SAO PAULO
J<n
~ TlL '
N e ls o n W o lo s k e r , A lv a r o G u a d e n c io , S e r g io K u z n ie c ,
R u b e n A iz in R o s o k y , C la u d io K a lu m e , C e s a r A m o r im P a c h e c o
N e v e s , R ic a r d o A u n , B e r ilo L a n g e r
Surgical treatmentof noniatrogenic
trauma of the femoral arteries
Discipline of Vascular Surgery, Department of Surgery, School of Medicine,
University of sao Paulo - sao Paulo, Brazil
T ra u m a to th e fe m o ra l a rte rie s c o rre s p o n d s to 3 0 p e rc e n t o f a ll a rte ria l tra u m a s . T h e a u th o rs re v ie w e d 7 4 p a tie n ts w ith n o n ia tro g e n ic tra u m a o f th e fe m o ra l a rte rie s tre a te d fro m J a n u a ry 1 9 9 1 to D e c e m b e r 1 9 9 3 . A g e s ra n g e d fro m 1 1 to 5 0 y e a rs , w ith a m e a n o f 2 4 . S e v e n ty -o n e p a tie n ts w e re m a le a n d th re e fe m a le . F ifty -tw o p a tie n ts (7 0 .2 p e rc e n t) w e re w h ite , 2 0 (2 7 p e rc e n t) w e re b la c k a n d tw o (2 .8 p e rc e n t) w e re A s ia n . T ra u m a d u e to fire a rm s h a d th e h ig h e s t in c id e n c e , w ith 6 1 c a s e s (8 2 .4 p e rc e n t). A b s e n c e o f p u ls e w a s th e m o s t fre q u e n t c lin ic a l s y m p to m (6 2 .5 p e rc e n t). S e v e re is c h e m ia , w ith ris k o f lo s s o f lim b , w a s fo u n d in 6 6 .2 p e rc e n t o f th e c a s e s . T h e s u p e rfic ia l fe m o ra l a rte ry w a s im p a ire d in 7 7 p e rc e n t o f th e c a s e s . A p re o p e ra tiv e a rte rio g ra p h y w a s p e rfo rm e d o n o n ly fiv e p a tie n ts , v ic tim s o f m u ltip le p e n e tra tin g tra u m a o r a n a s y m p to m a tic p e n e tra tin g w o u n d a lo n g a v e s s e l p a s s a g e . In s ix c a s e s , a rte ria l a n d v e n o u s lig a tu re w a s th e c h o s e n p ro c e d u re . In th re e c a s e s , a p rim a ry a rte ria l a n a n to m o s is w a s p e rfo rm e d . S im p le a rte rrio rra p h y w a s fe a s ib le in o n e p a tie n t. In 6 4 o f th e p a tie n ts , a v e n o u s g ra ft w a s u n d e rta k e n u s in g a s e g m e n t o f th e in v e rte d g re a t s a p h e n o u s v e in w ith d ra w n fro m th e o th e r lo w e r lim b . F a s c io to m o y w a s u s e d in 3 2 p a tie n ts (4 3 .2 p e rc e n t), a ll o f w h o m e x h ib ite d p a s tin g o f th e lo w e r lim b m u s c le s a t a d m is s io n . O n e p a tie n t d ie d d u rin g th e im m e d ia te p o s to p e ra tiv e p e rio d a s th e re s u lt o f m u ltip le o rg a n fa ilu re c a u s e d b y p o ly tra u m a tis m . P re s e rv a tio n o f th e lim b w a s a tta in e d in 7 2 p a tie n ts (9 7 .3 p e rc e n t) S e v e re , p re v io u s ly -in c u rre d is c h e m ia w a s re s p o n s ib le fo r th e o n ly tw o a m p u ta tio n s , a g g ra v a te d b y a n e x c e e d in g ly lo n g d e la y b e tw e e n th e tim e o f in ju ry a n d s u rg e ry . O n e o f th e s e p a tie n ts , in a d d itio n to s e v e re is c h e m ia , h a d e x te n s iv e in ju rie s to th e s o ft tis s u e s . W e c o n c lu d e th a t tra u m a o f th e fe m o ra l a rte rie s , a tte n d e d w h ile th e lim b s till m a in ta in s its v ita lity , h a s a p o s itiv e c lin ic a l o u tc o m e w ith a h ig h ra te o f lim b p re s e rv a tio n . M o rta lity u s u a lly re s u lts fro m in ju ry to o th e r o rg a n s .
U N IT E R M S : F e m o ra l a rte ry . V a s c u la r s u rg e ry . W o u n d s a n d in ju rie s . T ra u m a .
IN T R O D U C T IO N
T
here is a high incidence
arteries, w hich correspond
of traum a
to one-third of all arterial
of the fem oral
traum as
2.9•A s the com m on
and superficial
fem oral
arteries are m ajor blood-conveying
vessels, acute occlusion
usually
leads
to severe
consequences
and
a delay
in
treatm ent
m ay cause a poor outcom e.
D uring
W orld W ar
II, patients
subm itted
to ligature
of the com m on
fem oral
artery
had an am putation
rate of 80 percent
3•In this paper,
the authors
analyze
noniatrogenic
traum a of the fem oral arteries in B razil, w here the prim ary
agents
of traum a
are
penetrating
w ounds
caused
by
firearm s,
cutting
instrum ents,
or fem oral
fractures,
resulting
in distincti ve aspects
of surgical
procedure
and
postoperative
evolution.
C A S E S
A d d r e s s f o r c o r r e s p o n d e n c e :
N e ls o n W o lo s k e r
R . E s p e r ia , 3 0
S a o P a u lo / S P - B r a s il - C E P 0 1 4 3 3 - 0 6 0
Seventy-four
patients
w ith noniatrogenic
traum a of
the fem oral
arteries
w ere treated
after being
adm itted
to
the
em ergency
room
of the
"H ospital
das
C linicas"
(G eneral H ospital),
School of M edicine,
U niversity
of Sao
Paulo, betw een
January
1991 and D ecem ber
1993.
W O L O S K E R . N .; G U A D E N C IO , A .; K U Z N IE C . S . e t a l. - S u rg ic a l tre a tm e n t o f n o n ia tro g e n ic tra u m a o f th e fe m o ra l a rte rie s
1 0 8 0
T a b le 3 re p o rts th e to p o g ra p h ic
o f th e in ju rie s.
T a b le 3
T o p o g ra p h y
o f A rte ria l
In ju rie s
P a tie n ts
n
=7 4
A g e s ra n g e d
fro m
1 1 to 5 0 y e a rs, w ith a m e a n o f
2 4 . S e v e n ty -o n e
p a tie n ts w e re m a le a n d th re e fe m a le . F ifty
-tw o p a tie n ts
(7 0 .2 p e rc e n t)
w e re w h ite , 2 0 (2 7 p e rc e n t)
w e re b la c k a n d tw o (2 .8 p e rc e n t)
w e re A sia n . T ra u m a d u e
to fire a rm s
w a s p re v a ilin g ,
6 1 c a se s (8 2 .4 p e rc e n t), se v e n
(9 .4
p e rc e n t)
w e re
c a u se d
b y b lu n t
tra u m a ,
fiv e
w e re
a sso c ia te d
w ith fe m o ra l
fra c tu re ,
a n d th e re m a in in g
six
(8 .1 ' p e rc e n t)
b y p e n e tra tin g
w o u n d s.
T h e c lin ic a l sy sm p to m s
c a u se d b y th e a rte ria l in ju ry
a re sh o w n
in T a b le
1 , w ith
a b se n c e
o f p u lse
b e in g
th e
m o st fre q u e n t. R e d u c tio n
o f p e rfu sio n o r te m p e ra tu re
w e re
c o n sid e re d
a s m ild isc h e m ia ,
w h ile
se v e re
isc h e m ia ,
in
a d d itio n
to th e a b o v e
sy m p to m s,
p re se n te d
m o to r
a n d
se n so ry
im p a irm e n t
o f th e in ju re d
lim b .
In ju re d A rte ry C o m m o n fe m o ra l S u p e rfic ia l fe m o ra l D e e p fe m o ra l
S u p e rfic ia l
+
d e e p fe m o ra l T o ta l6 ,0
5 7 ,0
8 ,0
3 ,0
7 4 ,0
% 8 .2
7 7 .0
1 0 .8
4 .0
1 0 0 .0
T a b le 1
C la s s ific a tio n
b y C lin ic a l
S y m p to m s
P a tie n ts
n
=
7 4C lin ic a l S y m p to n s N Q % A b s e n c e o f p u ls e
5 3 ,0
7 1 .6
Is c h e m ia o f lim b
4 9 ,0
6 6 .2
H e m o rrh a g e
2 0 ,0
2 7 .0
A s y m p to m a tic
2 ,0
2 .7
T a b le 2 sh o w s th e d istrib u tio n
o f p a tie n ts
a c c o rd in g
to th e d e g re e o f isc h e m ia .
T a b le 2
D is trib u tio n
b y D e g re e o f Is c h e m ia
P a tie n ts
n
=
7 4D e g re e o f Is c h e m ia N Q % A b s e n q e
8
1 0 .8
M ild
1 5
2 0 .2
S e v e re
4 9
6 6 .2
N o c lin ic a l e v a lu a tio n p o s s ib le
2
2 .7
U p o n
c lin ic a l
e x a m in a tio n ,
th e p u lse
ra te
in th e
in ju re d lim b w a s n o rm a l in 2 0 c a se s (2 7 p e rc e n t). A b se n c e
o f p u lse w a s n o te d
in 5 3 c a se s (7 1 . p e rc e n t)
O n e p a tie n t
c o u ld n o t b e e v a l u a te d b e c a u se o f h e m o d y n a m ic
i n sta b i Iits.
P rio r
to su rg e ry ,
o n ly
fiv e p a tie n ts,
v ic tim s
o f m u ltip le
p e n e tra tin g
tra u m a o r a n a sy m p to m a tic e
p e n e tra tin g w o u n d
a lo n g a v e sse l p a ssa g e ,
w e re su b m itte d
to a rte rio g ra p h y .
METHODS
A ll p a tie n ts
w ith a rte ria l
in ju rie s
w e re su b m itte d
to
a sp e c ific
su rg ic a l p ro c e d u re .
In six o f th e m , a rte ria l
a n d
v e n o u s lig a tu re w a s th e c h o se n p ro c e d u re .
In th re e c a se s,
a p rim a ry
a rte ria l a n a sto m o sis
w a s p e rfo rm e d .
O n ly o n e
p a tie n t c o u ld b e su b m itte d
to sim p le a rte rio rrh a p h y .
In 6 4
p a tie n ts, a v e n o u s re sto ra tio n
w a s p e rfo rm e d
w ith a g ra p h
fro m
a n in v e rte d
se g m e n t
o f th e g re a t
sa p h e n o u s
v e in
w ith d ra w n
fro m
th e o th e r lo w e r
lim b . U p o n
a d m issio n ,
fa sc io to m y
w a s p e rfo rm e d
o n 3 2 p a tie n ts
(4 3 .2 p e rc e n t),
a ll o f th e m w ith se v e re isc h e m ia
o f th e lo w e r lim b .
RESULTS
O n e p a tie n t d ie d d u rin g th e im m e d ia te
p o sto p e ra tiv e
p e rio d a s a re su lt o f a se v e re c ra n io -e n c e p a lic
tra u m a . T h e
lim b o f7 2
p a tie n ts (9 7 .3 p e rc e n t)
w a s p re se rv e d ,
w h e re a s
tw o a m p u ta tio n s
re su lte d fro m o c c lu sio n
o f th e sa p h e n o u s
v e in g ra ft in p a tie n ts w ith se v e re isc h e m ia
a n d a p ro lo n g e d
d e la y b e tw e e n
th e tim e o f in ju ry a n d th e su rg e ry . O n e o f
th e se
p a tie n ts
p re se n te d
e x te n siv e
d a m a g e
to th e so ft
tissu e s.
DISCUSSION
P e n e tra tin g
fire a rm
w o u n d s
a re th e p rim a ry
c a u se
o f tra u m a
to th e
fe m o ra l
a rte rie s,
a s re p o rte d
in th e
lite ra tu re
7,a n d a s o b se rv e d
in th is
stu d y .
D ia g n o sis
o f
tra u m a
o f th e fe m o ra l
a rte rie s
is re a c h e d
b y c lin ic a l
"
1081
e x a m in a tio n .
P h y s ic a l
e x a m in a tio n
re v e a ls
a b s e n c e
o f
p u ls e ,
is c h e m ia ,
lo c a l
h e m o rrh a g e ,
a n d th e p re s e n c e
o f
b ru its in a rte ria l
p a s s a g e s
b e c a u s e
o f th e s u p e rfic ia lity
o f
th e a rte rie s .
It is n o te w o rth ly
th a t
a s a re s u lt
o f p re c a rio u s
c o lla te ra l
c irc u la tio n ,
in ju ry to o n e o f th e fe m o ra l a rte rie s ,
e x c lu d in g
th e d e e p fe m o ra ls ,
u s u a lly
c a u s e s
is c h e m ia
o f
th e lim b , a n d th a t th e s e v e rity
o f is c h e m ia
is a g g ra v a te d
b y a m o re c ra n ia l
lo c a tio n
o f in ju ry .
D u rin g .W o rld
W a r II, w h e n
a rte ria l
tra u m a s
w e re
tre a te d
s o le y b y a rte ria l
lig a tu re ,
th e a m p u ta tio n
ra te w a s
8 0 p e rc e n t
fo r c o m m o n
fe m o ra l
a rte ry
in ju rie s
a n d o v e r
5 0
p e rc e n t
fo r
s u p e rfic i
a l
fe n o ra l
a rte ry
i n ju rie s
7 •N o tw ith s ta n d in g
th e s e
ra te s ,
lig a tu re
w a s th e p ro c e d u re
c h o s e n
fo r 8 .1 p e rc e n t
o f th e p a tie n ts
in th is s tu d y , d u e to
th e c lin ic a l
s ta te o f th e p a tie n t
(p o ly tra u m a ),
a n d n o lo s s
o f lim b w a s re c o rd e d .
T h is p ro c e d u re
h a s b e e n re s tric te d
to p a tie n ts
w ith
m u ltip le
o rg a n
tra u m a
a n d a n in c re a s e d
s u rg ic a l
ris k d u e to a m o re p ro lo n g e d
o p e ra tio n .
T h e d e v e lo p m e n t
o f a rte ria l
re s to ra tio n
te c h n iq u e s
h a s b ro u g h t
a b o u t
a p ro g re s s iv e
d e c re a s e
in a m p u ta tio n
ra te s . D u rin g
th e V ie tn a m
W a r, th e ra te w a s
1 2 .1
p e rc e n t').
In o u r s tu d y , th e a m p u ta tio n
ra te w a s 2 .7 p e rc e n t. T h e o n ly
s u rro g a te
u s e d fo r th e a rte ria l
g ra fts w a s th e a u to g e n o u s
g re a t
s a p h e n o u s
v e in
w ith d ra w n
fro m
th e o th e r
lim b ;
s y n th e tic
p ro s th e s e s
w e re n o t u s e d
6 •In c a s e s o f s e v e re
is c h e m ia
o f th e lo w e r lim b , w ith
s w e llin g o f th e e x tre m ity , fa s c io to m y
is a n e x tre m e ly
u s e fu l
c o m p le m e n ta ry
p ro c e d u re ,
u n d e rta k e n
b y th e o p e n in g
o f
th e a n te rio r a n d la te ra l c o m p a rtm e n ts ,
a n d o f th e s u p e rfic ia l
a n d d e e p c o m p m 1 m e n ts
o f th e le g , p rio r to flo w re s to ra tio n .
S u c h a p ro c e d u re
w a s u n d e rta k e n
in 4 3 .2
p e rc e n t
o f o u r
p a tie n ts '.
A rte rio g ra p h y
w a s re s tric te d
to c a s e s
w ith m u ltip le
tra u m a
o r w o u n d s
o f th e v e s s e l p a s s a g e s
w ith n o c lin c a l
fin d in g s
lO•
A s a rte ria l
le s io n s o c c u r in y o u n g
in d iv id u a ls ,
in g e n e ra l
w ith
n o p re v io u s
h is to ry
o f a rte ria l
d is e a s e ,
o u tflo w c o n d itio n s
fo r th e re p e rfu s io n
a re in m o s t in s ta n c e s
a s u ffic ie n t
re a s o n
to h a v e re a c h e d
9 7 .3 p e rc e n t
o f g ra ft
p e rv io u s n e s s .
M o rta lity
re la te d to th is ty p e o f tra u m a
is ra re , a n d is
a lw a y s re la te d to in ju ry o f o th e r o rg a n s . T h e o n ly d e a th in
th is s tu d y re s u lte d
fro m c ra n io -e n c e p h a lic
tra u m a s ,
x.C O N C L U S IO N
F e m o ra l
a rte ry
tra u m a ,
tre a te d
w h ile
th e lim b
s till
m a in ta in s
its v ita lity , h a s a p o s itiv e
c lin ic a l
o u tc o m e
w ith
a h ig h ra te o f lim b p re s e rv a tio n .
M o rta lity
u s u a lly
re s u lts
fro m in ju ry to o th e r o rg a n s .
RESUMO
o
tra u m a d e a rte ria s fe m o ra is c o rre s p o n d e a 3 0 p e rc e n t d o to ta l d e tra u m a s a rte ria is . O s a u to re s a n a lis a ra m 7 4 p a c ie n te s c o m tra u m a n a o -ia tro g e n ic o d e a rte ria s fe m o ra ls a te n d id o s d e ja n e iro d e 1 9 9 1 a d e z e m b ro d e 1 9 9 3 . A id a d e v a rio u d e n tre 1 1 e 5 0 a n o s , c o m m e d ia d e 2 4 a n o s , 7 1 p a c ie n te s e ra m d o s e x o m a s c u lin o e tre s d o fe m in in o . C in q u e n ta e d o is p a c ie n te s (7 0 .2 p e rc e n t) e ra m d a ra 9 a b ra n c a , v in te d a n e g ra (2 7 p e rc e n t) e d o is d a a m a re la (2 ,8 p e rc e n t). 0 tra u m a p o r fe rim e n to p o r a rm a d e fo g o fo i 0 m a is fre q u e n te c o m . 6 1 c a s o s (8 2 ,4 p e rc e n t). A a u s e n c ia d e p u ls o s fo i a m a n ife s ta 9 a o c 1 in ic a m a is fre q u e n te (6 2 ,S p e rc e n t). A is q u e m ia g ra v e , c o m . ris c o d e p e rd a d e m e m b ro fo i c o n s ta ta d a e 6 6 .2 p e rc e n t d o s c a s o s . A a rte ria fe m o ra l s u p e rfic ia l fo i a le s a d a e m 7 7 p e rc e n t d o s c a s o s . F o i re a liz a d a a rte rio g ra fia p 6 s -o p e ra t6 ria e m a p e n a s c in c o p a c ie n te s . v iti m a s d e m u ltip lo s tra u m a s p e n e tra n te s o u fe rim e n to p e n e tra n te a s s in to m a tic o tic o e m tra je to v a s c u la r. E m s e is d e le s , o p to u -s e p e la lig a d u ra a rte ria l e v e n o s a . E m tre s c a s o s fo i re a liz a d a a n a s to m o s e a rte ria l p rim a ria . E m u m p a c ie n te fo i re a liz a d a a rte rio rra fia s im p le s . E m s e s s e n ta e q u a tro p a c ie n te s , fo i re a liz a d o e n x e rto v e n o s o c o m . s e g m e n to d e v e ia s a fe n a m a g n a in v e rtid a , re tira d a d o o u tro m e m b ro in fe rio r. E m p re g o u -s e a fa s c io to m ia e m 3 2 p a c ie n te s (4 3 ,2 p e rc e n t), to d o s e le s c o m e m p a s ta m e n to d e m u s c u la tu ra d e m e m b ro in fe rio r d e s d e a a d m is s a o . U m p a c ie n te fa le c e u n o p 6 s -o p e ra t6 rio im e d ia to d e v id o a fa le n c ia d e m u ltip lo s 6 rg a o s p o r p o litra u m a tis m o . A p re s e rv a 9 a o d o m e m b ro fo i o b tid a e m 7 2 d o e n te s (9 7 ,3 p e rc e n t). A s u n ic a s d u a s a m p u ta 9 0 e s s e d e v e ra m a is q u e m ia , p re v ia m e n te m u ito g ra v e , c o m lo n g o te m p o d e c o rrid o e n tre 0 m o m e n to d o tra u m a e 0 p ro c e d im e n to c iru rg ic o . U rn d e s te d o e n te s , a le m d e is q u e m ia g ra v e , a p re s e n ta v a le s o e s e x te n s a s d e p a rte s m o le s . C o n c lu im o s q u e 0 tra u m a d a s a rte n a s fe m o ra is tra ta d o q u a n d o 0 m e m b ro a in d a m a n te m a v ia b ilid a d e , te m u m b o m p ro g n 6 s tic o c lin ic o , c o m a lto in d ic e d e p re s e rv a 9 a o d e m e m b ro . A m o rta lid a d e e g e ra lm e n te c a u s a d a p e lo tra u m a a o u tro s 6 rg a o s .W O L O S K E R , N .; G U A D E N C IO , A .; K U Z N IE C , S . e t a l. - S u rg ic a l tre a tm e n t o f n o n ia tro g e n ic tra u m a o f th e fe m o ra l a rte rie s
1082
••
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