The management of vascular injuries associated with total hip arthroplasty

Approximately 100,000 total hip reconstructions are done annually in the United States. The nature of the surgical technique in a field close to the iliac and femoral vessels makes the occurrence of vascular injury an occasional but serious complications. We have reviewed retrospectively our experience of five cases of vascular injuries with total hip replacement and an additional 63 cases in the literature to identify those patients at risk and to define the management of these injuries. For the entire group of 68 patients, most injuries were sustained on the left side (66%), and 39% were seen in revisions. Complications were related to cement incorporation of the iliac vessels (44%), aggressive medial retraction (17%), excessive traction on atherosclerotic vessels (10%), and improper technique in preparation of the acetabulum. The most commonly injured vessels were the external iliac artery (36), common femoral artery (17), and external iliac vein (6). Twenty-seven of these injuries required emergent surgery, most for hemorrhage (66%). Injuries consisted of thromboembolic complications leading to distal ischemia (46%), vessel lacerations (26%), pseudoaneurysms (25%), and arteriovenous fistulas (3%). Vascular repair was individualized and included suture repair, thrombectomy and patch angioplasty, embolectomy, and arterial and venous bypass procedures. There was an overall 7% mortality and a 15% incidence of limb loss. Risk factors include (1) revision procedures, (2) left-sided procedures, and (3) intrapelvic migration of the acetabular component of the hip prosthesis. Elective vascular workup and preliminary retroperitoneal exposure of the iliac vessels at time of hip arthroplasty is recommended for patients at risk.

Vascular injuries and amputation following limb fractures

Sixty-seven cases treated for peripheral vascular injuries associated with fractures between the years of 1977 and 1988 in the Department of Thoracic and Cardiovascular Surgery of the Dicle University, Faculty of Medicine, were reviewed retrospectively. The cause of injury was blunt trauma in 37 cases (55%) and penetrating wounds in the others, 29 gunshot injuries and one case with a stab wound. The maintenance of vessel continuity was aimed at in all patients. The ratio of limb amputation was 13% in patients operated upon within the first 8 hours after the injury. The same ratio was 39% in cases where the surgical intervention was delayed beyond 8 hours.

Rupture of the vein patch: a rare complication of carotid endarterectomy

Vein patch closure after carotid endarterectomy has been used to reduce the incidence of residual and recurrent stenosis at the carotid bifurcation. A rare but potential serious complication is rupture of the vein patch during the early postoperative period. In our experience of 2359 carotid operations performed from 1962 through 1986, saphenous vein was used for closure in 2275 (96.5%) operations. In three patients out of 75 in whom the vein patch had been harvested from the ankle, rupture of the patch occurred 2 to 5 days after uneventful carotid surgery. At emergency reoperation, the central portion of the vein was necrotic, with no evidence of infection. In each case the carotid artery was closed again with fresh thigh saphenous vein, and recovery was uneventful. The use of ankle vein was discontinued in December 1983 in favor of groin saphenous vein, and similar complications have not occurred in more than 600 carotid endarterectomies performed since. Early noninfectious ruptures of the saphenous vein patches have been mentioned in other reported series of carotid operations and have often been related to the use of ankle vein, but they remain unexplained.

[Vascular reconstruction following trauma. Experience in Basel 1980-1988]

From 1980-1988 twenty patients with vascular trauma were treated at the Kantonsspital Basel, Switzerland. The incidence of 1% in open fractures is low. Nerve lesions in combination with vascular trauma are very frequent, specially at the upper extremity. Nearly all patients were treated with the interposition of a venous graft from the vena saphena magna. We deplore 3 amputations after successful vascular reconstruction, mainly due to extensive bone and soft tissue damage. Our long-term control shows very satisfying vascular results, but poor neurological results. We therefore conclude that the functional outcome is--apart from a short ischemia time--highly related to the neurological situation at the time of the trauma.

Percutaneous central venous catheterization in a pediatric intensive care unit: a survival analysis of complications

We investigated the relationship between the duration of percutaneous central venous catheterization and the occurrence of catheter-related complications in critically ill children by survival analysis techniques. Data were collected prospectively and analyzed for infectious and noninfectious complications from 379 pediatric patients in whom central venous catheters had been placed in the pediatric ICU over a 45-month period. Cumulative survival rate analysis revealed a linear decrease in the number of complication-free catheters with time. The median duration of complication-free catheter survival was projected to be 23.3 days. The risk of catheter complication did not increase with increasing daily duration of catheter use as demonstrated by probability density function: catheter complication rates were similar on the first day after insertion (1.06 +/- 0.5%), the seventh day (4.27 +/- 1.6%), and the 24th day (2.48 +/- 2.4%). Therefore, in this population, routine catheter replacement would not be expected to lower the incidence of catheter-related complications, but may unnecessarily increase the number of insertion-related complications.

Noniatrogenic pediatric vascular trauma

Twenty-four noniatrogenic pediatric vascular injuries in 20 patients (75% male; mean age, 14 years) were treated during a 3-year period. Of 18 arterial and six venous injuries, 65% were penetrating and 35% were blunt injuries. Eighty percent of all patients had significant associated injuries that required repair. Angiography was performed in 13 of 20 patients, with four performed during surgery. Repair methods were ligation in two of six venous injuries and three of 18 arterial injuries, primary repair in three of six venous injuries and six of 18 arterial injuries, and autogenous saphenous vein graft in seven of 18 arterial injuries. Exploration and debridement, thrombectomy, and nonoperative management were used in one arterial injury each. Fasciotomy was employed in six of 13 arterial injuries in the extremities. There was one operative death, no reoperations, and no early or late amputations. Mean follow-up of 27 months demonstrated normal palpable and Doppler pulses (by noninvasive testing) distal to all arterial repairs. This study supports an aggressive approach to the diagnosis and treatment of noniatrogenic pediatric vascular trauma, emphasizing the liberal use of fasciotomy and meticulous vascular repair for the successful management of these challenging injuries.

Vascular complications associated with orthopedic procedures

Damage to vascular structures during orthopedic procedures occurs relatively infrequently; when it does occur, however, recognition and prompt intervention are essential. We report herein 11 vascular injuries secondary to orthopedic procedures encountered between 1978 and 1988. Two injuries occurred as a consequence of lumbar laminectomy, three as a result of total hip replacement, three secondary to open reduction and internal fixation of a fracture of a lower extremity, two secondary to attempted closed reduction of humeral fractures and one injury as a result of hip flexion contracture release. Injury occurred to three iliac arteries, three popliteal arteries, two brachial arteries, one femoral artery, one graft to femoral anastomosis and two iliac veins. Five arterial injuries were repaired primarily, one with a vein patch, while five required bypass grafts. One venous injury was repaired primarily and the other required placement of a Greenfield filter for thrombosis. Major complications were a result of diagnostic delay and subsequent ischemia in most patients. There were no deaths. We conclude that vascular injuries can occur as a result of laceration, compression or traction during orthopedic procedures as a result of the proximity of vascular structures to the spine, joints and long bones. Also, we conclude that injuries manifest themselves primarily as hemorrhage or ischemia; that excellent results can be obtained with prompt recognition and treatment; that angiography is useful in those with mild ischemia in whom diagnosis is delayed, and that preoperative documentation of the vascular status of patients is critical prior to orthopedic procedures.

Venous rupture during transvenous approach to a carotid-cavernous fistula. Case report

An attempt at transfemoral transarterial balloon occlusion of a high-flow spontaneous carotid-cavernous fistula was unsuccessful because the carotid artery rent was too small for this approach. During a subsequent transvenous approach to the cavernous sinus through the jugular vein, the inferior petrosal sinus was perforated. A minor subarachnoid hemorrhage occurred before the tear could be sealed by the deposition of three Gianturco coils in the vein. The patient was taken to the operating room for emergency obliteration of the fistula and petrosal sinus in order to remove the risk of further hemorrhage. Under the guidance of intraoperative digital subtraction angiography, isobutyl-2-cyanoacrylate was injected directly into the surgically exposed cavernous sinus. Successful obliteration of the fistula was achieved with preservation of the carotid artery, and the angiography catheter was removed safely from the petrosal sinus. Although initially after surgery the patient had nearly complete ophthalmoplegia, at her 1-year follow-up examination she had normal ocular motility and visual acuity. The transvenous approach to the cavernous sinus and alternative methods of treatment of carotid-cavernous fistulas are discussed.

A twelve-year survey of cervicothoracic vascular injuries

This study of a large series of victims of trauma to the cervicothoracic great vessels confirms the lethal potential of these injuries: more than half of victims of such injuries died. The optimal management of patients potentially harboring such vascular damage appears to include skilled prehospital resuscitation and rapid transport to a trauma center, a high index of diagnostic suspicion, a low threshold for the performance of contrast arteriography, aggressive surveillance for associated neurologic and aerodigestive tract injuries, and timely technical repair, including liberal indications for sternotomy or thoracotomy to assure vascular control.

Perforation by central venous catheters: a new testament to an old test

Perforation by central venous catheters into the extravascular space is a rare complication of central venous lines that may explain new onset shortness of breath in hospitalized patients. We found that lowering bottles containing infusate and looking for return of venous blood is a highly specific test for this problem. Using Bayes' Theorem we calculated that for prior probabilities of catheter perforation of 0.01 and 0.05, corresponding posterior probabilities ranged from 0.1 to 0.15 and 0.35 to 0.49 respectively. This test should be used in all patients with new shortness of breath who have central venous catheters.

Coverage of acute vascular injuries of the axilla and groin with transposition muscle flaps: case reports

Acute axillary or groin vascular injuries caused by farm machinery or shotgun blasts are often associated with extensive soft-tissue loss. Coverage of the repaired blood vessels with healthy tissue is necessary to avoid infection, desiccation, pseudoaneurysm, and rupture. Adjacent muscles are not always available to rotate for coverage, due to unacceptable functional loss, or injury to the principal vascular pedicle. We used proximally based trunk musculature with vascular pedicles out of the areas of injury to achieve coverage of four extensive axillary wounds and one extensive groin wound. Arterial repair only was performed in three axillary wounds. Combined arterial and venous repair were performed in one groin wound and one axillary wound. Followup ranging from 9 months to 5 years revealed no vascular failure or soft-tissue complications. We conclude that coverage of vascular repairs and soft-tissue defects with viable muscle is necessary in cases of extensive injury. Adjacent muscle is preferred for coverage, but when this is unavailable, coverage can still be achieved using more proximally pedicled muscles of the trunk.

[Venous trauma of the limbs]

Traumatic lesions of veins in the limbs must be considered in 3 types of circumstances: (1) Extensive injuries, open or closed, affecting the principal vascular axis and usually damaging both the vein and artery at the same time; these wounds or ruptures in the principal venous supply pose the problem of repair using autogenous venous material, since it is now known that the result of arterial reconstruction (which is so essential for the limb) may be compromised by the lack of a satisfactory return circulation. Because of this, amputation may be resorted to, as is still too often seen in the case of the popliteal fossa. (2) Lesions of the collateral veins: these remain the most frequently encountered in civil practice; they result in either deep hematomas in the muscles (sub-aponeurotic), or superficial hematomas between aponeurosis and integument. The former may be a factor in compartment syndromes with the risk of irreversible ischemia in a muscular compartment if aponeurotomy is not carried out very rapidly, while the latter can give rise to skin necrosis if they are not drained in time. (3) Limited wounds affecting vein and artery, which are in contact, with formation of an arteriovenous fistula which may only be recognized after a certain delay if it is not systematically borne in mind. The question of assessing the sequelae over the medium and long term is raised in all cases; in the vast majority of cases, these correspond to a picture of post-traumatic thrombophlebitis. Correct preventive and curative treatment can lessen the disabling nature of the sequelae and especially their professional repercussions.

Evaluation of the elastic behaviour of central venous PVC, polyurethane and silicone catheters

Eighty used and 20 new silicone, polyurethane and polyvinylchloride central venous catheters were tested to establish the Young's modulus and the bending stiffness of the catheters and their introducers. The catheters were subjected to longitudinal traction forces and their lengthening measured. Young's modulus and the geometric moment of inertia were then calculated. It is shown that polyurethane catheters show least variation in their elastic characteristics, and that silicone catheters offer least resistance to bending and do not change their elastic properties after use. All catheters were equally unlikely to cause thrombus production if this is related to excessive bending stiffness.

[Venous access in anesthesia and resuscitation]

Veins are used not only in anaesthesia and reanimation, but also in the whole set of medical and surgical specializations, for blood-sampling, injecting, measuring and exploring. This study analyses the local, regional, and general complications arising from the puncture of the superficial and deep veins, their capacity for catheter insertion, and the medication or solutions injected.

Vascular trauma at a university teaching hospital

Fifty-two patients with vascular trauma have been managed by the St Vincent's Hospital Vascular Surgical Unit during the 5 year period 1982-86. The mean age of the patients was 39.7 years; 81% were male. Penetrating, blunt and iatrogenic trauma were equally represented. Forty-nine of the patients underwent 63 operations performed by members of the unit. Twenty-five of the patients had significant non-vascular injuries, requiring 29 other operations. Pre-operative angiography was used rarely in urgent cases. All vascular reconstructions were noted to be patent during the follow-up period, with a mean of 20 months, except in one instance, where an amputation resulted from failed surgery. One patient died from a complication of the vascular surgery.

Delayed recognition of vascular complications caused by central venous catheters

Three patients are described in whom vascular complications occurred after placement of central venous catheters. Inappropriate catheter length and site of cannulation, catheter movement, and unsuitable catheter material can lead to complications. Guidelines for cannulation of central veins are defined, and recommendations for chest roentgenography, which could result in early recognition of catheter misplacement, are provided.

Management of venous trauma

There has been considerable interest in the management of injured extremity veins since the American experience during the Vietnam War. Fortunately, there are an increasing number of reports from civilian experience in the United States that add valuable information. Although the controversy continues, it appears that there is merit in repair of many injured lower-extremity veins, particularly the popliteal vein when it is a single return conduit, assuming that the patient's general condition will permit, in an attempt to prevent acute venous hypertension initially and chronic venous hypertension subsequently. Figure 1 identifies the recovery potential that exists even if the initial venous repair fails. In contrast to thrombosis in the arterial system, recanalization is the rule in venous thrombosis. Patent valves can exist above and below the rather localized area of thrombosis. It appears that recanalization will prevent the problems of chronic venous insufficiency. It is obvious that many patients do well for years; however, the sequelae of acute venous hypertension may be more demonstrable after 10 or 15 years. There has not been similar evidence supporting a more aggressive approach in general in upper-extremity veins. However, it should be appreciated that a return pathway must remain patent, as noted in replantation of extremities. Obviously, there are differences in military and civilian wounds, with the former usually having more extensive soft-tissue destruction and obliteration of collateral veins and lymphatic channels. Unfortunately, many civilian gunshot wounds are being seen in the United States that are similar to the military type. We must not forget the lessons of the past, and we must continue to analyze our experience in the management of injured veins under a variety of conditions.