Management of Femoral Vessel Injury

The femoral vessels are injured in 70% of all traumas involving arterial injury. Traumatic femoral vessel injury results most commonly due to gun shot wounds.   While the classic signs of any vascular injury include pulsitile bleeding, an expanding hematoma, a palpable thrill, an audible bruit, or a pulseless limb, patients with femoral vessel injuries typically present with active hemorrhage, shock, or a pulseless extremity. In the rare hemodynamically stable patient, arteriography can be utilized as a helpful “roadmap” for identifying the extent of the injury as well as planning operative intervention. However, the hemodynamically unstable patient with a femoral vessel injury warrants emergent operative intervention.

 Operative preparation should include surgical prep of the entire abdomen to the toes to assure adequate access to obtain both proximal and distal control. Additionally, the contralateral extremity should also be included in the sterile field to allow for possible saphenous vein graft harvest. If one suspects that there is injury to the proximal vessels, it may be most advantageous to begin with a suprainguinal approach to gain proximal control. Once proximal control is achieved, one may then perform a longitudinal incision over the femoral triangle to further identify the full extent of the injury.

Typically, for injuries less than 2cm the vessel may be mobilized and repaired primarily. For injuries greater than 2cm a saphenous vein graft (often taken from the contralateral leg) is the standard choice for repair. However, synthetic grafts may also be utilized.   For patients with grossly contaminated wounds or extensive soft tissue defects (such as from gun shot wounds or crush injuries), it may be safest to perform an extra-anatomic bypass of the injury.  Regardless of the choice of repair, it is imperative to remember to pass a Fogarty catheter prior to completion to evacuate distal clots.  While open surgical repair is the classic approach for femoral vessel injuries, endovascular repair is beginning to be utilized as well.  For example, several recent papers describe coil embolization of the profunda as well as endograft repair of superficial femoral artery injuries. Prevention of post-operative compartment syndrome is also an important consideration following operative repair of femoral vessel injuries.  Specifically, fasciotomies should be performed when there has been over 4-6 hours of ischemic time, complex or multiple extremity fractures, combined arterial and venous injuries, vascular injury combined with bone or soft tissue injury, elevated compartment pressures (>25mmHg), or increased calf swelling or tenderness on exam.

For further reading about trauma to the femoral vessels, please see the following papers:

1. Femoral vessel injuries. Carrillo EH, Spain DA, Miller FB, Richardson JD. 2002. Surgical Clinics of North America. 82(1): 49-65.

2. A 5 year-review of management of lower extremity arterial injuries at an urban level I trauma center. 2011. Franz RW, Shah KJ, Halaharvi D, Franz ET, Hartman JF, Wright ML. J Vasc Surg. 53: 1604-10.

3. Use of stent grafts in lower extremity trauma. 2011. Stewart DK, Brown PM, Tinsley EA, Hope WW, Clancy TV. Ann Vasc Surg. 25(2): 264e9-13.

4. Extremities---indications and techniques for treatment of extremity vascular injuries. 2008. Doody O, Given MF, Lyon SM. Injury. 39(11): 1295-1303.

Thanks to Dr. Erica Carlisle for this post.