Advertisement

The Role of Endovascular Repair of Popliteal Arterial Injuries in the Acute Setting

      Background

      The role of endovascular surgery in the treatment of popliteal arterial injuries is not well established. As with other popliteal pathology, open repair has traditionally been considered the gold standard. As data has accumulated and technology advanced, however, a reassessment of the role of endovascular surgery is warranted. The aim of this study is to perform a noninferiority comparison of open versus endovascular management of traumatic popliteal injuries. Our hypothesis is that endovascular management is noninferior to open management of traumatic popliteal injuries.

      Methods

      The National Trauma Data Bank was searched for adult patients from 2002–2016 for isolated popliteal arterial injury. The study used a standard noninferiority methodology to compare rates of amputation and compartment syndrome between endovascular and open surgery. Margins for noninferiority were established using established published rates of complications: 17.1% for amputations and 23.0% for compartment syndrome. Endovascular intervention would be considered noninferior to open surgery if the lower bound confidence of the complication proportion (endo/open complication rate) was greater than the predefined noninferiority margin.

      Results

      A total of 3,698 patients met inclusion criteria, with blunt injury accounting for 2,117 (57%) and penetrating injury accounting for 1,581 (43%). Within the blunt group, 1,976 (93.3%) underwent open and 141 (6.7%) endovascular surgery. The rate of compartment syndrome (percentage and 95% confidence interval) after surgery for open repair was 9.9 (8.6–11.2) and 6.4 (3.2–11.3) for endovascular repair. The complication proportion is 64.6 (59.7–69.5). The rate of amputation for open repair was 15.7 (14.2–17.4) and 14.2 (9.2–20.6) for endovascular repair. The complication proportion is 90.4 (87.4–93.4). Within the penetrating group, 1,525 (96.5%) underwent open repair and 56 (3.5%) endovascular surgery. The rate of compartment syndrome after surgery for open repair was 14.9 (13.2–16.7) and 5.4 (1.5–13.6) for endovascular repair. The complication proportion is 36.2 (31.3–41.1). The rate of amputation for open repair was 4.3 (3.3–5.4) and 3.6 (0.7–11.0) for endovascular repair. The complication proportion is 83.7 (75.3–90.6).

      Conclusions

      These data suggests that endovascular repair of popliteal artery injury may be noninferior to open repair with respect to limb preservation. Further examination of endovascular repair in popliteal artery injury is warranted.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Jiang C.
        • Chen Z.
        • Zhao Y.
        • et al.
        Four-year outcomes following endovascular repair in patients with traumatic isolated popliteal artery injuries endovascular repair of popliteal artery injuries.
        J Vasc Surg. 2021; 73: 2064-2070
        • Kauvar D.S.
        • Sarfati M.R.
        • Kraiss L.W.
        National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma.
        J Vasc Surg. 2011; 53: 1598-1603
        • Banderker M.A.
        • Navsaria P.H.
        • Edu S.
        • et al.
        Civilian popliteal artery injuries.
        S Afr J Surg. 2012; 50: 119-123
        • Morrison J.J.
        • Madurska M.J.
        • Romagnoli A.
        • et al.
        A surgical endovascular trauma service increases case volume and decreases time to hemostasis.
        Ann Surg. 2019; 270: 612-619
        • Scalea T.M.
        • Feliciano D.V.
        • DuBose J.J.
        • et al.
        Blunt thoracic aortic injury: endovascular repair is now the standard.
        J Am Coll Surg. 2019; 228: 605-610
        • Abdou H.
        • Kundi R.
        • DuBose J.J.
        • et al.
        Repair of the iliac arterial injury in trauma: an endovascular operation?.
        J Surg Res. 2021; 268: 347-353
        • Branco B.C.
        • DuBose J.J.
        • Zhan L.X.
        • et al.
        Trends and outcomes of endovascular therapy in the management of civilian vascular injuries.
        J Vasc Surg. 2014; 60: 1297-1307.e1
        • Reuben B.C.
        • Whitten M.G.
        • Sarfati M.
        • et al.
        Increasing use of endovascular therapy in acute arterial injuries: analysis of the National Trauma Data Bank.
        J Vasc Surg. 2007; 46: 1222-1226
        • Desai S.S.
        • DuBose J.J.
        • Parham C.S.
        • et al.
        Outcomes after endovascular repair of arterial trauma.
        J Vasc Surg. 2014; 60: 1309-1314
        • Butler W.J.
        • Calvo R.Y.
        • Sise M.J.
        • et al.
        Outcomes for popliteal artery injury repair after discharge: a large-scale population-based analysis.
        J Trauma Acute Care Surg. 2019; 86: 173-180
        • Zhong S.
        • Zhang X.
        • Chen Z.
        • et al.
        Endovascular repair of blunt popliteal arterial injuries.
        Korean J Radiol. 2016; 17: 789-796
        • Hutto J.D.
        • Reed A.B.
        Endovascular repair of an acute blunt popliteal artery injury.
        J Vasc Surg. 2007; 45: 188-190
        • Kovacs F.
        • Pollock J.G.
        • DeNunzio M.
        Endovascular stent graft repair of iatrogenic popliteal artery injuries--a report of 2 cases.
        Vasc Endovascular Surg. 2012; 46: 269-272
        • Macedo F.I.B.
        • Sciarretta J.D.
        • Salsamendi J.
        • et al.
        Repair of an acute blunt popliteal artery trauma via endovascular approach.
        Ann Vasc Surg. 2015; 29: 366.e5-366.e10
        • Potter H.A.
        • Alfson D.B.
        • Rowe V.L.
        • et al.
        Endovascular versus open repair of isolated superficial femoral and popliteal artery injuries.
        J Vasc Surg. 2021; 74: 814-822.e1
        • Majidi S.
        • Hassan A.E.
        • Adil M.M.
        • et al.
        Incidence and outcome of vertebral artery dissection in trauma setting: analysis of National Trauma Data Base.
        Neurocrit Care. 2014; 21: 253-258
        • Hashmi Z.G.
        • Kaji A.H.
        • Nathens A.B.
        Practical guide to surgical data sets: National Trauma Data Bank (NTDB).
        JAMA Surg. 2018; 153: 852-853
      1. Annual call for data: National Trauma Data Bank (NTDB).
        • Adnan S.M.
        • Romagnonli A.N.
        • Elansary N.N.
        • et al.
        Radial versus femoral arterial access for trauma endovascular interventions: a noninferiority study.
        J Trauma Acute Care Surg. 2020; 89: 458-463
        • García A.F.
        • Sánchez Á.I.
        • Millán M.
        • et al.
        Limb amputation among patients with surgically treated popliteal arterial injury: analysis of 15 years of experience in an urban trauma center in Cali, Colombia.
        Eur J Trauma Emerg Surg. 2012; 38: 281-293
        • Dua A.
        • Patel B.
        • Desai S.S.
        • et al.
        Comparison of military and civilian popliteal artery trauma outcomes.
        J Vasc Surg. 2014; 59: 1628-1632
        • Franz R.W.
        • Shah K.J.
        • Halaharvi D.
        • et al.
        A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center.
        J Vasc Surg. 2011; 53: 1604-1610
        • O’Banion L.A.
        • Dirks R.
        • Farooqui E.
        • et al.
        Popliteal scoring assessment for vascular extremity injuries in trauma study.
        J Vasc Surg. 2021; 74: 804-813.e3
        • Mullenix P.S.
        • Steele S.R.
        • Andersen C.A.
        • et al.
        Limb salvage and outcomes among patients with traumatic popliteal vascular injury: an analysis of the National Trauma Data Bank.
        J Vasc Surg. 2006; 44: 94-100
        • Chang I.S.
        • Chee H.K.
        • Park S.W.
        • et al.
        The primary patency and fracture rates of self-expandable nitinol stents placed in the popliteal arteries, especially in the P2 and P3 segments, in Korean patients.
        Korean J Radiol. 2011; 12: 203-209
        • Kröger K.
        • Santosa F.
        • Goyen M.
        Biomechanical incompatibility of popliteal stent placement.
        J Endovasc Ther. 2004; 11: 686-694
        • Hanley S.C.
        • Neequaye S.K.
        • Steinmetz O.
        • et al.
        Sheath-shunt technique for avoiding lower limb ischemia during complex endovascular aneurysm repair.
        J Vasc Surg. 2015; 62: 762-766
        • Österberg K.
        • Falkenberg M.
        • Resch T.
        Endovascular technique for arterial shunting to prevent intraoperative ischemia.
        Eur J Vasc Endovasc Surg. 2014; 48: 126-130
        • Zhu Y.
        • Xu Y.
        • Li J.
        • et al.
        Medial approach for popliteal artery injuries.
        Chin J Traumatol. 2010; 13: 83-86
        • Makaloski V.
        • Stellmes A.
        • Wyss D.
        • et al.
        Posterior approach for revascularization in blunt popliteal vessel injury.
        Ann Vasc Surg. 2018; 48: 89-96
        • Dua A.
        • Desai S.S.
        • Ali F.
        • et al.
        Popliteal vein repair may not impact amputation rates in combined popliteal artery and vein injury.
        Vascular. 2016; 24: 166-170
        • Guice J.L.
        • Gifford S.M.
        • Hata K.
        • et al.
        Analysis of limb outcomes by management of concomitant vein injury in military popliteal artery trauma.
        Ann Vasc Surg. 2020; 62: 51-56
        • Shah P.M.
        • Wapnir I.
        • Babu S.
        • et al.
        Compartment syndrome in combined arterial and venous injuries of the lower extremity.
        Am J Surg. 1989; 158 (discussion 140-141): 136-140
        • Modrall J.G.
        • Sadjadi J.
        • Ali A.T.
        • et al.
        Deep vein harvest: predicting need for fasciotomy.
        J Vasc Surg. 2004; 39: 387-394