Vascular injuries in the popliteal space are exposed through a medial incision with the surgeon seated and lights over his or her shoulder. The dissection is extended from above to below the knee and is facilitated by a lift or “bump” under the calf of the leg with the knee flexed. When exposing below the knee, this bump is placed under the thigh. Natural dissection planes exist in exposing the above knee popliteal artery (i.e. popliteal space) except for the need to divide the fibers of the adductor magnus which envelop the distal superficial femoral artery (Hunter’s canal). Similarly, a natural dissection plane exists into the popliteal space from below the knee but added exposure should be accomplished by division of the gastrocnemius and soleus muscle fibers from the medial tibial condyle to allow a lengthy exposure of the below knee popliteal artery to the takeoff of the anterior tibial artery and the tibial-peroneal trunk. To completely expose the popliteal space, the medial attachments of the sartorius, semitendinosis, semimembrinosis and gracilis to the medial condyle of the tibia can be divided. When feasible, the pes anserinus should be reconstructed given its significant role in medial knee stabilization. Weitlaner, cerebellar retractors, flexible Adson-Beckman or Henly popliteal retractors with detachable side blades are necessary to expose the popliteal space. Typically, the medial head of the gastrocnemius can be retracted down using one of these devices and does not need to be divided.3

TIBIAL ARTERIES

- Recommendations: Selective repair (i.e. some but not all)4
- Utility of temporary shunt: Moderate (medium probability of shunt thrombosis)
- Method/Conduit: Ligation or interposition graft with saphenous vein

Pearls

- If a Doppler signal is present at the ankle, there is no need for additional tests or repair.
- Doppler exam should be repeated as patient is resuscitated and warmed.
- Repair with vein if three tibial arteries injured and an absence of a Doppler signal persists.
- As long as there is at least one of the three tibial vessels intact, injuries to one or even two of the tibial vessels can safely be managed by ligation.
- Equipment: Similar retractors to popliteal exposure. Henly popliteal retractor with removable, varied depth side blades is valuable. Weitlaner or Cerebellar retractors, medium and small, are also helpful.

EXTREMITY VENOUS INJURY

- Recommendations: Selective repair (i.e. some but not all)
- Utility of temporary shunt: Moderate (medium probability of shunt thrombosis)
- Method/Conduit: Ligation, repair, or saphenous interposition graft

Pearls

- Repair of proximal veins is indicated to reduce venous hypertension and congestion.
- Shunts in proximal veins will remain patent until formal repair can be performed.
- Pneumatic compression device on distal extremity to augment venous flow after repair.

Many extremity venous injuries, especially small, distal veins, can be ligated with no adverse effects because of collateral venous drainage. However, ligation of more proximal or watershed veins, or even axial veins when collaterals have been destroyed by soft tissue wounds, will result in venous hypertension and congestion. In such instances an attempt should be made to repair the vein and restore venous outflow. Temporary shunts have been shown to be effective in restoring venous outflow in the femoral veins until formal repair can be accomplished. Techniques of lateral venorrhaphy are acceptable, although an interposition graft using saphenous vein from the uninjured limb is often necessary.

The patency of vein repairs in the lower extremity is 80% at 24 months with no increased incidence of pulmonary emboli compared to ligation. Additionally, a limb salvage benefit of vein repair compared to ligation has been shown 2 years after injury.5,6 Despite these advantages, repair of extremity venous injury should only be considered in instances when the patient’s overall status is able to tolerate additional procedures; otherwise, venous ligation is preferred, despite the increase in morbidity.

Technical considerations include removing thrombus from the distal venous segments with compression (e.g., ace wrap or Esmark bandage) prior to repair. Additionally, following venous repair, placement of a pneumatic compression device distal on the extremity will augment venous flow and improve patency. Lastly, if there is no contraindication, a prophylactic dose of low-molecular weight heparin (LMWH) should be initiated or low-rate heparin drip when LMWH is contraindicated.5

ALGORITHM FOR EXTREMITY VASCULAR INJURY