PARTIAL
TRANSECTION OF FEMORAL ARTERY-THE ADVANTAGE OF YOUNG AGE
Being young with optimal physiology
makes a lot of difference when it comes to healing as the compensatory
mechanisms are all in check. Below is a case history of a 34 years male who was
referred 48 hours after suffering a stab wound in his left inner thigh.
History
A 34 years, African male was out
with his friends enjoying a drink when a fight erupted, and someone stabbed him
on his left inner thigh with a sharp knife. There was immediate gush of blood
and profuse bleeding continued. He was rushed to a nearby health facility.
At the facility, a tourniquet
was applied, and pressure packing done. Bleeding minimized but all the packs
used, were fully soaked. The tourniquet was intermittently placed and
removed to inspect on the bleeding and add on more packs.3-5 Liters of I.V
Fluids were given.
After 24 hours when the pressure
packing was removed to assess the wound, bleeding was still profuse, described
as pulsatile, repacking was done. Gauzes were placed deep into the wound,
bleeding was contained. A tourniquet was applied during the packing sessions
and removed once bleeding was contained. Patient was kept in this facility for
another 24 hours and eventually a decision was made to refer the patient. (Thankfully
😊 )
Examination at Referral
Alert. Sick looking
Severely pale
HR 96 beats/min
BP 92/54
Temp-36.6
Pulsation noted on the packing in
the inner left thigh. No color change in the limb, no temperature difference. Weak
popliteal and dorsalis pulses were felt. *could perceive pain above knee
but numbness below knee reported.
More layers of packing added. Decision was
made to keep the packing for further examination and exploration of the injury
in theater.
He did not have any other injuries.
Lab works Pre-Op
FHG-HCT 15, HB 5, PLT-120
UECS-Na-138, K-4.2, Urea-4,
Creatinine-83
4 units of blood secured. I unit
given before surgery
*No imaging was done.
Intra-op
Exploration and Findings
Upon removal of gauzes, a gush of
bright red blood-pulsatile bleeding continued. Tourniquet applied and more
packing was done. The femoral vessels were identified at the inguinal region
and clamped. Working with a tourniquet time of 90minutes the injury was
explored and repaired as follows:
Wound size-5cm long, 2 cm
wide, deep into the muscular region. There were sharp margin cuts across
muscle striae. No muscle necrosis noted. There was partial transection of the superficial
femoral artery, the posterior wall intact. Femoral Vein was also partially
transected. No nerve injuries were visualized.
Repair
Clean cuts were made across the Superficial
femoral artery. Primary end to end anastomosis was done. No tension on repaired
vessel-Approximate length of lost artery 5mm.
The femoral vein. the margins were
freshened and end to end anastomosis done. Heparin infusion was used to flush
the vein.
Perforating branched at the site of
injury were ligated.
The clamp at the femoral artery was
released and flow of blood through the repaired artery was established as
satisfactory as well as the venous flow back.
Hemostasis was achieved.
The wound was cleaned and left open.
*Fascia not closed. Wound dressings applied. Limb splinted.
Blood loss intraop-1L
Intra-op replacement-1L
*Hemodynamic status- relatively
stable intra-op.
Post op
2 more liters of fresh whole blood
was given. The limb was immobilized and bed rest for 24 hours. Pain was managed
with tramadol and intravenous paracetamol. No bleeding post op. Hemodynamic
status of patient were satisfactory with blood pressure remaining above 100/60
and heart rate 80-60 beats per minute
Day 1-4 post op. Pain lessened and
numbness though present was reducing in amount. Patient started ambulating with
a walk aid. Physiotherapy on limb started. 6 hourly assessments of distal limb
pulse and color were satisfactory.
Wound care-Secondary wound repair
done on day 4 post op under local anesthesia. Doppler ultrasound done showed
satisfactory blood flow through the repaired vessels. Patient was discharged
home. Walked with a slight limp. Hb at discharge was 10g/dl.
Follow-up
Review in 2 weeks was unremarkable.
Discussion
The deep femoral artery was intact
and could explain how the limb was alive 48 hours after the occurrence of the
injury with no muscle necrosis. Other arteries that do not arise from femoral
artery were also able to supplement the blood supply to this limb: obturator
artery, gluteal arteries
Pressure packing established a
stable hematoma, this prevented further bleeding, and this helped in maintenance
of hemodynamic status. (Whether some blood was able to flow through the partially
transected vessel is unknown) Platelet consumption was very high (PLT just before
operation were 120) and thankfully patient did not get into DIC. Infection of
the wound was also controlled. Intravenous antibiotics had been given from facility of first contact.
Thrombolytic agents were not used
post op. Early ambulation and physiotherapy helped prevent thrombus formation. Young
male age was a very favorable factor.
Learning point
Recognition of vascular injuries, referral to center that can repair as well as early involvement of a vascular surgeon.
