ABSTRACT: We describe a 20-year-old male with profound leg ischemia due to knee dislocation from a surfing accident. The patient presented with popliteal artery occlusion and was successfully treated with stent placement. The popliteal artery was patent at 18-month follow-up. This case report highlights the recent trend to utilize endovascular approaches in treating traumatic arterial injuries, but also the lack of certainty about how best to cross the lesion and what the long-term results are in this setting.
VASCULAR DISEASE MANAGEMENT 2013:10(5):E92-E95
Key words: popliteal artery injury, pulseless extremity, knee dislocation
Large surf can deliver adequate force to dislocate major joints. Blunt trauma resulting in knee dislocation can have devastating consequences, because neurovascular structures are rigidly tethered from the distal femoral shaft to the proximal tibia. The traditional approach to popliteal artery injury with ischemic symptoms is emergent surgical bypass.
This is a proven approach but has some disadvantages. There is a continued rate of major amputation of 10% to 20% and the bypass is performed under extremely compromised conditions with tense muscle compartments, severe soft tissue damage, and diffuse vasospasm.1,2 In this report we describe a case of knee dislocation with popliteal artery occlusion after a surfing accident that was managed with popliteal stent placement.
A healthy 20-year-old male presented to our institution within 2 hours of a surfing accident at a known big-wave surf location. His condition was stable but he complained of left foot pain. His left foot was cold and insensate, and motor function was compromised. The left knee was dislocated posteriorly associated with severe swelling and soft tissue damage (Figure 1). The left femoral pulse was palpable but there were no popliteal, dorsalis pedis, or posterior tibial pulses.
The knee was reduced but the foot did not improve and there were no pedal pulses or Doppler signals. Contralateral femoral access was obtained and a left lower extremity arteriogram demonstrated popliteal artery occlusion with no identifiable tibial runoff (Figure 2A). Intravenous heparin was administered and a 6F, 90-cm sheath was inserted over the aortic bifurcation to the left popliteal artery.
Using a 4F Glidecath (Terumo) for support and directionality, a 0.014 inch diameter Prowater guidewire (Abbot Vascular) was used to gently probe the dissected segment. The guidewire entered the true lumen by probing the artery wall opposite the location of the dissection flap. The guidewire was advanced across the popliteal artery occlusion and into the peroneal artery (Figure 2B).
A 7mm diameter x 3cm length self-expanding Precise Rx nitinol stent (Cordis) was placed at the knee joint, at the location where the arterial injury was likely to have occurred, given the mechanism of injury (Figure 2C).
Arteriogram demonstrated a patent popliteal artery, but critical stenosis remained in the tibioperoneal trunk, apparently where the dissection had extended distally from the popliteal injury (Figure 2D). The anterior tibial artery was occluded with some evidence of visible dissection in the proximal stump. An Xpert self-expanding nitinol stent, 5mm diameter x 2cm length (AbbottVascular), was placed in the tibioperoneal trunk (Figure 2E).
Completion angiography showed a patent popliteal artery with posterior tibial and peroneal runoff. The dissection extending into the anterior tibial artery was visible but the artery had antegrade flow restored. The posterior tibial artery reconstituted the dorsalis pedis artery distally. Closure of the right common femoral artery was performed with an Angio-Seal Vascular Closure Device (St. Jude Medical).
The foot was warm with a palpable posterior tibial pulse at the conclusion of the procedure. The leg was elevated to reduce compartment pressure and a knee immobilizer was placed. The patient was started on clopidogrel 75 mg and aspirin 325 mg daily. Neurologic function improved significantly within an hour. An MRI of the left knee revealed a tear of the anterior, posterior and lateral cruciate ligaments. The following day, the dorsalis pedis pulse was palpable.
Follow-up at 18 months revealed palpable posterior tibial and dorsalis pedis pulses. Noninvasive studies showed no evidence of stenosis with triphasic waveforms and normal Ankle Brachial Index of the left leg. Computed tomographic angiography scan was obtained at 1 year, which confirmed that the reconstruction was patent (Figure 3).
Emergency lower extremity bypass for limb salvage after blunt arterial trauma is accepted therapy but is uniformly performed under adverse circumstances. Incisions are made in damaged tissue. The shortest possible bypass is sometimes not possible due to limited access caused by compartment and muscle swelling. The time to restoration of perfusion may be lengthy. There may be competing injuries that also require major surgery. Endovascular repair offers potential advantages, including that it is more expeditious, it causes no additional soft tissue damage, it avoids vein harvest and open dissection, it preserves all possible arterial length, and it avoids open surgery in the setting of swollen muscles and tense compartments.
However, stenting for traumatic popliteal artery occlusion is not completely developed. Only 2 other cases have been reported in addition to this one.3,4 The main disadvantage is that it may not be possible to cross the occluded segment. In crossing an acute dissection, the operator does not want to worsen the damage by enlarging the subintimal space and extending the dissection. Probing of the dissection flap and eventual passage of the wire is somewhat blind. In this case the dissection flap was eccentric and located opposite the side of the artery where the “beak” of contrast was visible and static where it was trapped under the dissection flap.
In this case a hydrophilic wire was avoided because these are more likely to move easily along a subintimal plane. Re-entry devices are available but may be difficult to use because the distal artery is soft-walled and is likely to be collapsed. Lastly, a retrograde pedal or distal puncture would permit wire passage in the direction of the flap and this approach has become a useful maneuver for occlusive cases in our lower extremity practice. This would have been a reasonable next step if the guidewire had not crossed the lesion antegrade. If the guidewire will not traverse the lesion, the operator must be ready with contingency plans and there should be no delay in proceeding to bypass since ischemia time often dictates the resulting disability.
The longevity of stent placement in this setting is unknown. In this case, endovascular repair was offered as a temporary bridge to a bypass to be performed later under better conditions. However, a subsequent bypass was postponed due to the excellent recovery and follow-up of the patient and the injured popliteal artery.
This location is not an optimal environment for metal implants due to arterial mobility. Most popliteal stents have been placed for peripheral arterial disease and results have only been fair. Therefore, it may be possible that stents have better longevity after arterial injury.
This case and two other cases of stenting for blunt trauma popliteal occlusion provide follow-up with patent stents at 6 to 18 months. Angiletta et al3 reported endovascular repair in a 13-year-old boy with blunt popliteal trauma. The decision was to delay open vascular reconstruction due to a small saphenous vein caliber and wait until the arteries and veins matured. The patient underwent successful placement of a self-expanding nitinol stent.
At 1 year follow-up the stent remained patent and the child had grown 10 cm with no leg length discrepancy. Zimmerman et al4 reported endovascular repair of the popliteal artery after knee dislocation with placement of a self-expanding stent. Follow-up at 6 months showed a patent popliteal artery.
In each of the two previously reported cases, short segment thrombotic occlusions were treated with a single stent. In this case, care was taken to cross an occlusion that extended to the trifurcation and two stents were required. In each of the previously reported cases and the present case, the initial plan was to use stent as a bridge to bypass but results were reasonable and bypass was not performed.
This case demonstrates successful endovascular management of an acute popliteal artery occlusion due to blunt popliteal artery injury sustained in a surfing accident. Advances in endovascular approaches may lead to increased use of catheter-based treatment for traumatic popliteal artery injuries. More experience is required to develop the best methods to cross the artery and assess the long-term patency.
- Frykberg ER. Popliteal vascular injuries. Surg Clin North Am. 2002;82(1):67-89.
- Mullenix PS, Steele SR, Andersen CA, Starnes BW, Salim A, Martin MJ. Limb salvage and outcomes among patients with traumatic popliteal vascular injury: an analysis of the national trauma data bank. J Vasc Surg. 2006;44(1):94–100.
- Angiletta D, Impedovo G, Pestrichella F, Marotta V, Perilli F, Regina G. Blunt femoropopliteal trauma in a child: is stenting a good option? J Vasc Surg. 2006;44(1):201-204.
- Zimmerman P, d’Audiffret A, Pillai L. Endovascular repair of blunt extremity arterial injury: case report. Vasc Endovascular Surg. 2009;43(2):211-214.
Editor’s Note: Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Schneider reports receiving royalties from Cook Medical and reimbursements from Cordis, W.L. Gore, and Abbott Vascular.
Manuscript received December 23, 2012; final version accepted January 4, 2013.
Address for correspondence: Megan M. Hanson, DO, Tripler Army Medical Center, Surgery, 1 Jarrett White Road, Tripler AMC, HI 96859, United States. Email: email@example.com