(a) After skin is open, the incision is deepened to the subcutaneous tissue protecting greater saphenous vein. (b) and (c) The deep fascia is dissected and femoral sheet is open, exposing the neurovascular bundle: artery, vein, and femoral nerve. (d) For vascular control of the femoral bifurcation, it is necessary to control proximal and distal flow by silastic vessel loops for the superficial and deep femoral artery
Superficial Femoral Artery
The patient is placed in the supine position. Sterile skin preparation should extend from the lower abdomen to the knee, and both legs should be prepared.
Deep Femoral Artery
The patient is placed in the supine position. Sterile skin preparation should extend from the lower abdomen to the knee, and both legs should be prepared. The exposure of the deep femoral artery to the level of the second perforating branch requires division of the adductor longus muscle. The best exposure of the deep femoral artery is achieved for division of the adductor longus insertion on the linea aspera (femur).
Ligation of the common femoral artery and superficial femoral artery results in ischemia and limb loss. For this reason, the distal flow must be recovered with definitive vascular repair or temporary shunt. The deep femoral artery and the femoral vein can be ligated without any issues.
For vascular repair, it is necessary to ensure vascular control of proximal and distal flow with double passing silastic vessel loops around the vessel; the injured vessel wall should be debrided and a Fogarty catheter should be used proximally and distally in the artery for removing clots and ensuring adequate flow. The heparinized solution (5000 U in 100 mL of Saline solution) is flushed locally. The vascular repair is performed with arteriorrhaphy, anastomosis, vein patch, interposition of autogenous reverse saphenous vein, or prosthetic graft. At the end of arterial repair check that ether is a palpable pulse (Figs. 11.3, 11.4, and 11.5).
When a trauma occurs in the femoral bifurcation, vascular repair is performed by joining distal segments of the superficial femoral and deep femoral arteries. This creates a common trunk that allows for vascular repair. The temporary shunt is used to maintain distal flow to the injured leg in damage-control surgery. Routine prophylactic fasciotomies are not indicated.
Popliteal Artery Injury
The popliteal artery is the direct continuation of the superficial femoral artery. This artery extends from adductor hiatus, entering the popliteal fossa passing between the femoral condyle to the lower border of the popliteus muscle, posterior to the knee joint. The popliteal artery bifurcates below the knee into the anterior tibial artery and tibioperoneal trunk. At 2–3 cm from the trunk, the fibular artery emerges. The tibioperoneal trunk continues in the posterior tibial artery. The popliteal fossa is behind the knee and is limited superiomedially by semimembranosus and semitendinosus muscles, superolaterally by biceps femoris, and the lateral and medial head of gastrocnemius muscles are the limits of the lateral and medial inferior border. The popliteal vessels are surrounded by firm connective tissue; the small fat of the popliteal fossa facilitates surgical mobilization. The popliteal vein and tibial nerve are more superficial than the popliteal artery. The popliteal artery gives rise to the genicular branches that perfuse the knee joint.
Exposure and Vascular Repair
The popliteal artery can be exposed by two approaches, medial and posterior.
The patient is placed in the supine position with the injured leg externally rotated and knee flexed 30 degrees and supported with a bump. Skin preparation of both lower extremities is indicated.
The exposure of the entire popliteal artery is performed with an incision that starts 1 cm posterior to the femur, between the sartorius and vastus medialis muscles, passing the knee until 1 cm posterior to the tibia. All junctions of posteromedial muscles are sectioned (semitendinosus and semimembranosus muscles). The union to medial head gastrocnemius muscle is sectioned too.
The easiest way to perform medial repair of the popliteal artery is to exclude the injured segment between ligatures and perform a interposition of autogenous reverse saphenous vein.
Prosthesis graft is used only in specific situations. Examples include extensive bilateral lower extremity injuries, inadequate saphenous size, and previous saphenous vein harvest for cardiac surgery. In these cases, a synthetic graft is an acceptable second choice (Fig. 11.8).
Vascular trauma of the popliteal artery is associated with a high incidence of loss of limb; for this reason is essential to maintain distal blood flow, because occlusion or ligature of the popliteal artery results in amputation in 75% of cases. If the vascular injury is associated with a fracture, a vascular shunt reestablishes the blood flow. After that, fixation of the fracture should be performed. During the dissection of popliteal vessels, it is necessary to protect the saphenous vein. If popliteal vein ligation is performed, the saphenous vein will allow adequate venous drainage to the extremity.