Partial Transection of Femoral Artery-The advantage of a young age

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.

(Borrowed from anatomy atlas)

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.

(Borrowed from ImageLib 1994 David Proffitt)

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.