A classıcal vascular dılemma: lımb salvage or amputatıon ?

Case Report

A CLASSICAL VASCULAR D ILEM M A :

LIMB SALVAGE OR A M P U TA TIO N ?

A tike Te k e li, M.D.* / Serdar A k g ü n , M .D.* / K o ray A k , M.D.*

Selim İsbir, M.D.* / A li Civelek, M.D.* / Feyyaz Baltacıoğlu, M.D.**

* D e p a r t m e n t o f C a r d i o v a s c u l a r S u r g e r y , S c h o o l o f M e d i c i n e , M a r m a r a U n i v e r s i t y , I s t a n b u l , T u r k e y .

** D e p a r t m e n t o f R a d i o l o g y , S c h o o l o f M e d i c i n e , M a r m a r a U n i v e r s i t y , İ s t a n b u l , T u r k e y .

ABSTRACT

P opliteal a rtery in juries are the m ost cha lle n g in g of all e xtre m ity v a s c u la r injuries. T he p o p lite a l vein, in fra p o p lite a l a rte rie s and the tibial nerve are the m ost co m m o n ly injured s tru c tu re s in penetratin g p oplitea l tra u m a p a tie n ts. D espite the e xperience o b taine d from th e m a jo r w a rs in this century, ongoin g a d v a n c e s in v a s c u la r su rg e ry and near 1 0 0% lim b sa lva g e re p o rts from c u rre n t

literature in p o p lite a l a rte ry p e n e tra tin g traum a, th e re is s till an o n g o in g d e b a te a b o u t th e m a n a g e m e n t of such injuries. T h e se injuries re q u ire a m u ltid is c ip lin a ry a p p ro a c h fo r a p p ro p ria te m a n a g e m e n t. O n e of th e m a jo r co n flicts is the d e c is io n b e tw e e n a m p u ta tio n or salvaging the lim b. A cco rd in g to th e c u rre n t d a ta and o u r c lin ic a l e x p e rie n c e , e v a lu a tio n and decision m aking in this g ro u p o f in juries is m ostly p atient d e p e n d e n t.

In this case report, w e p re s e n t a young m an w ith a left p o plitea l region g u n s h o t injury. Im m ediately a fte r the in ju ry a lim b s a lva g e p ro ce d u re w as perform ed by o u r team . N ow the p a tie n t has a c o n s e rv e d lim b b u t fu n c tio n a lly a m p u ta te d e xtrem ity a fte r 4 m o n th s of h o sp ita l stay.

K ey W o rd s:

IN TR O D UCTIO N

S uccessful! m a n a g e m e n t of p o p lite a l v a s c u la r injuries re q u ire s a m u ltid is c ip lin a ry ap p ro a ch . P opliteal a rte ry in ju rie s are a m o n g the m ost ch a lle n g in g of all e x tre m ity v a s c u la r injuries. T he p o p lite a l vein, in fra p o p lite a l a rte rie s and the tibial nerve are the m o st c o m m o n ly in jured stru c tu re s in p e n e tra tin g p o p lite a l tra u m a p a tie n ts . P e netratin g tra u m a s are m o stly se e n in w a rs and m uch e x p e rie n c e has been o b ta in e d , but th e re is also an on g o in g d e b a te a b o u t the m a n a g e m e n t of th e se injuries.

CASE REPORT

A 2 4 -y e a r-o ld m an w a s a d m itte d to the e m e rg e n c y room w ith a left lo w e r e x tre m ity g u n s h o t injury. He w a s c o m a to s e d ue to m assive blood loss. T ig h t c irc u la r left p o p lite a l ba n d a g e a p p lica tio n , rapid s ta b iliz a tio n of h e m o d y n a m ic state and blood tra n s fu s io n s w e re p e rfo rm e d by th e e m e rg e n c y sta ff on a d m issio n . O n a rriva l at

(Accepted 1 March, 2001)

Marmara Medical Journal 2001 ;14(2):110-112

110

A classical vascular dilemma: Limb salvage or amputation?

the e m e rg e n c y room , the w arm ischem ia tim e w a s d o c u m e n te d to be 13 hours. T h ere w as also p a llo r, a b s e n c e o f d is ta l p u ls e s , p u ls a tile h e m a to m a and c o m p le te m otor and sensory d e fic it o f th e s a m e lim b w ith o u t o rth o p e d ic p ro b le m s . P re o p e ra tiv e le ft lo w e r e x tre m ity d ig ita l s u b tra c tio n a n g io g ra p h y re v e a le d e xtra v a s a tio n of b lood from the popliteal artery w ith the a b s e n ce o f d ista l flo w (Fig. 1). The p a tie n t w a s ta ke n to the o p e ra tin g room , first the ip sila te ra l c o m m o n fe m o ra l a rte ry w as explored and cla m p e d to c o n tro l the bleeding. Exploration of the p o p lite a l s tru c tu re s revealed that there was a co m p le te tra n s s e c tio n of both the artery and th e v e in . B o th th e a rte ria l a nd ve n o u s re v a s c u la ris a tio n s w e re p e rfo rm e d w ith the co n tra la te ra l s a p h e n o u s vein interposition . A fter v a s c u la r re p a ir, a n te rio r a nd p o s te rio r fa s c io to m ie s w e re p e rfo rm e d through separate in c is io n s to p re v e n t th e d e v e lo p m e n t o f a c o m p a rtm e n t s y n d ro m e . T h e p a tie n t w as h e p a rin ize d fo r the firs t 5 p o sto p e ra tive days, th e n o ra l a n tic o a g u la tio n w ith w a rfa rin w as started. O n the p o s to p e ra tiv e 7th day, due to the d e v e lo p m e n t o f in fe ctio n , repeated d e b ridem e nts w ere p e rfo rm e d . O n the p o sto p e ra tive 30th day, w e co n firm e d the p a te n cy of the saphen ous gra fts by a co n tro l a n g io g ra p h y (Figs. 2-3). A fter 45 days, fa s c io to m ie s w e re closed w ith split

F i g . l . : Preoperative arteriography showing complete transection of the left popliteal artery due to gunshot injury.

F ig .2 . : Early postoperative control angiography showing the patent saphenous vein graft.

F i g .3 Late postoperative angiography showing the patent saphenous graft and improved distal flow due to resolution of edema.

th ickn e ss skin g ra fts from the co n tralatera l low er extrem ity. T w o m onths later, a n o th e r control a n g io g ra p h y w as carried out and revealed a better g ra ft flo w and distal flo w due to the re s o lu tio n of e d e m a d is ta l to th e in ju ry . T h ro u g h o u t this period, the p a tie n t had w h a t is designa ted as a fu n ctio n a l a m putation .

Atike Tekeli, et al

DISCUSSION

T he a m p u ta tio n rate d ue to the p o p lite a l artery injuries w a s re p o rte d to be as high as 73% during the W orld W a r II, to d a y it is p o ssib le to find rates ne a r 2 0 % fo r g u n s h o t w o u n d s (1,2). W hen co m p a re d to p e n e tra tin g a rte ria l injuries, blunt va s c u la r in juries have h ig h e r a m p u ta tio n rates due to the d e la y in d ia g n o sis (3,4). W hen the p atient is adm itted to the e m e rg e n c y room , q u ick diffe re n tia tio n of "hard" fin d in g s of the arterial injury (w hich include sig n s of a rte ria l o cclusion, a rte ria l b le e d in g , e x p a n d in g h e m a to m a and palpab le thrill) from the "soft" ones (history of active bleeding, p ro x im ity of p e n e tra tin g w ound to a m ajor artery, sm all n o n p u ls a tile h e m a to m a and n e u ro lo g ic d e ficit) is n e c e s s a ry to d e cide w h e th e r the case is u rg e n t (5). P re se n ce of hard s ig n s in d ic a te s im m e d ia te o p e ra tiv e a rte rio g ra p h y a nd u ltra s o n o g ra p h y in both gro u p s of p a tie n ts (6). T o in cre a se the lim b

s a lv a g e ra te a n d m in im iz e th e lo n g te rm d is a b ility , g o o d m ic ro s u rg ic a l te c h n iq u e s fo r va s c u la r and nerve re co n stru ctio n , a p p ro p ria te skeletal fixation and p re v e n tio n of se p sis by a n tib io tic th e ra p y a re m a jo r n e c e s s itie s . A ccording to c u rre n t stu d ie s, it has been show n that p o sto p e ra tive se p s is and the surro u n d in g soft tissue injury, instead o f w a rm isch e m ia tim e, are the m ost im p o rta n t fa c to rs th a t put the p a tie n t in the g ro u p of a m p u ta tio n o r s a lva g e (2). It is possible to e va lu a te the p a tie n t w ith the scores th a t a re b a s e d on d is tu rb e d a n a to m ic a l structures, w arm is c h e m ia tim e and som e o th e r variables such as age, blood pre ssu re etc... e.g; L im b S a lv a g e In d e x S c o rin g S y s te m a nd M angled E xtrem ity S e ve rity S co re s (M E S S ) (7-9). Interpretatio n of th e se s co re s w ith re sp e ct to each p atient and d e te rm in a tio n of th e a p p ro p ria te tre a tm e n t s tra te g ie s is o u r m ain goal in the m a n a g e m e n t of th e se p a tie n ts. In co nclusion , th is case re p re s e n ts a c la s s ic a l d ile m m a in va scu la r injury tre a tm e n t. O u r p a tie n t is still living with a fu n c tio n a lly a m p u ta te d left lo w e r lim b due to the tibial nerve injury and m uscle necrosis. W e co n c lu d e th a t it m ig h t ha ve b een b e tte r to a m putate the p a tie n t's lim b, be ca u se all the operation s, the h o sp ita l stay and the outco m e failure of the p a tie n t ca u s e d him and his fam ily p sycholog ical and fin a n c ia l problem s.

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