Penetrating popliteal vascular injury: Surgical management and early outcome during current war in Taiz-Yemen

Author(s): Abudar Al-Ganadi, Naseem Al-Ossabi, Naseem Al-Ossabi, Mamon Al-Mekhlafi, Maha Hizam, Abdulkafi Shamsan

Background: Popliteal vascular injury remains a challenging entity, and carries the greatest risk of limb loss among the lower extremity vascular injuries. Operative management of traumatic popliteal vascular injuries continues to evolve. We aim to review our experience with complex penetrating popliteal vascular injuries, thereby focusing on initial presentation, therapeutic challenges, and early outcomes.

Methods: From September 2015 to December 2019, we managed total of 728 penetrating vascular injuries with 157 popliteal vascular injury presented to the Authority of Althawra hospital in Taiz- Yemen. Of 125 patients, 103 patients were fulfilling the inclusion criteria. Traumatic limb amputations were excluded from this study. Variables were retrospectively collected included patient demographics, mechanism and type of injury, limb ischemia time, clinical status at presentation, type of vascular reconstruction, associated complications, limb salvage, and mortality.

Results: 157 vascular reconstructions were performed for 103 patients with penetrating popliteal vascular injuries, 94 (91.3%) were males and 9 (8.7%) were female. The mean age was 27.3 ± 12.3 years. There were 84 (18.6%) penetrating gunshot high-velocity injuries, and 19 (18.4%) blast injuries. Popliteal vascular injuries were the second most common accounting for 35% of lower extremity vascular injuries and 22.4% of the total vascular injuries. Nearly half 54 (52.4%) of the patients sustained complex popliteal vascular injuries (arterial and venous injuries), 85 (82.2%) isolated arterial injuries, and 72 (69.9%) isolated venous injuries. Management of vascular injury was repaired by saphenous venous interposition graft in 68 (66%), end-to-end anastomosis in 15 (14.5%), ligation in 1 (1%), and venous patch in 1(1%). Venous injury was repaired in 53 (51.4%) and ligated in 18 (17.5%). Less than 6 hours from injury to completed revascularization was achieved in 58 (56.3%) patients. The overall fasciotomy was 28 (27.2%) which significantly increased the length of hospital stays (17 days vs. 7 days, P=0.0003). The overall limb-salvage rate in our study was 94.2%. During the study period, the most common complication was 14 (13.6%) wound infection, 14 (13.6%) graft thrombosis, 6 (5.8%) bleeding, 4 (3.9%) graft infection. Early limb loss occurred in 6 (5.8%). In our study, the mortality rate was 2 (1.9%).

Conclusions: Wartime penetrating popliteal vascular injury is a real challenge. However, team approach and promptly vascular repair found to associate with a remarkable limb salvage rate of 94.2%. We advocate repair of arterial injury with vein graft as the treatment of choice whenever possible.