The management of vascular injuries associated with total hip arthroplasty

Transcription

1 The management of vascular injuries associated with total hip arthroplasty Norman A. Shoenfeld, MD,* Steven A. Stuchin, MD,** Richard Pearl, MD,* and Stephen Haveson, MD,* New York, N.Y. Approximately 100,000 total hip reconstructions are done annually in the United States. The nature of the surgical technique in a field close to the iliac and femoral vessels makes the occurrence ofvascttlar injury an occasional but serious complication. We have reviewed retrospectively our experience of five cases of vascular injuries with total hip replacement and an additional 63 cases in the literature to identify those patients at risk and to define the management of these injuries. For the entire group of 68 patients, most injuries were sustained on the left side (66%), and 39% were seen in revisions. Complications were related to cement incorporation of the iliac vessels (44%), aggressive medial retraction (17%), excessive traction on atherosclerotic vessels (10%), and improper technique in preparation of the acetabulum. The most commonly injured vessels were the external iliac artery (36), common femoral artery (17), and external iliac vein (6). Twenty-seven of these injuries required emergent surgery, most for hemorrhage (66%). Injuries consisted of thromboembolic complica~ons l~ading to distal ~schenua (46%), vessel laceratmns (26%), pseudoaneurysmsl(25%), and arteriovenous fistulas (3%). Vascular repair!was individualized and included suture repair, thrombectomy and patch angioplasty, embolectomy, and arter~a~ and venous bypass procedures. There was an overall 7% mortality and a 15% incidence o~ fimb loss. Risk factors include (1) revision procedures, (2) leftsided procedures, and (3)intrapelvic migration of the acetabular component of the hip prosthesis. Elective vascular workup and preliminary retroperitoneal exposure of the iliac vessels at time of hip arthroplasty is recommended for patients at risk. (J VAse SugG 1990;i1! ) Since its inception in the 1960s, total hip arthroplasty has grown in volume and complexity. Currently approximately 350,000 reconstructions are performed on a yearly basis worldwide, with approximately 100,000 per year performed in the United States alone. The proximity of pelvic and [ noral vessels to the operative field has led to a subset ofspecificvascular injuries associated with this surgery. 1-3 The combination of an aging population with an increasing need for orthopedic reconstructions, and a large number of total hip prostheses already in place and at risk of requiring revision, points to an increasing incidence of these vascular complications in the coming decade. We have re- From the Department of O~hopaedic Surgery, the Hospital for Joint Disease Orthopaedic Institute, New York University School of Medicine,** and the Division of Vascular Surgery, Beth Israel Medical Center, the Mount Sinai School of Medicine of the City University of New York.* Presented at the Third Annual Meeting of the Eastern Vascular Society, Bermuda, May 4-7, Reprint requests: Norman A. Shoenfeld, MD, Department of Surgery, Dazian 9, Beth Israel Medical Center, First Ave. and 16th St., New York, NY /6/18087 viewed our experience at a large tertiary care orthopedic hospital and that in the literature 111 to identify the mechanism of and risk factors for vascular injury, and to define the management of these injuries. CASE REPORTS During the period of 1979 to 1988 five vascular injuries with total hip arthroplasty were identified at the Hospital for Joint Disease Orthopedic Institute. (The total number of total hip replacements performed yearly at the Hospital for Joint Disease Orthopedic Institute averages 750, with 85 (11%) of these being revision procedures.) Case 1. A 78-year-old man was admitted 16 years after a left total hip arthroplasty for component loosening, Preoperative x-ray films were notable for protrusion of the acetabular cup into the pelvis with intrapelvic cement, in addition to a loose femoral component (Fig. 1). The hip was exposed through a lateral approach. Excessive venous bleeding filled the operative field on mobilization of the acetabular cup. Hypotension and tachycardia subsequently developed in the patient. The acetabulum was packed, the acetabular component was left in place, and a vascular surgery consultation was obtained. The lateral hip incision was closed over drains, and the patient was turned over into a supine position, prepared again, and draped. Through an oblique left lower quadrant retroperitoneal 549

2 550 Schoenfeld et al. Journal of VASCULAR SURGERY Fig. 2. Angiogram of Case 2 performed through a right femoral artery approach by means of the Seldinger technique in which the left external iliac vessels are encased~in cement (solid arrow). The circular structure in the left pei is (open arrow) is the acetabular component of the hip prosthesis, which is markedly displaced into the pelvis and rotated. Fig. 1. Preoperative x-ray film for Case 1. Protrusion of the acetabular component into the pelvis is seen (arrow). incision a large retroperitoneal hematoma was explored. A complete avulsion of the left external iliac vein from the common iliac bifurcation to the inguinal ligament was identified as the source of hemorrhage. Cement was seen in the vicinity of the external iliac vessels. The vein was ligated proximally and distally, and the wound was closed. Because ofhemodynamic instability, the decision was made to complete the total hip arthroplasty at a second operation. However, on removal of the drapes the patient's left leg was noted to be extremely tense and edematous, with mottling and cyanosis. For threatened limb loss as a result of venous obstruction, venous thrombectomy and femoralfemoral venom bypass surgery was performed with externally supported polytetrafluoroethylene. The edema subsided, and normal color quickly returned to the left leg. The patient's postoperative course was marked by urosepsis, pseudomembranom colitis, gastritis, and thrombocytopenia contraindicating heparinization. However, the graft remained patent, and after a prolonged course of antibiotics he subsequently underwent revision of his total hip arthroplasty with bone grafting to the acetabulum without incident. His prosthetic venous bypass occluded at i year; however, with recruitment of collateral vessels this was well tolerated. Two years after surgery the patient walks well with only mild leg edema controlled with a graduated compression stocking. Case 2. A 67-year-old man underwent revision through a lateral approach of a previously revised left total hip replacement for loosening at 4 years. X-ray films revealed protrusio. At time of mobilization of the acetabular cup, brisk venous bleeding was noted. Retroperitoneal exploration revealed cement incorporation of the external iliac artery and vein, with a calcified external iliac artery and a laceration of the external iliac vein. A lateral venorrhaphy was performed, and the operation was terminated. A postoperative angiogram (Fig. 2)demonstrated cement in the region of the external iliac artery. Reexploration 5 months later through a retroperitoneal incision was performed with dissection of the external iliac vesse& from the cement, followed by revision of the left total hip arthroplasty. The external iliac artery was noted to be thrombosed at this time, and no vascular reconstruction was performed. After surgery the complication of wound infection occurred. The patient subsequently underwent elective femoral-femoral bypass grafting for symptoms of severe claudication. Case 3. A 70-year-old woman was noted to have severe ischemia of the right foot 5 days after right total hip arthroplasty. Angiography revealed occlusion of the right common femoral artery (Fig. 3). Exploration demonstrated ecchymosis around a thrombosed common femoral artery. The nature of this injury was thought to have been excessive traction on the artery from dislocation/relocation maneuvers, leading to creation of an intimal flap. Thrombectomy was unsuccessful, and a femoral-popliteal bypass was placed. Her postoperative course was uneventful, with relief of the ischemia. Case 4. A 79-year-old man was noted to have a mottled

3 Volume 11 Number 4 April 1990 Vascular injuries with total hip arthroplasty 551 Table I. Vascular injuries with total hip arthroplasty Total no of injuries: 68 Average age: 65 Sex: Male: 32% Female: 68% Side: Left: 67% Right: 33% Operations: Primary: 61% Revision: 39% Causes: Cement related: 30 (44%) Retractor injuries: 12 (18%) Excessive traction on vessels: 7 (10%) Related to intrapelvic cup migration: 5 (7%) Reaming injury: 2 (3%) Osteotome injury 1 (1%) Unknown: 11 (16%) Types of injuries: Thromboembolic: 31 (46%) Lacerations: 18 (26%) Pseudoaneurysms: 17 (25%) Arteriovenous fistula: 2 (3%) Mortality: 7% Major amputation: 15% Minor amputation: 4% Fig. 3. Angiogram of Case 3. Occlusion of the common femoral artery 1s present (arrow). foot after undergoing an otherwise uncomplicated left total hip arthroplasty through a lateral approach. Preoperative pulse examination had revealed 2 + femoral, 1 + popliteal, and absent pedal pulses; after operation the femoral and all distal pulses were absent in the left leg. X-ray films demonstrated dramatic straightening of a once tortuous ~upcrficial femoral artery. After unsuccessfial attempts at thrombectomy, the patient underwent above knee amputation on the third postoperative day. Case 5. An 84-year-old man had severe right foot pain after right total hip arthroplasty. Examination showed absent pulses in the right leg below a 3 + femoral pulse, with severe right foot ischemia. Angiography demonstrated embolization to the midpopliteal artery without reconstitution. Popliteal embolectomy with vein patch angioplasty was performed, and the patient ultimately required several toe amputations. LITERATURE REVIEW A Medline search limited to English-language literature was performed. Sixty-three additional cases of vascular injuries associated with total hip arthroplasty were identified 1-~1 (Table I). The average age of the total group of 68 patients was 65 years, and 68% were womcn. Two thirds of the operations involved were on the left side. Sixty-one percent of the procedures were primary operations, thc remainder (39%) were revisions. The overall mortality was 7%, with a 15% incidence of major amputations and a 4% incidence of minor amputations. Sixty-six arterial injuries and eight venous injuries occurred. Most of the injuries were to the external lilac artery and common femoral artery (Fig. 4). The injuries consisted of 17 pseudoaneurysms (25%), 31 instances of thromboembolic complications (46%), 18 vessel lacerations (26%), and two traumatic arteriovenous fistulas. Thirty of these were thought to be cement related, 12 caused by retractor trauma, seven as a result of excessive traction, and five the result of intrapelvic migration of the acetabular component. The remainder were causcd by reaming (2) or osteotome (1) trauma, or were of unknown cause (11). Fortythree percent of the injuries required emergent vascular surgical intervention. In the group of 17 pseudoaneurysms (Table II), the average age at presentation was 65 years. A female (82%) and left sided (68%) predominance was noted. Twenty-four percent of the orthopedic procedures were revisions. The most common presentations were bleeding (47%), hip pain (41%), and the presence of a pulsatile mass (29%). Two patients had symptoms ofhematuria, two had leg edema, and one had limb ischemia. Infection was associated with

4 552 Schoenfeld et al. Journal of VASCULAR SURGERY Injuries EIA 17 CFA EIV 3 Vessel FT-/'A v//a 8 r'27~ 2 2 V//~ F//A SFA DFA MCFA OTHER Fig. 4. Vessels injured in THR (EIA, External iliac artery; CFA, common femoral artery; EIV, external iliac vein; SFA, superficial femoral artery; DFA, profianda femoris artery; MCFA, medial circumflex femoral artery). There were isolated injuries to the common iliac, hypogastric, superior gluteal, obturator, lateral circumflex femoral, and popliteal arteries and to the common iliac and common femoral veins. Table II. Pseudoaneurysms associated with total hip arthroplasty Total no of injuries: 17 Average age: 65 Sex: Male: 18% Female: 82% Side: Left: 69% Righit: 31% Operations: Primary: 77% Revision: 24% Causes: Cement related: 13 Retractor injuries: 2 Related to intrapelvic cup migration: 2 Location of the injury: External iliac artery: 11 Common femoral artery: 3 Medial circumflex femoral artery: 2 Deep femoral artery: 1 Type of management: Bypass grafting: 44% Primary repair: 44% Ligation: 12% Mortality: 6% Amputation: 11% # pseudoaneurysms // I l l l. I 271 /11 I I I z/,/, //',4, /// In" 1 too. 2-6 ;r2"751 I l i a fl/a Ilia IIIJ fli,a 11~1 f/ia i/ij tllj ella I l i a 6-12 /;5 i l l I I i I l l III 1-2y. 2-5y. 5-10y y. Time Fig. 5. Time to diagnosis of pseudoaneurysms. 29% of these cases. The average time to diagnosis of the pseudoaneurysm was 29 months (Fig. 5). Eleven (65%) involved the external iliac artery, three (18%) were in the common femoral artery, with two injuries to the medial circumflex femoral artery and one of the deep femoral artery. Most of these injuries were thought to be cement related (76%), with two injuries caused by excessive retraction, and two related to intrapelvic migration of the acetabular cup. The treatment consisted of bypass grafting (44%) or primary repair (44%), with the medial circumflex artery pseudoaneurysms treated by ligation. Two patients (11%) ultimately required hip disarticulation as a result of ischemic complications. One patient had a graft-enteric fistula after a Dacron iliofemoral bypass placement for an external iliac artery pseudoaneu- rysm. This was successfully treated with graft excision and femoral-femoral bypass grafting. One patient died in the postoperative period of a pulmonary embolus. Arterial thromboembolic complications occurred in 31 patients (Table III 1. Sixty-five percent of the patients were women, 63% of the operations were on the left side, and 35% were revisions. Emergent vascular surgical intervention was required in 41%. The external iliac artery was the most likely vessel to suffer thrombosis (17). Thrombosis occurred nine times in the common femoral artery and twice involved the superficial femoral artery. One instance of popliteal artery embolism occurred (Case 5). ~e cause of the thrombosis was deemed cement related in 32%, a result of excessive traction on the vessel with limb manipulation in 23%, or was related to cup migration (10%) or overly aggressive retraction (6%). The cause in 29% of the injuries was not defined. Treatment consisted of thrombectomy with or without patch angioplasty in 58% or bypass grafting in 42% (iliofemoral/femoral-femoral/femoralpopliteal). Complications included a 25% major amputation rate, a 10% minor amputation rate, one wound infection, and one instance of compartment syndrome. No deaths were associated with thrombotic complications. Emergent vascular intervention for complications occurring at time of total hip arthroplasty was necessary in 43% (Table IV). Excessive bleeding was the most common sign of injury, occurring in 67% of

5 Volume 11 Number 4 April 1990 Vascular injuries with total hip arthroplasty 553 Table III. Thromboembolic complications Total no of injuries: 31 Average age: 64 Sex: Male: 35% Female: 45% Side: Left: 63% Right: 37% Operations: Primary: 65% Revision: 35% Causes: Cement related: 10 Retractor injuries: 2 Excessive traction on vessels: 7 Related to intrapelvic cup migration: 3 Not defined: 7 Location of the injury: External iliac artery: 17 (59%) Common femoral artery: 9 (31%) Superficial femoral artery: 2 (7%) Popliteal artery (embolus): 1 (3%) Type of management: Thrombectomy ( _+ patch angioplasty): 55% Bypass grafting: 40% Iliofemoral bypass: 15% Femoral-femoral bypass: 15% Femoral-popliteal bypass: 5% Not defined: 5% Embolectomy: 5% Mortality: 0% Major amputation: 25% Minor amputation: 10% patients, and in six patients it was noted at time of mobilization of the acetabular component. Ischemia was the presenting sign in 52% and edema in 7%. Most of the procedures in this group were revisions (57%), and 76% were on the left side. The external iliac artery was involved in 15 instances (56%), the common femoral artery in seven (26%). Three iniff~i~s of the external iliac vein required immediate attention, and additional injuries occurred in the deep femoral, superficial femoral and obturator arteries, and common iliac vein. The injuries consisted of pseudoaneurysms discovered at time of acetabular cup mobilization (7%), vessel lacerations (48%), and thrombotic complications (44%). The overall mortality was 8%, with two patients requiring amputation and additional 8% complication rate consisting of postoperative deep venous thrombosis, edema, and vascular prosthetic infection requiring graft removal and femoral-femoral bypass grafting. Cement was a causative factor in 30 of these injuries (44%). Thirteen cases of pseudoaneurysms were thought to be directly related to the methylmethacrylate. Ten thrombotic complications and seven instances of vessel lacerations occurred. The e~ernal iliac artery was the vessel most likely to be Table IV. Emergent vascular interventions Total no of injuries: 27 Average age: 66 Sex: Male: 52% Female: 48% Side: Left: 76% Right: 24% Operations: Primary: 43% Revision: 57% Causes: Cement related: 8 Retractor injuries: 8 Excessive traction on vessels: 3 Related to intrapelvic cup migration: 1 Reaming injury: 2 Osteotome injury: 1 Unknown: 4 Location of the injury: External iliac artery: 15 Type of management: Arterial: Thrombectomy: 8 Primary repair: 9 Bypass graft: 1 Ligation: 2 Not specified: 4 Venous: Ligation: 2 Venorrhaphy: 1 Bypass: 1 Mortality: 8% Amputation: 8% Common femoral artery: 7 External iliac vein: 3 Common iliac vein: 1 Superficial femoral artery: 1 Deep femoral artery: 1 Obturator artery: 1 injured (67%), followed by the external iliac vein (13%) and common femoral artery (10%). Isolated injuries to the hypogastric, deep femoral, obturator, and medial circumflex femoral arteries were also described. There was a clear left-sided predominance to these injuries (73%). Twelve instances of retractor-induced injuries (18%) occurred, all left-sided, and most (73%) requiring emergent vascular intervention. Bleeding was the presenting sign in two thirds, ischemia in 50%, and pseudoaneurysms in 17%. There were six injuries to the common femoral artery, two to the external iliac artery, and isolated injuries of the medial and lateral circumflex arteries, the superficial and deep femoral arteries, and the superior gluteal artery. All seven injuries caused by excessive traction used in hip dislocation and relocation maneuvers (10%) presented as ischemia with vessel thrombosis. The left sided predominance was again noted. There

6 554 Schoenfeld et al. Journal of VASCULAR SURGERY were thrce occlusions of the common femoral artery, two of the external iliac artery, and two of the superficial femoral artery. Local wound infection was associated. With five of these injuries (7%). DISCUSSION Total hip arthroplasty is a common orthopedic procedure often performed in the elderly, a population group also at higher risks for coexistent atherosclerosis and the complications thereof. The growth in popularity of this procedure, along with the abundance of perhaps less reliable hip prostheses already in place and at risk of failure suggest that the number of vascular complications seen related to total hip arthroplasty will continue to increase, and that this injury is one that will become more familiar to vascular surgeons in the future. The potential mechanisms involved in vascular injuries with surgery of the hip joint has been elucidated by Nachbur et al.,1 Aust et al., 3 and others, a'4,6,9-n These include retractor injuries, which can injure the common femoral artery that lies directly anterior and medial to the hip joint. The iliopsoas and rectus femoris muscles afford a degree of protection to the common femoral artery from the effects of the narrow bone lever used anterior to the acetabular rim. However, this protection may be overcome by excessive force used in a flexed, adducted, and rotated limb. The medial and lateral circumflex femoral arteries both originate from the deep femoral artery or distal common femoral artery. The medial circumflex femoral artery lies along the medial aspect of the hip capsule, and its terminal branches supply the acetabulum. The lateral circumflex femoral artery crosses the plane between vastus latcralis and rectus femoris muscles to supply the lateral aspect of the hip joint. Both are susceptible to injury from injudicious placement of retractors in total hip arthroplasty. The location of the external iliac artery directly medial to the pubic component of the acetabulum places this vessel at risk of injury with drilling or reaming maneuvers. In addition, cement extruded through a defect in the acctabular wall can surround the external iliac vessels. In so doing, thrombosis can occur as a result of the exothermic reaction present as methylmethacrylate sets, and cement spiculae can erode through the artery and result in perforation and pseudoaneurysm formation. The vessels are vulnerable to avulsion if a revision procedure becomes necessary and intrapelvic cement is injudiciously removed. Excessive limb manipulation to enact joint dislocation and relocation and to correct for limb length discrepancies can exert longitudinal stress to the iliac and femoral vessels. The presence of atherosclerotic plaque in this elderly population increases the risk of development of an intimal flap with resultant thrombosis and distal ischemia. Prevention of vascular complications in total hip arthroplasty is the most important aspect of treatment. A complete history to search for symptoms of lower extremity arterial insufficiency, and full pulse examination should be performed in appropriate patients. Baseline arterial Doppler and pulse volume amplitude determinations are performed in patients with symptoms or with an abnormal pulse examination and in all revision procedures deemed at risk. Intrapelvic migration of the acetabular component is an indication to study the patient preoperatively with angiography (with both anteroposterior and oblique views), intravenous pyelography, and phlebogra,v~.y. In patients with vessels at risk, a preliminary retroperitoneal exposure of the external iliac vessels before extraction of the acetabular component is advised to prevent life-threatening hemorrhagic complications associated with lacerations or avulsions of these vessels. Clearly, precise, gentle technique by the orthopedic surgeons may avoid some of these injuries. Comparison of the efficacy of alternate vascular surgical interventions in the treatment of these injuries cannot be made in this small group of patients; however, several considerations in the management of these injuries can be stated. Surgical intervention remains specific to the injury present. Pseudoaneurysms can be treated successfully by standard vascular techniques ofdebridement and reconstruction by. primary mobilization with end-to-end anastomosis.~: by graft interposition. Thrombotic complications are treated by thrombectomy with autogenous tissue patch angioplasty or by bypass grafting. The resistance of polytetrafluoroethylene to infection, as compared to Dacron, makes this the preferred graft if a prosthetic is to be used. 12 Of note is that revision total hip arthroplasty is at increased risk for infection with component loosening often a manifestation of infection. In the case of preexisting infection or if the patient is thought to be at higher risk of infectious complications, vessel ligation with extraanatomic bypass (i.e., femoral-femoral bypass for external iliac artery injury) should be performed. Lateral venorrhaphy is the technique of choice for injuries to the external iliac vein. In the face of extensive injury to the vein, placement of an autogenous venous bypass graft in a stable patient is the preferred alternative

7 Volume 11 Number 4 April 1990 Vascular injuries with total hip arthroplasty 555 but if necessary, ligation may be performed. Whereas the latter is acceptable in the trauma setting, 13 it may be less well tolerated in the patient who has already had extensive dissection with division of collateral venous channels associated with hip surgery. REFERENCES 1. Nachbur B, Meyer RP, Verkkala K, Zurcher R. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop 1979;141: 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 1984; 186: Aust JC, Bredenberg CE, Murray DG. Mechanisms of arterial injuries associated with total hip replacement. Arch Surg 1981; 116: Bergqvist D, Carlsson AS, Ericsson BF. Vascular complications after total hip arthroplasty. Acta Orthop Scand 1983; 54: Schlosser V, Spillner G, Breymann T, Urbayni B. Vascular injuries in orthopaedic surgery. J Cardiovasc Surg (Torino) 1982;23: Heyes FLP, Aukland A. Occlusion of the common femoral artery complicating total hip arthroplasty. J Bone Joint Surg [Br] 1985;67: Rutsaert R; Van Schil P, Martens C, Vaneerdeweg W, Schoofs E. Occlusion of the left common femoral artery after total hip replacement. Report of a case and review of the literature. J Cardiovasc Surg (Torino) 1988;29: Stubbs DH, Dorner DB, Johnson RC. Thrombosis of the iliofemoral artery during revision of a total hip replacement. A case report. J Bone Joint Surg [Am] 1986;68: Brentlinger A, Hunter JR. Perforation of the external iliac artery and ureter presenting as acute hemorrhagic cystitis after total hip replacement. Report of a case. J Bone Joint Surg [Am] 1987;69: Hennessy OF, Timmis JB, Allison DJ. Vascular compfications following hip replacement. Br J Radiol 1983;56: Lozman H, Robbins H. Injury to the superior gluteal artery as a complication of total hip replacement arthroplasty. A case report. J Bone Joint Surg [Am] 1983;65: Schmitt DD, Bandyk DF, Pequet AJ, Towne JB. Bacterial adherence to vascular prostheses. A determinant of graft infectivity. J Vase SURG 1986;3: Ryan W, Snyder W III, Bell T, Hunt J. Penetrating injuries of the iliac vessels. Early recognition and management. Am J Surg 1982;144:642-5.