Acute Occlusion of a Femoro-Popliteal Bypass Graft after Primary Cementless Total Hip Arthroplasty

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1 Case Report J Korean Orthop Assoc 2013; 48: Acute Occlusion of a Femoro-Popliteal Bypass Graft after Primary Cementless Total Hip Arthroplasty Kyung-Soon Park, M.D., Taek-Rim Yoon, M.D., and Young-Jun Seol, M.D. Center for Joint Disease, Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, Hwasun, Korea pissn : , eissn : Vascular complications after total hip arthroplasty (THA) are rare and mainly occur after revision surgery, and of these complications, large artery thrombosis is relatively uncommon. Nevertheless, this complication has potentially devastating effects on the affected lower extremity. The authors report a case of acute thrombosis in an iliac artery stent and femoro-popliteal bypass graft after primary cementless THA, and include relevant literature review. Key words: total hip arthroplasty, occlusion, arteries, bypass graft Total hip arthroplasty (THA) produces satisfactory results without significant complications in most cases. Generally, vascular complications after THA are relatively rare (approximately 0.08%), 1) and are more commonly encountered after revision surgery. Large artery thrombosis is even more uncommon, 2-5) but has potentially devastating consequences. In fact, only two previous reports of thrombosis of a bypass graft of a major artery after THA have been published in literature. 6,7) We encountered a patient with acute thrombosis at the site of an iliac artery stent and femoro-popliteal bypass graft after primary cementless THA. Here, we report this case and include the literature review. Informed consent for publication of case data was taken from the patient. walk without any limitation. Physical examination revealed that left hip range of motion was limited (flexion 80 o, external rotation 30 o, internal rotation 5 o, abduction 20 o, adduction 20 o ), and plain radiographs showed non-union of the left femoral neck fracture and limb shortening of about 15 mm (Fig. 1). He has suffered from diabetes mellitus for 10 years. He had undergone left common iliac artery stent insertion and femoropopliteal bypass grafting for left femoral artery occlusion about CASE REPORT A 77-year-old male patient, with a left femoral neck fracture after a fall, underwent 3 screw fixation at another hospital about 6 months ago before, presenting at our hospital with a complaint of persistent pain. Prior to the femoral neck fracture, he could Received May 30, 2012 Revised August 7, 2012 Accepted November 27, 2012 Correspondence to: Taek-Rim Yoon, M.D. Center for Joint Disease, Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun , Korea TEL: FAX: tryoon@chonnam.ac.kr Figure 1. Anteroposterior radiograph of both hips showing left femoral neck fracture nonunion after cannulated screw fixation. There was a left iliac stent (white arrow) and leg shortening about 15 mm. 대한정형외과학회지 : 제 48 권제 2 호 2013 Copyright 2013 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 125 Acute Occlusion of a Femoro-Popliteal Bypass Graft after Primary Cementless Total Hip Arthroplasty 2 years ago. However, we observed no signs of bypass graft occlusion on preoperative arterial angiography (Fig. 2). Preoperatively the pulsation of dorsalis pedis artery of left foot was normal. Motor power and sensation of left lower extremity was normal. He had been prescribed Astrix 100 mg (Aspirin, Boryung Co. Ltd., Seoul, Korea) once a day, Anplag 100 mg (Sarpogrelate hydrochloride, Yuhan, Seoul, Korea) three times a day and Cumadin 3 mg (Warfarin Sodium, Jeil Pharmaceutical Co. Ltd., Daegu, Korea) once a day. On the 5th inpatient day, we performed a cementless THA Figure 2. Preoperative lower extremity 3 dimensional computed tomographic angiograph demonstrating no occlusive lesion at left femoro-popliteal bypass graft. for nonunion of the left femoral neck fracture using a posterolateral approach under general anesthesia and corrected the limb shortening (Fig. 3). The total duration of the surgery was 1 hour 10 minutes and the total intraoperative blood loss was 400 ml. The operative procedure was essentially uneventful. Four hours after surgery, he complained of inability to dorsiflex the left ankle and numbness of the left foot. A physical examination revealed reduced pulsation of the dorsalis pedis artery and a slightly lower temperature compared to the contralateral foot. Emergency lower limb arterial computed tomographic angiography was performed 4.5 hours after surgery, and revealed a large thrombus just below the left common iliac arterial branch from origin of the external iliac artery to the bypass graft (Fig. 4). The patient was referred to the vascular surgery department and the thrombus was removed 12 hours postoperatively by selective thrombolytic therapy using urokinase by a radiologist specialized in interventional procedures. Briefly, after placing a guide wire in the left proximal superficial femoral artery, urokinase 340,000 units was infused for 4 hours. Distal blood flow was restored after this selective thrombolytic therapy and confirmed by angiography (Fig. 5). Postoperative heparin (5,000 IU, P/S 500 ml mix, 15 ml/h) was administered for 7 days and aspirin 100 mg was continued. The drain was removed on the first postoperative day and the total amount of drain was 180 ml. The postoperative rehabiliation was delayed for a week because of anticoagulation therapy and we elastic compression dressing was applied for 7 days postoperatively to prevent hematoma formation. The rehabiliation program after 1 week was same as usual. No other compli- Figure 3. (A) Immediate postoperative anteroposterior and (B) lateral radiographs showing the cementless total hip arthroplasty and equal leg length.

3 126 Kyung-Soon Park, et al Figure 4. (A) The axial and (B) 3 dimensional images of postoperative computed tomographic angiograph showing an occlusive lesion in the external iliac artery through the previous bypass graft (white arrows). Figure 5. (A) Arteriography before selective thrombolytic therapy showing impaired distal arterial flow. (B) After selective thrombolytic therapy, (C) arteriography demonstrated patent distal flow to the popliteal artery via the bypass graft. cation such as hematoma or wound problem was noted due to urokinase or heparin. The patient was followed up for 12 months and the ankle dorsiflexion and numbness had fully recovered. He was able to walk without a walking aid, but there was mild limping. DISCUSSION Complications after THA are primarily dislocation, loosening, and infection, but vascular complications are uncommon. Furthermore, of the various vascular injuries, occlusion of a large artery is extremely rare. Parfenchuck and Young 6) classified types of vascular complication after THA as hemorrhage due to vessel perforation, pseudoaneurysm, arterio-venous fistula, and thrombosis. However, though vascular complications are uncommon, they should not be overlooked because they are potentially limb or even life threatening. Only two case reports of major bypass graft occlusion after THA have been published. Trousdale et al 7) performed 14 THAs in 10 patients with aortofemoral bypass grafting. No thrombosis was seen in 10 cases operated by anterior approach, but in 4 cases operated using a posterior approach, one case had thrombosis in bypass graft. In this case, preoperative angiography showed partial occlusion of the bypass graft, and thus, the authors considered that the occlusion resulted from compression of the graft, due to the flexed, adducted, internally rotated position adopted during surgery using the posterior approach. Therefore, they reported when THA is performed on a patient with a history of iliofemoral arterial occlusive disease or of an aortofemoral bypass graft, an anterior approach may help avoid intraoperative graft occlusion and thrombosis. Parfenchuck and Young 6) also reported a case of intraopera-

4 127 Acute Occlusion of a Femoro-Popliteal Bypass Graft after Primary Cementless Total Hip Arthroplasty Table 1. Literature Reviews of Major Artery Thrombosis after Total Hip Arthroplasty Report Case (n) Thrombosis level Approach for THA Treatment for thrombosis Parfenchuck and Young 6) 1 Ilio-femoro-popliteal artery bypass graft; primary THA N/M N/M Trousdale et al. 7) 1 Aortobifemoral bypass graft; primary THA Posterolateral Thrombectomy Matos et al. 3) 4 Iliac artery (1 case) N/M N/M Iliofemoral artery occlusion (3 cases); revision THA Stubbs et al. 5) 1 Iliofemoral artery occlusion; revision THA Lateral Thrombectomy Heyes and Aukland 8) 2 Femoral artery; primary THA Anterolateral Thrombectomy Saphenous vein graft Simon et al. 9) 2 Femoral artery; primary THA Posterolateral Thrombectomy THA, total hip arthroplasty; N/M, not mentioned. tive occlusion in a patient with an aortoiliac graft for an abdominal aortic aneurysm. In this case, they concluded that vascular occlusion may have occurred during THA in the absence of any demonstrable preexisting signs or symptoms. It is known that vascular complications are more common after revision THA. Stubbs et al. 5) reported an iliofemoral artery thrombosis after revision THA using a lateral approach, and Matos et al. 3) reported one case of iliac artery and three cases of iliofemoral artery thrombosis after revision THA. They commented that multiple procedures on same hips resulted in extensive scaring, shortening, and flexion contracture or even fusion, and that these could have caused the arterial occlusion. Large arterial occlusion can also occur during primary THA. Heyes and Aukland 8) reported two cases of femoral artery thrombosis after primary cemented THA using an anterolateral approach. Simon et al. 9) reported two cases of femoral artery thrombosis after primary THA performed using a posterolateral approach, and Reiley et al. 10) reported a case of femoral artery occlusion after cemented THA due to cement leakage under the transverse ligament (Table 1). We hypothesize that limb lengthening by 15 mm could have stretched the bypass graft in our case and caused the thrombosis, and, as mentioned before, the position adopted while performing the posterior approach could be another reason. Also in this patient, we felt that the junctional area of iliac stent and bypass graft was more vulnerable to be hyperflexed due to the difference of the flexibility between stent and graft and it could have caused the thrombosis. In order to reduce the likelihood of iliofemoral artery occlusion after THA, the possibility of a vascular complication should be borne in mind. However, immediate intervention is required to salvage the limb when a vascular complication is encountered. In addition, as was the case in our patient, in those with a previous history of arterial occlusive disease and bypass grafting, typical symptoms, such as, pain and signs such as pulselessness and cold limb may not be obvious after arterial occlusion because of well-developed collateral circulation. In our case, the initial symptoms were loss of ankle dorsiflexion and numbness of the foot, which more resembled a sciatic nerve injury or peroneal nerve palsy. Therefore, if a postoperative vascular complication is suspected or there is a history of vascular disease, angiography should be performed promptly to evaluate the entire lower limb affected and consultation with a vascular surgeon should be considered. Preoperatively demonstrated graft patency should not preclude a surgeon from taking necessary precautions and keep a watchful eye on development of postoperative thrombosis. REFERENCES 1. Calligaro KD, Dougherty MJ, Ryan S, Booth RE. Acute arterial complications associated with total hip and knee arthroplasty. J Vasc Surg. 2003;38: Crispin HA, Boghemans JP. Thrombosis of the external iliac artery following total hip replacement. A case report. J Bone Joint Surg Am. 1980;62: Matos MH, Amstutz HC, Machleder HI. Ischemia of the lower extremity after total hip replacement. J Bone Joint Surg Am. 1979;61: Nachbur B, Meyer RP, Verkkala K, Zürcher R. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop Relat Res. 1979;141: Stubbs DH, Dorner DB, Johnston RC. Thrombosis of the iliofemoral artery during revision of a total hip replacement. A case report. J Bone Joint Surg Am. 1986;68:454-5.

5 128 Kyung-Soon Park, et al 6. Parfenchuck TA, Young TR. Intraoperative arterial occlusion in total joint arthroplasty. J Arthroplasty. 1994;9: Trousdale RT, Donnelly RS, Hallett JW. Thrombosis of an aortobifemoral bypass graft after total hip arthroplasty. J Arthroplasty. 1999;14: Heyes FL, Aukland A. Occlusion of the common femoral artery complicating total hip arthroplasty. J Bone Joint Surg Br. 1985;67: Simon JP, Van Raebroeckx A, Bellemans J. Intraoperative arterial occlusion in total hip arthroplasty. A report of two cases. Acta Orthop Belg. 2007;73: Reiley MA, Bond D, Branick RI, Wilson EH. Vascular complications following total hip arthroplasty. A review of the literature and a report of two cases. Clin Orthop Relat Res. 1984;186:23-8.

6 129 pissn : , eissn : Case Report J Korean Orthop Assoc 2013; 48: Acute Occlusion of a Femoro-Popliteal Bypass Graft after Primary Cementless Total Hip Arthroplasty 무시멘트성인공고관절전치환술후발생한대퇴 - 슬와이식혈관의급성폐색 박경순 윤택림 설영준화순전남대학교병원정형외과, 관절센터 인공고관절전치환술후에발생하는혈관합병증은드물고주로재치환술후발생하며, 그중큰동맥의색전은비교적흔하지않다. 그러나이러한합병증은발생하였을경우병변측하지에큰위험을초래할수있다. 저자들은무시멘트성인공고관절전치환술후대퇴동맥스텐트와대퇴- 슬와동맥우회이식혈관의급성폐색이발생한증례를경험하였으며, 이에문헌고찰과함께보고하고자한다. 색인단어 : 인공고관절전치환술, 폐색, 동맥, 이식혈관 접수일 2012 년 5 월 30 일수정일 2012 년 8 월 7 일게재확정일 2012 년 11 월 27 일교신저자윤택림화순군화순읍서양로 322, 화순전남대학교병원정형외과, 관절센터 TEL , FAX , tryoon@chonnam.ac.kr The Journal of the Korean Orthopaedic Association Volume 48 Number Copyright 2013 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.