COMMON FEMORAL ARTERY

- Recommendations: Repair
- Utility of temporary shunt: High (low probability of shunt thrombosis based on authors experience)
- Method/Conduit: Interposition graft/ saphenous vein or 6-8mm prosthetic

Pearls

- Expose abdominal wall and artery coursing under inguinal ligament for proximal control.
- External iliac artery can be controlled through proximal groin or low abdominal incision.
- Coverage with tissue (femoral sheath), sartorius muscle or rectus flap.

Injury to the common femoral artery is often fatal as hemorrhage control in the field is difficult. Exposure is obtained through a single longitudinal incision above the artery (2-3 cm lateral to the pubic tubercle) exposing the artery at the inguinal ligament. A key point in exposing the femoral artery is ensuring there is adequate and reliable proximal and distal control prior to exploring the injury. Placing the incision proximal enough so that the abdominal wall and inguinal ligament can be identified first in a consistent and familiar location (oftentimes by drawing a line from the anterior superior iliac spine to the pubic tubercle on the skin prior to incision). Alternatively, proximal control can be obtained in the retroperitoneum (i.e. external iliac) through the proximal extension of this groin incision or by using a limited transverse incision in the lower abdomen. After a transverse-oblique skin incision, the external and internal oblique aponeuroses are divided, and the lateral fibers of the internal oblique separated. The transversus muscle and transversalis fascia are opened allowing entrance into the retroperitoneum, and the peritoneum is reflected cephalad, exposing the internal iliac vessels along the medial border of the psoas muscle. Common femoral artery injuries are commonly reconstructed using reversed saphenous vein, although e-PTFE or Dacron can be used if there is too great of a size mismatch. Placement of a prosthetic graft is acceptable if there is minimal to no contamination and there is adequate coverage. At a Role 2 facility, placing a shunt prior to transfer to a higher level of care is preferable to reconstruction with a prosthetic graft. Every attempt should be made to maintain flow into the profunda femoris artery, although the feasibility of this will depend upon the pattern of injury and the comfort level of the surgeon to perform a more complicated reconstruction. Coverage of vascular reconstruction in the groin is challenging; it may consist of local viable tissue, the sartorius muscle, or other options such as a rectus abdominis transfer flap. Coverage may be better addressed in a Role 3-4 facility. 1,3

PROFUNDA FEMORIS ARTERY

- Recommendations: Repair if possible
- Utility of temporary shunt: Low (high probability of shunt thrombosis)
- Method/Conduit: Ligation or interposition graft with saphenous vein

Pearls

- Exposure of proximal profunda is the same (distal extension) as the common femoral.
- If superficial femoral is patent, ligation of mid to distal profunda injury is acceptable.

Exposure of the proximal profunda femoris artery is obtained through a longitudinal incision used to expose the common femoral artery. Mid and distal segments are exposed through a vertical incision made parallel to the lateral border of the Sartorius muscle on the upper thigh, lateral to the proximal sartorius muscle. The sartorius is retracted medially and the rectus femoris is retracted laterally to expose the mid- and distal segments. Ligation of the circumflex profunda veins as they cross the artery is necessary. Often there are several of these crossing veins. Proximal profunda injuries should be repaired with reverse saphenous vein interposition graft. This is especially important if there is a question about the integrity of the superficial femoral or popliteal vessels. In this setting, flow through the profunda is most important to allow healing of subsequent lower extremity amputations. If patency of the superficial femoral artery can be confirmed, ligation of mid and distal profunda femoris injuries is acceptable as they lie deep in the thigh musculature and are not required for leg viability.3

SUPERFICIAL FEMORAL ARTERY

- Recommendations: Repair
- Utility of temporary shunt: High (low probability of shunt thrombosis)
- Method/Conduit: Interposition graft/ reversed saphenous vein

Pearls

- Medial incision with “bump” under calf, surgeon seated, OR lights over shoulder.
- Exposure of the proximal 1/3 posterior to the sartorius and distal 1/3 anterior to the Sartorius.
- Be wary of adjacent vein and geniculate branches of distal superficial femoral artery (Hunter’s canal).

Exposure is performed through a medial thigh incision and the adductors of the leg (i.e., adductor magnus). Exposure is facilitated by placing a lift or “bump” below the knee which allows the femoral artery, sartorius and adductors to be suspended, improving separation. Entry into the fascia of the lower thigh (distal superficial femoral artery) should be performed at the upper anterior margin of the sartorius which should be reflected down or posteriorly. Exposure is facilitated with the surgeon seated looking across to the dissection field with lights positioned directly over the surgeon’s shoulder if a headlight is not available.

When exposing the superficial femoral artery, it is important to recognize the femoral vein which is in proximity, if not adherent, to the artery. At the distal extent of the artery as it exits the adductor (Hunter’s) canal, there are large geniculate side branches which should be preserved or at least not injured as it causes hemorrhage. Repair of superficial femoral artery injury is best performed by reversed saphenous vein interposition graft from the uninjured leg.3

POPLITEAL ARTERY

- Recommendations: Repair
- Utility of temporary shunt: High (low probability of shunt thrombosis)
- Method/Conduit: Reversed saphenous vein

Pearls

- Medial incision with “bump” under calf for above knee and under thigh for below knee.
- Distal exposure by division of gastrocnemius and soleus from the tibia allowing dissection to anterior tibial origin (coursing away from dissection plane) and tibial-peroneal trunk.
- Equipment: Henley popliteal retractor with removable, varied depth side blades is valuable. Weitlaner or Cerebellar retractors, medium and small, are also helpful when Henley is not available.
- For popliteal artery intimal injuries found on initial evaluation that is not repaired at the time of injury, but instead surveilled, anti-platelet therapy is recommended (if no contraindications such as TBI) and consider repeat CTA in 48 hours for surveillance.