Common
femoral artery injury secondary to bicycle handlebar trauma
(Portuguese
PDF version)
Coordinated
by João Luiz Sandri
João Luiz Sandri1, José Monteiro de Souza Netto2,
Cláudio de Melo Jacques2, Bruno Bourguignon Prezotti2,
Giuliano de Almeida Sandri3
1.
Assistant Professor, Clinical Surgery, Faculty of Sciences of Santa
Casa de Misericórdia de Vitória. Vascular Surgeon, Vitória
Apart Hospital.
2. Vascular Surgeon, Santa Casa de Misericórdia and Vitória
Apart Hospital.
3. Medical Student, Universidade Federal do Espírito Santo.
Correspondence:
Dr. João Luiz Sandri
Av. N.S.da Penha 714/1007
CEP 29055-130 - Vitória - ES
E-mail: jlsandri@escelsa.com.br
J Vasc
Br 2003;2(3):281-83
Part
II - DIAGNOSIS
The patient's
manifestations were compatible with traumatic vascular lesion with compensated
ischemic syndrome. The left femoral pulse was absent and ecchymosis
without hematoma was observed. The patient reported claudication of
the LLE when he walked for approximately 100 meters, which he had not
had before. At rest, no signs of ischemia were noted.
Echo-Doppler color flow imaging of the left iliac and femoral vessels
was requested. The results showed segmental thrombosis of the common
femoral artery (Figure 2), with runoff distal to the thrombus and the
other vessels with a monophasic flow pattern distally to the echo-Doppler,
but permeable. The flow in the femoral vein was normal.
 Figure
2 - Echo-color-Doppler showing occlusion with thrombosis of the left
common femoral artery.
After
the diagnosis of contusion with thrombosis of the common femoral artery,
it was decided that the patient should be submitted to arterial exploration
of the inguinal region, performed electively 24 hours after the trauma.
An inguinal dissection was carried out on the left side, with section
of the inguinal ligament. The surgical finding revealed contusion of
the transition to the external iliac artery and common femoral artery,
showing total section of the intima with local thrombosis at arterial
dissection (Figure 3). The affected segment was resected and replaced
with a segment of the internal saphenous vein taken from the left thigh
through the same incision, only extended distally. The patient showed
good clinical outcome and was discharged two days later, with all distal
pulses reestablished, recovering uneventfully.
Figure
3 - Arteriotomy showing total section of the intima after thrombus removal.
COMMENTS
Closed
traumas caused by bicycle accidents have been quite frequent, accounting
for more than 500,000 emergency treatments a year in the USA. Five to
10 % of serious bicycle accidents are steadfastly associated with handlebar
trauma.1 As in recent years the interest
in recreational cycling has been aroused, emergency doctors should be
familiar with and aware of the different forms of trauma that could
affect both adults and children.2 The injuries
caused by bicycle accidents are usually orthopedic and neurological,
followed by thoracic, genitourinary and abdominal injuries, but renal,
hepatic, splenic, pancreatic, and mesenteric root injuries have also
been reported.3 Albeit more rare, arterial
injuries provoked by this kind of accident should be commented on so
that emergency doctors get familiarized with them. The present case
is concerned with a closed trauma produced by common femoral artery
injury secondary to a bicycle handlebar trauma, as shown in Figure 4.
Figure
4 - Anatomic schematic representation of handlebar trauma.
The common
femoral artery, continuation of the external iliac artery, penetrates
deeply into the femoral triangle at the midpoint of the inguinal ligament.
It is in the femoral triangle that the common femoral artery is more
exposed. The boundaries of the femoral triangle are the inguinal ligament
(superiorly), the medial border of sartorius (laterally) and the medial
border of adductor longus (medially). The floor of the femoral triangle
consists of adductor longus, pectineus and iliopsoas muscles (from medial
to lateral) and its roof is formed by fascia lata. The femoral
artery is enclosed in the femoral sheath along with the femoral vein
(medially), to which it is closely related. The femoral nerve descends
laterally to the artery and is not enclosed in the femoral sheath.
The bone structures related to the femoral artery in the femoral triangle
are (deeply to floor muscles): the superior ramus of the pubis (at the
inguinal ligament level) and the femoral head, more inferiorly.4
The trauma pressed the common femoral artery against the superior ramus
of the pubis.
The trauma that causes arterial obstruction may originate from several
mechanisms: dissection or subintimal hemorrhage, thrombosis, pseudoaneurysmal
dilation and intimal flap with thrombosis.2
The recognition of this condition by the physician is extremely important
in order for the definitive diagnosis to be established and proper treatment
to be prescribed.
A colder or paler foot and absence of distal pulses lead to the suspicion
or clinical diagnosis of vascular injury. The ankle brachial pressure
index could show arterial obstruction, as in the present case. The diagnosis
can be confirmed with echo-Doppler color flow imaging, which might be
sufficient as in the present case, reducing the time elapsed between
diagnosis and treatment. In this case, the echo-Doppler clearly showed
the aspect of the injury, with local thrombosis and permeability of
the distal vessel (Figure 2), which helped to establish the diagnosis
right away.
Angiography can be performed for diagnosis or further details, providing
the patient is hemodynamically stable. Rutherford states that arteriography
should be mandatory whenever the arterial pressure between lower extremities
is greater than 10-20 mmHg, in patients in which traumatic vascular
injury is suspected.5 As angiography can
delay surgery and prolong ischemia, some authors would rather not use
it in some situations.6 The rationale behind
this thought is endorsed even where echo-Doppler color flow imaging
is performed by experienced examiners. This method has been recently
introduced in the assessment of vascular trauma.7
Intraoperatively, the external and apparently normal aspect of the artery
could masquerade an underlying injury. Quite frequently, it is necessary
to resect the injured path when intimal tear is observed, as shown in
Figure 3. If the injury is longer than 1 to 1.5 cm, the excision of
the segment and the repair with autologous vein graft or synthetic graft
can be carried out, between which autologous vein graft is always preferred.
In the reported case, the injury occurred in a crease; therefore, this
is one more reason for preferring autologous material, that is, saphenous
vein.
In spite of being less frequently reported in the literature, the frequency
of such trauma seems to be underestimated. It was first reported by
Rich in 1975. Even though it concerned a scooter accident, the injury
was provoked by the handlebar.8
The injury mechanism was described by Sarfati. When a cyclist falls,
the front wheel spins and the handlebar is perpendicular to the cyclist,
who takes the impact of the tip of the handlebar, which concentrates
the impact on a relatively small area.1,9
The possibility of injury to the femoral artery should be considered
in patients who suffer handlebar trauma near the inguinal region.
Special attention should be confined to children, in whom a vascular
injury with thrombosis may be compensated and not cause ischemia immediately,
but develop disorders of the bone growth plate, which result in limb
length discrepancy and, consequently, in serious development problems.9
REFERENCES
1.
Winston FK, Shaw KN, Kreshak AA, Schwarz DF, Gallager PR, Cnaan A. Hidden
spears: handlebars as injury hazards to children. Pediatrics 1998;102:596-601.
2.
Roth JW, Boyd CR. Recreational bicycling and injury to the external
iliac artery. Am Surg 1999;65:460-3.
3.
Yelon JA, Harrigan N, Evans JT. Bicycle trauma: a five-year experience.
Am Surg 1995;61:202-5.
4.
Nascimento-Silva JLC. Anatomia médico-cirúrgica do sistema
vascular. In: Brito CJ, Duque A, Merlo I, Murilo R, Filho VL, editores.
Cirurgia Vascular. Rio de Janeiro: Revinter; 2002. p. 25-76.
5.
Rutherford RB. Diagnostic evaluation of extremity vascular injuries.
Surg Clin North Am 1988;68:683-91.
6.
Ekbom GA, Towne JB, Majewski JT, Woods JH. Intraabdominal vascular trauma:
a need for prompt operation. J Trauma 1981;21:1040-4.
7.
Kuzniec S. Traumatismos vasculares. In: Brito CJ, Duque A, Merlo I,
Murilo R, Filho VL, editores. Cirurgia Vascular. Rio de Janeiro: Revinter;
2002. p. 706-719.
8.
Rich NM, Hobson RW II, Fedde CW, Collins GJ Jr. Acute common femoral
arterial trauma. J Trauma 1975;15:628-37.
9.
Sarfati MR, Galt SW, Treiman GS, Kraiss LW. Common femoral artery injury
secondary to bicycle handlebar trauma. J Vasc Surg 2002;35:589-91.
|
