limb amputations in 3.7%. Males more often underwent OR (89.0% vs. 73.1%, p < 0.01). SGP patients were significantly older (44.9 vs. 32.5years; p < 0.01), and with Medicare insurance (20.5% vs. 6.5%; p < 0.01. Mortality, HLOS, and hospitalization cost were not significantly different. OR patients had higher rate of fasciotomy (35.4% vs. 15.4%; p < 0.01). Endovascular management is not inferior to OR following SFA injuries and both carry a low amputation rate. OR is associated with a higher fasciotomy rate. Endovascular repair should be considered when technically feasible.

Dichotomy in Fasciotomy: Practice Patterns Among Trauma/Acute Care Surgeons With Performing Fasciotomy With Peripheral Arterial Repair

Failure to perform adequate fasciotomy for a presumed or diagnosed compartment syndrome after revascularization of an acutely ischemic limb is a potential cause of preventable limb loss. When required, outcomes are best when fasciotomy is conducted with the initial vascular repair. Despite over 100 years of experience with fasciotomy, the actual indications for its performance among acute care and trauma surgeons performing vascular repairs are unclear. The hypothesis of this study was that there are many principles of fasciotomy that are uniformly accepted by surgeons and that consensus guidelines could be developed. A 20-question survey on fasciotomy practice patterns was distributed to trauma and acute care surgeons of a major surgical society which had approved distribution. The response to the survey was 160/1066 (15 %). 92.5% of respondents were fellowship trained in trauma and acute care surgery, and 74.9% had been in practice for fewer than 10 years. Most respondents (71.9%) stated that they would be influenced to perform a preliminary fasciotomy (fasciotomy conducted prior to planned exploration and arterial repair) based upon specific signs and symptoms consistent with compartment syndrome-including massive swelling (55.6%), elevated compartment pressures (52.5%), delay in transfer >6 hours (47.5%), or obvious distal ischemia (33.1%). 20.6% responded that they would conduct exploration and repair first, regardless of these considerations. Prophylactic fasciotomies (fasciotomy without overt signs of compartment syndrome) would be performed by respondents in the setting of the tense compartment (87.5%), ischemic time >6 hours (88.1%), measurement of elevated compartment pressures (66.9%), and in the setting of large volume resuscitation requirements (31.3%). 69.4% of respondents selectively measure compartment pressures, with nearly three-fourths utilizing a Stryker needle device (72.5%). The most common sequence of repairs following superficial femoral artery injury with a >6-hour limb ischemia was cited as the initial insertion of a shunt, followed by fasciotomy, then vein harvest, and finally interposition repair. While there is some general consensus on indications for fasciotomy, there is marked heterogeneity in surgeons' opinions on the precise indications in selected scenarios. This is particularly surprising in light of the long history with fasciotomy in association with major arterial repairs and strongly suggests the need for a consensus conference and/or meta-analysis to guide further care.

PC180 Endovascular Stent Repair of Traumatic Superficial Femoral and Popliteal Artery Injuries: An Analysis of the National Trauma Data Bank

Despite increasing use of endovascular stent repair of traumatic arterial injuries, such repair of superficial femoral artery (SFA) and popliteal artery (PA) injuries remains uncommon and poorly studied. We describe characteristics and outcomes of trauma patients with SFA and PA injuries repaired using endovascular stenting. This was a retrospective National Trauma Data Bank analysis of trauma patients with a vascular injury isolated to the SFA and PA who underwent endovascular stent repair from 2007 to 2014. The prevalence of SFA and PA injuries was 0.2%, with an increasing trend in the annual use of endovascular stent repair ranging from 1.3% to 3.1% across the study period (P = .004) despite stable injury burdens (Fig 1). Included were 137 patients (81.5% males) with a median age of 31 years (interquartile range [IQR], 22-45 years). The most common comorbidity was smoking (23.4%), and none had pre-existing peripheral vascular disease. Mechanism of injury (MOI) was 57.4% penetrating. On presentation, 5.1% were hypotensive (systolic blood pressure <90 mm Hg), 9.5% were tachycardic (heart rate >120 beats/min), and 4.5% had Glasgow Coma Scale of <9. Median Injury Severity Score was 10 (IQR, 9-17). SFA injury was more common (65.0%) and associated with penetrating MOI (P < .001). PA injury was associated with blunt MOI (P < .001) and with fasciotomy both alone (P = .015) and with concomitant SFA injury (P = .035). Femur fracture and associated vein injury occurred in 35.8% and 7.3% patients, respectively. Median time to stent repair was 5 hours (IQR, 3-11 hours). Fasciotomy was performed in 21.2% patients after a median of 4 hours (IQR, 3-8 hours). The most common in-hospital complication was deep vein thrombosis (11.1%). Overall mortality was 5.8%. Age ≥65 years (P = .025) and Glasgow Coma Scale <9 (P = .045) were associated with mortality on univariate analysis, but only age ≥65 years was independently predictive (odds ratio, 7.5; 95% confidence interval, 1.5-36.4; P = .013). Amputation was performed in 5.1% patients, equally distributed between SFA and PA injury, after a median of 10 days (IQR, 4-32 days). Fasciotomy was significant on both univariate (P = .005) and multivariate analysis (odds ratio, 14.2; 95% confidence interval, 2.3-88.5; P = .005) of amputation, yet time to initial fasciotomy was not associated with amputation (4 vs 3.5 hours; P = .869, Fig 2). Endovascular stent repair of SFA and PA injuries is performed in stable trauma patients with low injury burdens. Death and amputation are infrequent, but age ≥65 years and fasciotomy are significant risk factors, respectively. Despite increasing annual trends, prospective studies are necessary to elucidate the proper algorithm for patient selection in the endovascular management of this patient population.Fig 2Risk factors for (A) overall mortality and (B) amputation. CI, Confidence interval; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; OR, odds ratio.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Management of war-related vascular injuries: experience from the second gulf war

AimTo study the biomechanism, pattern of injury, management, and outcome of major vascular injuries treated at Mubarak Al-Kabeer Teaching Hospital, Kuwait during the Second Gulf War.MethodsThis is a descriptive retrospective study. War-related injured patients who had major vascular injuries and were treated at Mubarak Al-Kabeer Teaching Hospital from August 1990 to September 1991 were studied. Studied variables included age, gender, anatomical site of vascular injury, mechanism of injury, associated injuries, type of vascular repair, and clinical outcome.Results36 patients having a mean (SD) age of 29.8 (10.2) years were studied. 32 (89%) were males and 21 (58%) were civilians. Majority of injuries were caused by bullets (47.2%) and blast injuries (47.2%). Eight patients (22%) presented with shock.There were 31 arterial injuries, common and superficial femoral artery injuries were most common (10/31). Arterial repair included interposition saphenous vein graft in seven patients, thrombectomy with end-to-end / lateral repair in twelve patients, vein patch in two patients, and arterial ligation in four patients. Six patients had arterial ligation as part of primary amputation. 3/21 (14.3%) patients had secondary amputation after attempted arterial vascular repair of an extremity. There were a total of 17 venous injuries, 13 managed by lateral suture repair and 4 by ligation. The median (range) hospital stay was 8 (1–76) days. 5 patients died (14%).ConclusionsMajor vascular injuries occurred in 10% of hospitalized war-related injured patients. Our secondary amputation rate of extremities was 14%. The presence of a vascular surgeon within a military surgical team is highly recommended. Basic principles and techniques of vascular repair remain an essential part of training general surgeons because it may be needed in unexpected wars.

Superficial femoral artery injury resulting from intertrochanteric hip fracture fixation by a locked intramedullary nail

Iatrogenic vascular injuries are uncommon during the course of proximal femur surgical procedures. We report the case of an 85-year-old female presenting with an intertrochanteric fracture, treated by anterograde (cephalocondylic) intramedullary nailing (Stryker gamma 3 nail) and complicated by a superficial femoral artery laceration at the level of the distal locking screw. Lower limb traction in adduction and internal rotation on the operating table might put at risk the superficial femoral artery during distal screw drilling and insertion. We therefore recommend returning to the neutral position and reducing lower extremity traction after femoral head screw placing and before final distal screw insertion. This technical precaution should limit the risk of superficial femoral artery injury associated with short-nail anterograde intramedullary nailing. Level IV retrospective.

Stenting as an Alternative to Open Repair in Traumatic Superficial Femoral Artery Injuries

Lower limb ischemia may occur when a superficial femoral artery (SFA) is injured in blunt or penetrating trauma. Surgical repair of the injured artery can be challenging and time-consuming when there is an associated fracture. Two cases of traumatic SFA injury treated with endovascular stent grafting are described.

Superficial Femoral Artery Injury Resulting From Cerclage Wiring During Revision THA

Vascular injuries around the hip are uncommon with hip arthroplasty. However, given the close proximity of the external iliac and femoral vessels to the hip, iatrogenic injury may occur. We describe a case of superficial femoral artery injury occurring during revision THA using an extended trochanteric osteotomy, bulk allograft, and cerclage wires. We review the available literature on vascular injury in hip arthroplasty and illustrate the great care necessary when placing cerclage wires and the importance of prompt recognition of these potentially devastating complications.

Supracondylar Femur Nonunion Associated With Previous Vascular Repair

One case of a Gustilo type 3C open OTA 33A-1 supracondylar femur fracture with superficial femoral artery injury that underwent reverse saphenous vein graft repair and open reduction and internal fixation with a retrograde femoral nail is reviewed. The fracture progressed to a hypertrophic nonunion despite 2 bone-grafting procedures and a nail dynamization. Upon referral for revision of the nonunion, a vascular examination revealed a well-perfused extremity with slightly diminished pedal pulses. An arteriogram was ordered that revealed an intraosseous aneurysm associated with the nonunion site and vascular repair. In a joint procedure with vascular and orthopedic surgeons, the previous vessel repair was mobilized, the aneurysmal feeder vessels were ligated, and the nonunion was revised with bridge plating and iliac crest autograft. The nonunion healed uneventfully, and the patient shows no signs of vascular compromise at the 2-year follow-up. The importance of the preoperative vascular assessment is emphasized, and the literature is reviewed.