Surgical treatmentof noniatrogenic trauma of the femoral arteries

Trauma to the femoral arteries corresponds to 30 percent of all arterial traumas. The authors reviewed 74 patients with noniatrogenic trauma of the femoral arteries treated from January 1991 to December 1993. Ages ranged from 11 to 50 years, with a mean of 24. Seventy-one patients were male and three female. Fifty-two patients (70.2 percent) were white, 20 (27 percent) were black and two (2.8 percent) were Asian. Trauma due to firearms had the highest incidence, with 61 cases (82.4 percent). Absence of pulse was the most frequent clinical symptom (62.5 percent). Severe ischemia, with risk of loss of limb, was found in 66.2 percent of the cases. The superficial femoral artery was impaired in 77 percent of the cases. A preoperative arteriography was performed on only five patients, victims of multiple penetrating trauma or an asymptomatic penetrating wound along a vessel passage. In six cases, arterial and venous ligature was the chosen procedure. In three cases, a primary arterial anantomosis was performed. Simple arterriorraphy was feasible in one patient. In 64 of the patients, a venous graft was undertaken using a segment of the inverted great saphenous vein withdrawn from the other lower limb. Fasciotomoy was used in 32 patients (43.2 percent), all of whom exhibited pasting of the lower limb muscles at admission. One patient died during the immediate postoperative period as the result of multiple organ failure caused by polytraumatism. Preservation of the limb was attained in 72 patients (97.3 percent) Severe, previously-incurred ischemia was responsible for the only two amputations, aggravated by an exceedingly long delay between the time of injury and surgery. One of these patients, in addition to severe ischemia, had extensive injuries to the soft tissues. We conclude that trauma of the femoral arteries, attended while the limb still maintains its vitality, has a positive clinical outcome with a high rate of limb preservation. Mortality usually results from injury to other organs.


INTRODUCTION
T here is a high incidence of trauma of the femoral arteries, which correspond to one-third of all arterial traumas 2 . 9• As the common and superficial femoral arteries are major blood-conveying vessels, acute occlusion usually leads to severe consequences and a delay in treatment may cause a poor outcome.During World War II, patients submitted to ligature of the common femoral artery had an amputation rate of 80 percent 3 •   In this paper, the authors analyze noniatrogenic trauma of the femoral arteries in Brazil, where the primary agents of trauma are penetrating wounds caused by firearms, cutting instruments, or femoral fractures, resulting in distincti ve aspects of surgical procedure and postoperative evolution.Ages ranged from 11 to 50 years, with a mean of 24.Seventy-one patients were male and three female.Fiftytwo patients (70.2 percent) were white, 20 (27 percent) were black and two (2.8 percent) were Asian.Trauma due to firearms was prevailing, 61 cases (82.4 percent), seven (9.4 percent) were caused by blunt trauma, five were associated with femoral fracture, and the remaining six (8.1' percent) by penetrating wounds.

CASES
The clinical sysmptoms caused by the arterial injury are shown in Table 1, with absence of pulse being the most frequent.Reduction of perfusion or temperature were considered as mild ischemia, while severe ischemia, in addition to the above symptoms, presented motor and sensory impairment of the injured limb.Table 2 shows the distribution of patients according to the degree of ischemia.Upon clinical examination, the pulse rate in the injured limb was normal in 20 cases (27 percent).Absence of pulse was noted in 53 cases (71.percent) One patient could not be eval uated because of hemodynamic instabi Iits.Prior to surgery, only five patients, victims of multiple penetrating trauma or an asymptomatice penetrating wound along a vessel passage, were submitted to arteriography.

METHODS
All patients with arterial injuries were submitted to a specific surgical procedure.In six of them, arterial and venous ligature was the chosen procedure.In three cases, a primary arterial anastomosis was performed.Only one patient could be submitted to simple arteriorrhaphy.In 64 patients, a venous restoration was performed with a graph from an inverted segment of the great saphenous vein withdrawn from the other lower limb.Upon admission, fasciotomy was performed on 32 patients (43.2 percent), all of them with severe ischemia of the lower limb.

RESULTS
One patient died during the immediate postoperative period as a result of a severe cranio-encepalic trauma.The limb of72 patients (97.3 percent) was preserved, whereas two amputations resulted from occlusion of the saphenous vein graft in patients with severe ischemia and a prolonged delay between the time of injury and the surgery.One of these patients presented extensive damage to the soft tissues.

DISCUSSION
Penetrating firearm wounds are the primary cause of trauma to the femoral arteries, as reported in the literature 7  It is noteworthly that as a result of precarious collateral circulation, injury to one of the femoral arteries, excluding the deep femorals, usually causes ischemia of the limb, and that the severity of ischemia is aggravated by a more cranial location of injury.
During .World War II, when arterial traumas were treated soley by arterial ligature, the amputation rate was 80 percent for common femoral artery injuries and over 50 percent for su perfici al fenoral artery i nju ries 7 • Notwithstanding these rates, ligature was the procedure chosen for 8.1 percent of the patients in this study, due to the clinical state of the patient (poly trauma), and no loss of limb was recorded.This procedure has been restricted to patients with multiple organ trauma and an increased surgical risk due to a more prolonged operation.
The development of arterial restoration techniques has brought about a progressive decrease in amputation rates.During the Vietnam War, the rate was 12.1 percent').In our study, the amputation rate was 2.7 percent.The only surrogate used for the arterial grafts was the autogenous great saphenous vein withdrawn from the other limb; synthetic prostheses were not used 6 •   In cases of severe ischemia of the lower limb, with swelling of the extremity, fasciotomy is an extremely useful complementary procedure, undertaken by the opening of the anterior and lateral compartments, and of the superficial and deep compm1ments of the leg, prior to flow restoration.Such a procedure was undertaken in 43.2 percent of our patients'.
Arteriography was restricted to cases with multiple trauma or wounds of the vessel passages with no clincal findings lO • As arterial lesions occur in young individuals, in general with no previous history of arterial disease, outflow conditions for the reperfusion are in most instances a sufficient reason to have reached 97.3 percent of graft perviousness.
Mortality related to this type of trauma is rare, and is always related to injury of other organs.The only death in this study resulted from cranio-encephalic trauma s , x .

CONCLUSION
Femoral artery trauma, treated while the limb still maintains its vitality, has a positive clinical outcome with a high rate of limb preservation.Mortality usually results from injury to other organs.
Address for correspondence: Nelson Wolosker R. Esperia, 30 Sao Paulo/SP -Brasil -CEP 01433-060Seventy-four patients with noniatrogenic trauma of the femoral arteries were treated after being admitted to the emergency room of the "Hospital das Clinicas" (General Hospital), School of Medicine, University of Sao Paulo, between January 1991 and December 1993.
, and as observed in this study.Diagnosis of trauma of the femoral arteries is reached by clinical sao Paulo Medical Journal/RPM 114(1): 1079-1082, 1996 WOLOSKER, N.; GUADENCIO, A.; KUZNIEC, S. et al. -Surgical treatment of noniatrogenic trauma of the femoral arteries examination.Physical examination reveals absence of pulse, ischemia, local hemorrhage, and the presence of bruits in arterial passages because of the superficiality of the arteries.

Table 3
reports the topographic of the injuries.

Table 2
Distribution by Degree of Ischemia