Femoral vessel injuries

VASCULAR TRAUMA: COMPLEX ANDCHALLENGING INJURIES, PART II 0039–6109/02 $15.00 � .00

FEMORAL VESSEL INJURIES

Eddy H. Carrillo, MD, FACS, David A. Spain, MD, FACS,Frank B. Miller, MD, FACS, and J. David Richardson, MD, FACS,

HISTORICAL PERSPECTIVES

The history of trauma surgery has been closely related to the multi-ple military conflicts throughout history. Galen and Celsus were amongthe first that advocated vascular ligation in the treatment of penetratingvascular injuries. During the 1500s, Ambroise Pare demonstrated thevalue of arterial ligation to control bleeding. It was not until Carrel,Murphy and others described the principles of arterial reconstructionsthat vascular repairs became feasible. Vascular ligation, however, re-mained the treatment of choice of arterial injuries during World Wars Iand II. It was not until the Korean Conflict that military surgeons wereable to treat most vascular injuries.11 This was again confirmed duringthe Vietnam War, during which approximately 10,000 vascular injuriesin nearly 7500 US casualties are documented in the Vietnam VascularRegistry (1966–1973).33

INCIDENCE AND ETIOLOGY

As described before, military conflicts have been associated withlarge numbers of injured patients; in the United States, an increase inthe incidence of vascular injuries in the civilian population has paralleledthe increase in gunshot wounds (GSWs), motor vehicle accidents, andinvasive medical procedures. Femoral vessels are among the most com-monly injured vessels, comprising approximately 70% of all arterial

From the Department of Surgery, University of Louisville, Louisville, Kentucky

SURGICAL CLINICS OF NORTH AMERICA

VOLUME 82 • NUMBER 1 • FEBRUARY 2002 49

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injuries. More than 90% of these injuries are the result of penetratingtrauma, with most resulting from GSWs.12

DIAGNOSIS

Most patients do not present a diagnostic dilemma. Occasionally,and if the patient is hemodynamically stable, it may be helpful to obtainan arteriogram to determine the extent of the injury. This is particularlyimportant with GSWs or especially if multiple vascular injuries aresuspected. Injuries to the femoral artery are not commonly associatedwith fractures of the femoral shaft, although there is an association withthe more proximal fractures. There is also an increase in associatedvascular injuries in the presence of distal femur fractures, especiallythose that involve the knee. These patients, if hemodynamically stable,may require angiography to assess the status of the femoral and popli-teal arteries.

History

Most patients who have sustained penetrating injuries to the femo-ral vessels present with active hemorrhage, shock, or a pulseless extrem-ity. Shock or severe hypotension usually are not found unless thereis ongoing uncontrolled hemorrhage. Although exsanguination frompenetrating injuries to the femoral vessels is still encountered, hemor-rhage generally is controlled before patients’ arrival at the hospital.

Physical Examination

A thorough physical examination should be performed, with thepatient completely disrobed. All physical signs suggestive of a vascularinjury should be diligently searched for the 6 P’s of acute vascular injury(pulselessness, pain, pallor, paresthesias, paralysis, and poikilothermia).Pulses should be documented and compared with those of the nonin-jured extremity. Other clinical findings suggestive of an arterial injuryinclude the presence of a bruit, thrill, or distal ischemia, which shouldbe actively searched for and documented, as well as the so-called softor hard signs of vascular injury (Table 1). Absent pulses, persistentshock, and neurologic deficits are observed in more than 80% of patientswith vascular injury; however, some patients with arterial injuries (ABI)are seen with distal pulses.26, 32 The measurement of ankle-brachial in-duces is always helpful. Any ABI less than 0.9 is highly suggestive of avascular injury and requires angiography.

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Table 1. CLINICAL MANIFESTATIONS OF EXTREMITY VASCULAR TRAUMA

Hard Signs Soft SignsActive hemorrhage Stable hematomaPresence of bruit or thrill Unexplained hypotensionAbsent or diminished distal pulses Proximity of injury to major vesselHemorrhage, expanding or pulsatile Presence of neurological deficits

hematoma Transient hypotensionDistal ischemia (pain, pallor, paralysis,

paresthesias, pulselessness, coolness)

Arteriography

Arteriography is indicated only in hemodynamically stable patientsand should be used as a ‘‘roadmap’’ when questions arise. The arterio-graphic findings may help to indicate an operation; plan the appropriateapproach; or entertain alternatives of management, such as stenting.16

Currently, the two most accepted indications for arteriography in pa-tients with penetrating injuries to the limbs include (1) exclusion ofvascular injury in patients without hard signs of vascular injury and (2)the delineation of the location, nature, and extent of vascular injurywhen clinical signs are not easily identified during physical examinationand the ABIs are abnormal (Table 2).

Another scenario in which arteriography also may play a role is inpatients with clinical signs of vascular deficit but associated conditions,such as multiple possible sites of vascular injury, underlying chronicperipheral vascular disease, and extensive bone or soft tissue injuries.16

In general, arteriography has greater indications after blunt injuriesbecause associated injuries to bone, nerve, and soft tissues may accountfor the clinical findings.

Emergency center or ‘‘one-shot’’ arteriography also has been pro-posed as a safe, efficient, and cost-effective alternative to expedite thediagnosis of vascular injuries in the lower extremities.29 Because of theproximity of the angiography suite to the trauma room at the Universityof Louisville Hospital, the authors tend to perform multiplanar arteriog-raphy in most patients; however, surgeon-performed arteriography

Table 2. INDICATIONS FOR ARTERIOGRAPHY IN EXTREMITY TRAUMA*

Blunt trauma with signs of vascular injuryIntraoperative or postoperative evaluationDelayed diagnosisAbnormal ABIsFollow-up of nonoperatively managed arterial injuriesMultiple injuries (gunshot wounds, very comminuted fractures)Extensive orthopedic injuries or soft tissue defectsProximity in hemodynamic normal patients*

*Currently, most institutions perform some type of noninvasive study of the involved extremity.

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could be entertained in patients with low-risk extremity wounds thatrequire immediate surgery for associated injuries to other anatomicareas.

Noninvasive Studies

Noninvasive studies have recently seen an increase in the role inthe diagnosis of vascular injuries.14–16 Central to the debate surroundingthe role of noninvasive studies in penetrating extremity injuries iswhether the immediate cost reduction of little or no diagnostic testingbeyond physical examination and observation is outweighed by thelong-term expense and medicolegal exposure associated with missedvascular injuries.4 Noninvasive vascular studies include Doppler sonog-raphy, B-mode ultrasonography, and MR angiography.

Doppler Sonography

Doppler sonography documents arterial injury by measuring thearterial pressure index, which is the ratio of blood pressure distal to anextremity injury, to that in an uninjured extremity. Accuracy has beendescribed as consistently above 95%. Its major limitation is its failure todiagnose intimal defects and small false aneurysms.16

B-Mode Ultrasonography

B-mode ultrasonography has the advantage of imaging extremityvessels with nearly as much resolution as biplanar angiography. Eventhough its major application has been as a noninvasive screening ofcarotid vessels, deep vein thrombosis, and other vascular diseases, its usein the evaluation of patients with vascular injuries has been proposed inrecent years.1, 4, 16, 18 Its greatest advantage is that it is noninvasive andcan be obtained more rapidly, more safely, and at less expense. It canalso determine the presence of intimal defects missed by physical exami-nation or duplex examination.4, 16

MR Angiography

In the past 5 years, MR angiography has become another alternativefor the diagnosis of vascular trauma. Even though it is not widelyused, it has the advantages, compared with other modalities, of beingnoninvasive, obviating intravascular iodine contrast material, and im-aging several vascular structures simultaneously.35 Its major drawbacksare that it is not readily available in every institution and that thepresence of orthopedic instrumentation or other metal devices can causeits use to be extremely limited. However, the authors suspect that in thefuture the indications for MR angiography in vascular trauma willcontinue to expand.6


OPERATIVE MANAGEMENT AND SURGICALEXPOSURE

Patients with confirmed femoral vessel injuries should be trans-ported expediently to the surgical suite. Large intravenous accessthrough the upper extremities is secured. Every effort is made to avoidhypothermia. The authors routinely prepare the contralateral extremityto harvest the saphenous vein for autogenous grafts. The length of thesterile field includes the entire abdomen to the toes in both lowerextremities because, in some cases, particularly those involving the prox-imal femoral vessels, initial control may be obtained through a suprain-guinal approach.

In patients with proximal injuries to the femoral vessels, it is oftenwise to initially expose the distal common iliac vessels through a sepa-rate incision above the inguinal ligament and to obtain proximal vascularcontrol before entering the femoral triangle. Once proximal control hasbeen obtained, one can safely make a longitudinal incision over thefemoral triangle, extending it along the border of the sartorious muscleand exposing the injury in a more leisurely manner.5, 7

Bleeding from the femoral triangle occasionally can be challengingto control, especially with combined arterial and venous injuries. Venousbleeding can be more difficult to manage. More often than not, venousbleeding can be controlled by direct pressure from the source of bleeding.Blind clamping is strongly discouraged because damage to the numerouscollaterals that enter the common femoral vein from its posterior andmedial aspects as well as iatrogenic femoral nerve injuries may occur.

In patients sustaining injuries to the femoral vessels, the authorsroutinely use systemic or local heparin, especially in patients with com-bined injuries, long delay between injury and revascularization, or crushinjuries. If there are contraindications for systemic anticoagulation, theauthors use intermittent intra-arterial irrigation of heparinized saline (10U/ml). The systemic effects are minimized although not completelyavoided.10

Techniques of Vascular Repair

Once the vascular injury is identified, the bleeding is controlled andthe extent of the injury determined, and plans are entertained for thetype of vascular repair. The authors routinely pass a Fogarty catheterbefore completion of the vascular repair. The presence of retrogradebleeding by itself does not completely rule out the presence of distalclots within the arterial system. Completion arteriography is not rou-tinely obtained if distal perfusion is documented at the completion ofthe vascular repair.

In the presence of combined arterial and venous injuries, the veinis repaired first to optimize the likelihood of a successful revasculariza-tion. This issue becomes more clear in distal venous injuries when the

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ipsilateral saphenous vein has been damaged, or in the presence ofextensive soft tissue injuries. Although whether venous injuries need tobe repaired is controversial, it has been for years the philosophy of theUniversity of Louisville Hospital to attempt to repair the venous injuriesin all hemodynamically stable patients. Published data clearly show thatvenous repairs improve the likelihood of successful arterial repairs andminimize potential long-term complications.2, 7, 9, 23

The choice of the vascular repair is dictated by the extent of theinjury. Most injuries to the common and superficial femoral artery re-quire resection with primary anastomosis. These vessels can be mobi-lized for a length of up to 2 cm. If this cannot be accomplished withouttension in the suture line, an interposition graft is indicated. In mostinstances, the saphenous vein can be used; however, evidence suggeststhat synthetic grafts work as well as autogenous grafts, especially inpotentially contaminated wounds.5, 7, 13, 36

In grossly contaminated wounds or in those with associated exten-sive soft tissue defects, commonly seen with GSW or crush injuries, itmay be best to proceed with an extra-anatomic reconstruction throughthe posterior planes of the thigh covering the proximal and distal anasto-mosis with healthy, uninjured tissue. In the authors’ experience, therehas been no need to remove these extra-anatomic grafts after all thewounds are healed, and the potential of infection is minimized. Theonly indication for graft removal has been the presence of complicationssuch as infection or pseudoaneurysm formation.

Unless there is extensive bone and soft tissue destruction, andespecially associated extensive nerve injuries, every effort should bemade to restore vascular continuity. Acute ligation of the femoral arteryis associated with an amputation rate of nearly 50%, and although asignificant number of patients are able to preserve their extremities, themajority develop delayed claudication.13

The use of temporary vascular shunts to bypass injured vessels wasinitially described 30 years ago. More recently, some institutions haveadvocated their use as an alternative to maintain distal arterial perfusionwhile attention is directed toward repair of associated thoracic or ab-dominal injuries, wound debridement or skeletal fixation.7, 9, 17, 21 Al-though the details of the technique may vary from institution to institu-tion, the basic philosophy is the same: restoring early perfusion to theextremity. Shunting is an attractive alternative when the surgeon mustchoose between abbreviating the operation or proceeding to immediateamputation or vascular reconstruction.

NONOPERATIVE MANAGEMENT

Because of easy access to diagnostic angiography in most traumacenters, nonoperative treatment has been proposed as another alternativeof management in patients with minimal femoral vessel injuries. Nonop-erative treatment of vascular injuries includes observation or minimally


Figure 1. Small intimal defect (arrow) after a penetrating injury with no clinical angiographicevidence of vascular insufficiency. The patient was observed and a follow-up arteriogramshowed no evidence of the intimal lesion.

invasive procedures as the only alternatives of treatment. Easy access toangiography and a fully equipped noninvasive vascular laboratory aremandatory to entertain this form of treatment. Otherwise, the wholeconcept becomes meaningless in the presence of a single failure.

Prompt availability of angiography has resulted in the detection ofminimal or subtle injuries, such as small intimal flaps that aside fromtheir angiographic findings do not present any clinical signs of vascularinsuficiency, the so-called ‘‘clinically occult vascular injuries.’’ As de-scribed by Frykberg,16 these injuries are unique in their morphology as intheir absence of any significant clinical findings. The usual angiographicfindings include intimal flaps (Fig. 1), focal narrowing, small false aneu-rysms (Fig. 2), and arteriovenous fistulas.

Observation

Observation is indicated for patients with angiographic findingsdescribed earlier, with no manifestation of clinical signs of vascular

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Figure 2. Small false aneurysm of the proximal superficial femoral artery after a stabwound to the left thigh. In spite of the small size and no associated vascular insufficiency,the injury was surgically repaired.

insufficiency occurring in intact vessels without extravasation or occlu-sion of contrast during biplanar angiography.16 Anticoagulation or anti-platelet therapy is controversial and not used routinely in most patients.Failures of nonoperative treatment include acute vascular insufficiency,increased flow in the injured extremity by 25% compared with thenoninjured extremity, and increased size of a false aneurysm or anarteriovenous fistula. The authors have treated several patients followingthese principles; however, they have not expanded this concept to pa-tients with arteriovenous fistulas or false aneurysms, regardless of size.

Sonographically Guided Therapy

Classically, pseudoaneurysms have been managed surgically be-cause of the potential for rupture, thrombosis, or distal embolization.


Arteriography with coil or gel foam embolization of the pseudoaneu-rysm is both diagnostic and therapeutic. This may not be feasible insmall, distal vessels; it is time consuming, invasive, and occasionallytechnically difficult to obliterate the vessel completely.

Sonographically guided therapy is an alternative that has allowedfor the nonoperative treatment of femoral pseudoaneurysms, allowingfor gradual increases in pressure applied with the ultrasound transducerover the neck of the pseudoaneurysm until flow is arrested. This proce-dure cannot be performed in anticoagulated patients or in patients withpseudoaneurysms that are noncompressible, nonsuperficial, or at riskfor rupture.19

Another variation of this technique is the use of sonographicallyguided thrombin injection for the treatment of pseudoaneurysms.8, 20

Potential benefits include a success rate of 98%, decreased proceduraltime, decreased patient discomfort, and use in anticoagulated patientsand patients with deeply located pseudoaneurysms that are not accessi-ble for external compression.8

Endovascular Management

Transluminally placed endovascular stented graft repairs for arterialtrauma have become important tools in the management of patientssustaining complex injuries, especially for critically injured patients un-dergoing diagnostic angiography, or when priority is needed to dealwith more acute or life-threatening associated injuries and there is noclinical evidence of vascular insufficiency in the affected extremity.22, 30, 34

Although this is an evolving technology, endovascular grafts offer dis-tinctive advantages in some cases and are important tools that shouldbe a part of the armamentarium of vascular surgeons; however, few dataexist other than anecdotal reports in the management of acute peripheralvascular injuries, and no large series or long-term effects have beenpublished in the literature. At the present time, endovascular stentsfor surgically accessible injuries remain an experimental and evolvingtechnology.

COMPLEX PRESENTATIONS

Because large veins and important nerves are found within thefemoral triangle and are located adjacent to the femoral artery, associatedinjuries also are encountered frequently and contribute significantly tolong-term disability. Occasionally, despite successful arterial repairs, thepresence of associated venous or nerve injuries precludes a long-termsatisfactory result.

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Associated Venous Injuries

Combined injuries to the femoral artery and vein can be extremelydifficult to manage because of the special problems inherent in obtainingcontrol of the vein and its many tributaries in the femoral triangle. Theonly proven benefit of venous ligation is reduced operating time. Venousrepair has several potential benefits, including (1) improved patency ofassociated arterial repairs because preserved venous patency maintainsnormal distal vascular bed resistance, thus optimizing blood flow andreducing stagnation; and (2) reduced incidence of chronic venous insuf-ficiency and associated postphlebitic syndrome.7, 28, 37

The authors believe that attempts should be made to perform ve-nous repairs if the overall condition of the patient allows.2, 9, 13, 23 Lateralrepair is the first choice; however, the authors have relied on graftinterposition when indicated. Complex repairs have the potential forrecanalization despite their high rate of early thrombosis.28 Becauserestoration of axial patency and maintenance of valve competency aremajor objectives of venous trauma reconstruction, it would seem thatwhenever time and patient conditions permit, repair should be at-tempted.28

Extensive Soft Tissue Injuries

Extensive muscular and skin loss at the site resulting from blunttrauma may preclude limb salvage. High failure rates also may beexacerbated by the failure to initially diagnose associated arterial injuriesat the time of hospital admission. In some patients, amputation is theonly alternative to manage some of these injuries28; however, limb losscaused by delay in diagnosis is preventable. The authors strongly advo-cate that in patients with complex blunt injuries to the lower extremities,early use of angiography, if the patient is hemodynamically stable,during the initial assessment, results in reduced times to revasculariza-tion of ischemic limbs.

Extensive irrigation and debridement should be a part of the initialmanagement. If there is evidence of extensive contamination and dam-age to the soft tissues, extra-anatomic reconstruction should be enter-tained as a part of the initial reconstruction. Early fasciotomies, legelevation, and anticoagulation in selected patients are also a part of theoverall treatment.37 At the conclusion of the vascular repair, it is im-portant that soft tissues are approximated and used to cover the vessel.This may be difficult to achieve in patients with widespread soft tissuedamage, but the vascular repair must be covered with muscle or skinwithin the ensuing 48 hours after the vascular injury to prevent dessica-tion and vessel repair ‘‘blowouts.’’


INDICATIONS FOR FASCIOTOMY

The current indications for fasciotomy are listed in Table 3. Theseindications are best used in concert with measurements of compartmentpressure; however, early detection of deficits in nerve function is veryimportant. Hypoesthesia in the first interdigital cleft on the dorsum ofthe foot, for example, indicates dysfunction of the deep peroneal nerve,usually from increased pressures in the anterior compartment.

Early work by Matsen24 showed that once the compartment pressureexceeds 45 mm Hg, irreversible nerve damage is likely if decompressionis not performed expeditiously, regardless of the presence of distalpulses. The techniques of fasciotomy have been described in detail.31

Suffice it to say that the anterior compartment of the leg, bounded byrelatively rigid fascial sheaths, is more vulnerable than the others andmost often is involved. Usually, bilateral skin incisions are made togain entrance into the four compartments. The anterior and lateralcompartments are decompressed through a 20- to 25-cm incision mid-way between the fibula and tibial crest. The anterior compartment isincised longitudinally by a transverse incision in the anterior septum,the adjacent superficial peroneal nerve can be identified as it coursesdistally in the lateral compartment, penetrating the deep fascia betweenthe peroneus longus and brevis muscles. Injury of the nerve should beavoided when making the incision in the investing fascia of the lateralcompartment.24

AMPUTATIONS

The dilemma faced when treating patients with combined orthope-dic and vascular injuries of the lower extremity centers around thebenefit of primary amputation versus limb salvage at any cost. In com-plex injuries involving bone, soft tissues, and vascular structures, revas-cularization of vascular injuries is often successful; however, limb func-tion is usually poor. Patients are frequently left with a revascularizedyet nonfunctional extremity as the result of neurologic impairment orextensive soft tissue injury.27

Scoring systems may help to determine the need for an early ampu-tation; however, most scoring systems are complex and not always

Table 3. INDICATIONS FOR FASCIOTOMY

Prolonged hypotensionSwelling of the extremityExtensive soft tissue damageCombined venous and arterial injuryCombined bony plus arterial or venous injury or bothDelay between injury and definitive repairDocumented compartmental pressure �35 mm Hg

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Table 4. MANGLED EXTREMITY SEVERITY SCORE

Criterion Points

Skeletal/soft tissue injuryLow energy (stab, simple fracture, low energy GSW, etc.) 1Medium energy (dislocation, open fracture, etc.) 2High energy (crush, close range shotgun, military GSW, etc.) 3Very high energy (above plus contamination, avulsion 4

Limb ischemia*Pulse reduced but perfusion normal 1Pulseless, paresthesias, decreased capillary refill 2Cool, paralyzed, insensate, numb 3

ShockSystolic BP always �90 mm Hg 0Hypotensive transiently 1Persistent hypotension 2

Age(y)�30 030–50 150� 2

*Score doubles for ischemia �6 hours.GSW � gunshot wound.Data from Winkelaar GB, Taylor DC: Vascular trauma associated with fractures and dislocations.

Semin Vasc Surg 11:265, 1998.

applicable to the general patient population, making them difficult touse during the initial assessment, and they are not very accurate inpredicting functional outcome. Currently, the most commonly used scor-ing system is the Mangled Extremity Severity Score (MESS). The advan-tage of the MESS is that it takes into consideration the patient’s age anddegree of skeletal and soft tissue injury, limb ischemia, and hemorrhagicshock in calculating a score (Table 4). Values of 7 or more predict theeventual need for an amputation with high accuracy.37

Because the determination of the need for early amputation ismultifactorial and not always possible at the time of initial operation,especially in the multiply injured patient, avoidance of amputation onthe day of admission and delay of such procedure for 1 to 2 days allowfor a more careful analysis of the pros and cons of limb preservationand allows the trauma surgeon to involve the patient and his or herfamily in the decision process.

Current philosophy in most trauma units is that when limb amputa-tion occurs as a result of trauma, reimplantation should be entertained;however, clinical experience shows that unfavorable factors for success-ful reimplantation include crush or avulsion injury, multiple trauma, asevered limb that has been frozen, prolonged ischemia time, high level,and lower extremity amputation.37

POSTOPERATIVE MANAGEMENT

Postoperative care is similar to that provided for other vascularrepairs, with particular attention directed to prevent external compres-


sion by splints, bandages, or other external devices. Early ambulation isallowed and encouraged if the extremity is stable and there are no othercontraindications. Physical therapy should prevent venous stasis andwill preserve joint mobility.

Clinically, if a patient presents a warm extremity with good neuro-logic function, this provides evidence of successful revascularization.Unfortunately, many patients have associated nerve damage, swelling,fractures, and orthopedic devices, such as external fixators, that mayimpair clinical assessment of the vascular repair. A transcutaneous oxy-gen sensor and a Doppler flow detector can be extremely helpful inmonitoring distal perfusion.

COMPLICATIONS

Complications after femoral vessel injuries are classified as eitherimmediate or delayed. The most common immediate complication isearly thrombosis. This is generally considered as a failure of surgicaltechnique. In primary repairs, they are the result of tension in the sutureline or, less commonly, a result of distal clots or intimal flaps. Patientswith an abdominal compartment syndrome also can present with failureof a lower extremity arterial graft as a result of increasing intra-abdomi-nal hypertension.3

Delayed complications include graft infection, arteriovenous fistu-las, and false aneurysms. Graft infection usually is seen in patients withextensive contamination after extensive soft tissue injuries. More oftenthan not, patients require removal of the graft with an extra-anatomicreconstruction to maintain distal tissue perfusion. Arteriovenous fistulasand false aneurysms usually result from missed vascular injuries andoccur in some patients in whom observation and nonoperative manage-ment were chosen as the initial management strategy (Figs. 3 and 4).Arteriography is required to make a definite anatomic diagnosis. Most ofthese complication require surgical management although, as technologyadvances, the use of an endoprosthesis may be an option for somepatients.

SUMMARY

Early diagnosis, expeditious vascular repair, and aggressive man-agement of complications have resulted in an amputation rate of lessthan 9%. Repair rather than ligation of an associated femoral veininjury is commonly practiced by experienced trauma surgeons. In mostcircumstances, a reversed autogenous saphenous vein graft from thecontralateral extremity is the conduit of choice; however, if a saphenousvein cannot be used because of size discrepancies, multiple associatedtrauma, or extensive contamination, polytetrafluoroethylene can be usedwith good results. If vein ligation is performed, early fasciotomy isindicated for close and meticulous monitoring of the compartmental

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Figure 3. Multiple small pellets and significant swelling of the left lower extremity arevisualized in this patient who sustained a shotgun wound to the left thigh 10 years beforepresenting to the hospital complaining of increase in size of the extremity, ulcerations inthe distal extremity, and the presence of a thrill.


Figure 4. Arteriogram shows a large superficial femoral arteriovenous fistula with massivedilation of the left femoral and iliac vein. The fistula was repaired with a resection andinterposition graft of the superficial femoral artery and repair of the vein from within thefistula. The patient had an uneventful recovery with healing of the ulcers and decrease insize of the extremity.

pressures. Clearly, the most crucial components for a successful outcomeare a thorough evaluation, early operation, and a flawless vascular re-pair.

ACKNOWLEDGMENTS

The authors acknowledge editorial assistance and manuscript preparation by Mr. JohnMcKiernan and the Editorial Office at the Department of Surgery of the University ofLouisville.

References

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Address reprint requests to

Eddy H. Carrillo, MDDepartment of SurgeryUniversity of Louisville

Louisville, KY 40292

e-mail: [email protected]

Femoral vessel injuries

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