Guo动脉损伤诊治中的失误

目的：分析Guo动脉损伤诊治中的失误及其原因，以预防失误的发生，方法：对25例Guo动脉损伤诊治过程中存在失误的12例作回顾性分析，结果：2例因延误诊断，1例因延误手术时机，导致肢体缺血时间过长而一期截肢；由于清创不彻底，引起术后软组织坏死感染而被迫二期截肢者3例，因血管处理技术不当需再次血管修复建者3例，另外3例因延误筋膜切开减压或切开减压不彻底，造成缺血性肌挛缩，结论：及早正确论断，及时修复血管，手术清创彻底，血管处理技术得当，早期彻底的筋膜间隙切开减压是处理Guo动脉损伤损伤，提高率，降低截肢率的重要因素。     

两种骨筋膜室减压方法治疗腘动脉延误伤的比较

常规小腿骨筋膜室切开减压虽能达到减压目的，但并发症多，伤口愈合时间长。现就我院采用的小腿坏死肌肉彻底切除、工期缝合皮肤的方法与常规切开方法对腘动脉延误伤的治疗效果和并发症进行回顾性比较。     

35例腘动脉损伤的治疗体会

[目的]探讨腘动脉损伤的诊断及处理原则。[方法]对于35例腘动脉损伤病人，30例行腘动脉Ⅰ期修复，合并腘静脉及神经损伤的同时处理，损伤至动脉通血6h以上给予小腿筋膜室切开，检查渗出液性质，电刺激了解肌肉收缩情况。[结果]受伤至动脉通血6h以内及6h以上给予小腿筋膜室切开电刺激肌肉收缩良好，组织水肿渗出较轻，术后恢复满意；电刺激肌肉收缩差，组织水肿重，但渗出液较清淡，部分发生缺血性肌挛缩，肌肉发暗，电刺激无反应，并有血性渗出5例，3例Ⅰ期截肢，2例Ⅱ期截肢；2例因外院转来时皮肤已部分坏死，并发肾功能不全行Ⅰ期截肢。[结论]仔细的临床检查是早期诊断肢体血管损伤的重要手段，及时恢复循环是保肢关键，6h以上小腿筋膜室切开，不仅可以预防小腿筋膜室综合征的发生，而且通过电刺激肌肉收缩情况及组织水肿渗出情况，可以对预后给予判断，肌肉发暗，刺激无反应，并且有血性渗出，腘动脉修复价值不大，应该截肢。     

闭合性Guo动脉损伤11例

目的：总结闭合性Guo动脉损伤的诊治经验。方法：1983－2000年共11例闭合性Guo动脉损伤患者。肢体血循环重建时间最短3．5h,最长27h平均9h。结果：8h以内重建血循环5例肢体循环功能恢复功能,8－10h2例遗有小腿缺血性挛缩,超过10h4例中有1例小腿肌肉坏死,3例截肢。截肢率为27％,总病残率达55％。结论：Guo动脉损伤应在6－8h内进行修复,超过这一时限病残率及截肢率均明显上升。延误诊断是导致闭合性Guo动脉损伤后截肢率居高不下的主要因素。     

小腿严重开放性损伤保肢术后远期疗效分析

目的 分析小腿严重开放性损伤施行显微外科保肢手术后远期功能恢复情况。方法 根据Gustilo和Anderson分类，临床应用28例中ⅢB型20例，ⅢC型8例，分别采用游离皮瓣、组合皮瓣、桥式皮瓣、携带骨瓣的肌皮瓣修复软组织及骨缺损。其中一期修复9例，二期修复19例。有6例同时行胫前或胫后动脉吻合。胫骨骨折分别采用带锁髓内钉、钢板、交叉针、外固定支架等固定。按照Punor标准，对保肢后的小腿功能进行评定。结果 远期随访时间1．5～7．0年，组织皮瓣移植全部成活，软组织缺损和骨缺损全部修复，骨折愈合，关节及肢体功能正常15例关节及功能基本正常8例，关节及肢体功能差的5例。最终因骨髓炎或其他原因截肢7例。结论 显微外科技术的应用可明显提高小腿开放性损伤的保肢成功率，对伴有足踝部软组织严重损伤，或小腿肌群已出现坏死，或血管损伤后肢体缺血时间过长已出现血栓，或胫神经损伤难以恢复的病例不应再施行保肢手术。     

保肢治疗创伤性腘血管损伤

目的 探讨保肢治疗创伤性腘血管损伤的疗效。方法 对83例腘血管损伤患者采用保肢治疗。直接吻合修复腘血管35例(直接吻合腘动脉9例，直接吻合腘静脉4例，直接吻合腘动脉及静脉22例);大隐静脉桥接修复腘血管48例(桥接腘动脉13例，桥接腘静脉2例，直接吻合腘动脉+桥接腘静脉13例，桥接腘动脉+直接吻合腘静脉10例，桥接腘静脉及动脉10例),移植长度3～30(6.8±4.2) cm。结果 住院时间10～244 (62.4±16.3) d。82例保肢成功，保肢率98.8%;1例行一期截肢术。术后未发生死亡、严重肝肾功能损伤。术后数字减影血管造影或B超检查腘血管修复均全部血流通畅。1例单纯腘动脉损伤患者术后10 d切口无感染，出院时未拆除缝线。其余82例一期创面愈合59例；二期创面愈合17例(扩创缝合后愈合4例，扩创皮片移植3例，扩创后股前外侧皮瓣带蒂转移修复2例，游离股前外侧皮瓣修复8例);三期及以上创面愈合6例。住院期间除1例截肢者未保留膝关节外，其余82例膝关节均恢复部分主、被动屈伸功能。出院时，踝关节及跖趾关节跖屈功能恢复62例，背伸功能恢复20例；趾感觉恢复至S2级别以上81例，恢复至...     

小腿闭合性动脉损伤诊疗体会

目的探讨小腿闭合性动脉损伤的术前诊断和治疗。方法自2002年1月至2009年6月,为17例21肢小腿闭合性动脉损伤的患者行血管探杏吻合,其中4例无骨折脱位的患者术前行B超检查,17例均行多普勒血流探测仪检查。术中发现胴动脉断裂7例10肢．胭动脉栓塞5例6肢,咽动脉分叉处断裂2例,栓塞1例,胫前及胫后均断裂2例。12例14肢探盒后直接吻合．5例7肢行静脉移植。小腿缺血至冉通血时间3～12h,平均7．jh。血管吻合后全部行筋膜室预防性切开。结果11例14肢体成活良好,筋膜事减压处Ⅱ期植皮成活;4例5肢术后皮肤部分坏死,行皮瓣修复成活;1例术后血管广泛栓寨,肢体坏死。给予截肢;1例术后出现持续高热,急性肾功能衰竭,给予截肢。结论小腿闭合性血管损伤的治疗重点在早期诊断．手术成功的关键在于尽快恢复肢体供血,术后注意防止肾功能衰竭。     

闭合性腘动脉损伤的诊断与治疗

目的探讨闭合性腘动脉损伤的诊断与治疗。方法收治26例闭合性腘动脉损伤患者,13例采用彩色多普勒超声检查明确血管损伤部位,8例DSA检查明确损伤部位,5例直接手术探查。11例行断端吻合,14例大隐静脉移植,25例均行预防性小腿切开减张。术后应用激素、甘露醇等治疗。结果 22例15h内手术者均成功保肢,并且功能良好,3例24～36h内手术者2例保肢成功,1例截肢,72h明确诊断者肢体坏死直接行截肢手术。结论闭合性腘动脉损伤只要肢体不出现坏死,一旦确诊均应尽早修复血管以求保肢可能。     

腘动脉下段分叉部损伤的早期修复

文章报告了9例腘动脉下段分叉部损伤的治疗结果。除1例为土枪霰弹伤外,其余均为钝性暴力所致。早期截肢2例,后期截肢1例,截肢率33.3％。存活肢体中1例明显小腿缺血性挛缩,1例轻度小腿缺血性挛缩,4例功能基本正常。腘动脉下段分叉部损伤具有血管损伤范围广,远端缺血严重,常伴有骨、关节及皮肤、肌肉、神经等组织损伤等特点。尽早手术,同时重建胫前、胫后动脉血循环,尽量修复及保护伤肢静脉,常规行小腿深筋膜切开减压,骨折、脱位同时予以修复并可靠固定是提高治疗效果的必要措施。     

外固定架在膝及小腿血管损伤修复中的应用

 目的 探讨外固定架在膝、小腿血管损伤中的应用效果。方法 回顾性分析2004年5月至2010年10月应用外固定架治疗的208例（234侧）膝及小腿血管损伤患者资料,男192例（217侧）,女16例（17侧）;年龄14~67岁,平均39.6岁。损伤血管：腘动脉84例（86侧）,胫前动脉36例（46侧）,胫后动脉41例（49侧）,胫前后动脉47例（53侧）。伤肢远端完全缺血129例（141侧）,不完全缺血79例（93侧）。所有患者均行急诊手术。采用AO通用外固定架164例,创生镶嵌式外固定架37例,组合式外固定器7例。血管采用直接或大隐静脉桥接吻合。创面采用一期包扎、植皮、皮瓣移植和VSD负压吸引治疗。结果 194例保肢成功, 14例因伤肢毁损严重及全身情况差于术后2~4 d截肢。术后43例患者创面自行愈合,127例二期行手术清创植皮或皮瓣治疗,24例一期行游离皮片或皮瓣移植覆盖。148例获得8个月~3年的完整随访,其中6例因患肢功能严重受限且伴发骨髓炎而自愿要求截肢。拆除外固定架时间1~18个月,平均7.2个月。102例骨折获得愈合,时间为3~13个月,平均5.6个月;40例出现骨折不愈合、骨缺损,行骨折内固定+植骨术或骨段滑移术,骨折均愈合。结论 外固定架具有固定可靠,可在短时间内复位骨折,减少肢体缺血时间等优点,利于膝、小腿血管损伤的修复。     

Blunt popliteal artery trauma: one hundred consecutive injuries

An institutional experience with 100 consecutive blunt popliteal artery injuries over a 20-year period was reviewed. The overall amputation rate was 15%; however, during the past 7 years this has declined from 23% to 6%. Minimizing delay in the revascularization of ischemic limbs, routine systemic heparinization, primary arterial repair when possible, repair of popliteal venous injuries, aggressive wound debridement, and early soft tissue coverage have contributed to improved limb salvage during the 1980s.     

Popliteal artery trauma. Systemic anticoagulation and intraoperative thrombolysis improves limb salvage.

OBJECTIVE: This study was conducted to evaluate those factors associated with popliteal artery injury that influence amputation, with emphasis placed on those that the surgeon can control. SUMMARY BACKGROUND DATA: Generally accepted factors impacting amputation after popliteal artery injury include blunt trauma, prolonged ischemic times, musculoskeletal injuries, and venous disruption. Amputation ultimately results from microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. METHODS: Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic times) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studied. Severity of extremity injury was quantitated by the Mangled Extremity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). After univariate analysis, logistic regression analysis was performed to identify the independent risk factors for limb loss. RESULTS: One hundred two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating trauma. There were 25 amputations (25%; 11 primary and 14 secondary). Patients with totally ischemic extremities (no palpable or Doppler pulse) more likely were to be amputated (31% vs. 13%; p < 0.04). All requiring primary amputations had severe soft tissue injury and three had posterior tibial nerve transection; the average MESS was 7.6. Logistic regression analysis identified independent factors associated with secondary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MESS (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no complications with either heparin or urokinase. CONCLUSIONS: Minimizing ischemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputation. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvage. The authors recommend the use of these agents to maximize limb salvage in association with repair of popliteal artery injuries.     

Surgical treatment of popliteal artery injuries.

Twenty-seven patients with injury to the popliteal artery and associated structures were operated on during the past 15 years. There was no operative or hospital deaths. The limb salvage rate was 56%; the amputation rate was 44%. Those patients with penetrating injuries were found to have a much better salvage rate (85%) than those with blunt trauma (29%). Preoperative arteriography and immediate repair of the popliteal artery by either end-to-end anastomosis or a vein graft is advocated for these patients. Popliteal vein injuries should be repaired when possible by lateral suture or end-to-end anastomosis. Fasciotomy is advocated on a selected basis.     

Peripheral vascular injuries associated with falls from heights

Peripheral vascular injuries associated with falls from heights are uncommon. We report our 15-year experience with ten such injuries in 230 patients who jumped or fell from heights of at least 3 stories. These injuries occurred in seven patients and included four popliteal artery thromboses or disruptions, two popliteal vein disruptions, one traumatic tibial arteriovenous fistula, one subclavian artery pseudoaneurysm, one radial artery transection, and one lacerated medial circumflex artery. Although the mechanism of injury is multifactorial, all were associated with significant orthopedic trauma. Early recognition of vascular injuries, minimization of ischemic time, completion arteriography, venous repair, and liberal use of fasciotomy are emphasized to maximize limb salvage.     

Popliteal artery trauma: Update and recent advances in management

Management of vascular trauma has been standardized in the past two decades with a significant increase in limb salvage, but trauma to the popliteal artery still remains a challenge. A seven-year experience at San Bernardino County Medical Center was comprised of 20 popliteal artery injuries in 19 patients. Thirteen injuries (65%) were from blunt trauma, four injuries (20%) were from gunshot wounds, two injuries (10%) were from close-range shotgun blasts, and one (5%) was from a stab wound. Limb salvage was 100%. Liberal use of vein interposition grafts, routine intraoperative postreconstructive arteriogram, recognition of compartmental hypertension, and performance of fasciotomy were important steps taken to ensure a high limb salvage rate. Our standard technique at this time consists of repair of the artery with simultaneous repair of the dislocated knee and internal fixation of fractures.     

Popliteal artery injuries in an urban trauma center with a rural catchment area: do delays in definitive treatment affect amputation?

Extended length of time from injury to definitive vascular repair is considered to be a predictor of amputation in patients with popliteal artery injuries. In an urban trauma center with a rural catchment area, logistical issues frequently result in treatment delays, which may affect limb salvage after vascular trauma. We examined how known risk factors for amputation after popliteal trauma are affected in a more rural environment, where patients often experience delays in definitive surgical treatment. All adult patients admitted to the Level I trauma center, the University of Mississippi Medical Center, with a popliteal artery injury between January 2000 and December of 2007 were identified. Demographic information management and outcome data were collected. Body mass index, mangled extremity severity score (MESS), Guistilo open fracture score, injury severity score, and time from injury to vascular repair were examined. Fifty-one patients with popliteal artery injuries (53% blunt and 47% penetrating) were identified, all undergoing operative repair. There were nine amputations (17.6%) and one death. Patients requiring amputation had a higher MESS, 7.8 versus 5.3 (P < 0.01), and length of stay, 43 versus 15 days (P < 0.01), compared with those with successful limb salvage. Body mass index, injury severity score, Guistilo open fracture score, or time from injury to repair were not different between the two groups. Patients with a blunt mechanism of injury had a slightly higher amputation rate compared with those with penetrating trauma, 25.9 per cent versus 8.3 per cent (P = non significant). MESS, though not perfect, is the best predictor of amputation in patients with popliteal artery injuries. Morbid obesity is not a significant predictor for amputation in patients with popliteal artery injuries. Time from injury to repair of greater than 6 hours was not predictive of amputation. This study further demonstrates that a single scoring system should be used with caution when determining the need for lower extremity amputation.     

Popliteal vascular injuries and war: are Beirut and New Orleans similar?

Trauma to the lower extremity associated with fracture and vascular injury has a high reported incidence of limb loss. This study reviews and contrasts the experience at Tulane University affiliated hospitals (TU) and the American University of Beirut (AUB) (1980 to 1984), both of which are surrounded by hostile action. Seventy-six male patients (28--AUB, 48--TU) with an average age of 21.2 (TU) and 24.4 (AUB) years (range, 17 to 42) presented with popliteal artery injuries with (34 [14--AUB; 20--TU] ) and without (42 [14--AUB; 28--TU]) associated fractures. All patients were clinically evaluated, angiogrammed, begun on cephalosporin antibiotics, and operated upon. Fractures were treated with extraskeletal fixation or splinting. Time of initiation of operative therapy varied from less than one to greater than 12 hours. When necessary, contralateral limb reversed saphenous vein was used as an interposition graft. Fasciotomies were done for popliteal artery injuries with greater than 6 hours' ischemic time, and combined popliteal artery and popliteal vein injuries. Nine limbs of 76 at risk were amputated: 5/34 (2/14--AUB; 3/20--TU) with popliteal injuries and fractures, and 4/42 (1/14--AUB; 3/28--TU) with popliteal injuries and without fractures. Five of the amputated limbs had initiation of therapy at greater than 12 hours; three had initiation of therapy at greater than 8 hours. Good communication between surgeons, prompt fracture reduction, antibiotics, angiography, and total repair of the vascular injury resulted in limb salvage in 30/40 patients with popliteal artery injury and fracture, and in 39/42 patients with popliteal artery injury without fracture.(ABSTRACT TRUNCATED AT 250 WORDS)     

Popliteal artery aneurysms: a comparison of outcomes in elective versus emergent repair

OBJECTIVE: The purpose of this study was to assess and compare outcomes of elective versus emergent operative repair of popliteal artery aneurysms. DESIGN: A retrospective analysis of a prospectively recorded vascular surgery database from June 1992 to December 2002 was performed with chart review.Main outcome measures Patient survival, limb salvage, and graft patency were evaluated. RESULTS: Fifty-one popliteal artery aneurysms were repaired in 39 patients, all male and ranging in age from 18 to 87 years (mean 67.1). Mean follow-up was 47.8 months. Repair was elective in 37 (72.5%) and emergent in 14 (27.5%) limbs, 13 with acute ischemia and one with aneurysm rupture. Thrombolytic therapy was utilized in four ischemic limbs with no suitable bypass target vessel identified on initial arteriogram. Outflow vessels included the popliteal artery in 22 (43.1%) and infrapopliteal vessels in 29 (56.9%) limbs. Cardiac morbidity and 30-day mortality rates were 0%. Overall primary patency, secondary patency, limb salvage, and actuarial survival were 95.6%, 100%, 98.0%, and 98.0% at 1 year and 85.1%, 96.9%, 98.0%, and 83.8% at 5 years, respectively. Bypass graft redo or revision was performed for stenosis in one and occlusion in four limbs. Two amputations were performed at 6 days and 63.6 months after initial aneurysm repair. No difference was noted between elective and emergent groups with regard to patency, limb salvage, or survival (P >.26), and no association between the number of identified target vessels and limb salvage or patency was demonstrated (P =.12). CONCLUSION: In our experience, the outcome of the popliteal artery aneurysm repair was comparable in the emergent and elective settings. Aggressive tibial reconstruction plays a crucial role in the treatment of popliteal artery aneurysms, especially in those presenting with acute limb ischemia. Thrombolytic therapy is infrequently required in the acute setting, although it may be useful in patients with no identifiable outflow target vessel on initial arteriogram.     

晚期腘动脉损伤的围手术期治疗

目的　探讨晚期动脉损伤保肢治疗的围手术期处理方法 ,提高保肢率。方法　对 32例晚期动脉损伤进行保肢治疗者 ,应用术前评估患者的病情 ,术后防止感染和急性肾功能衰竭的方法 ,观察保肢治疗的效果。结果　 32例晚期动脉损伤中 ,2 8例保肢成功 ,保肢率 88%。未发生死亡 ,无急性肾功能衰竭。保肢成功者经进一步处理后恢复行走功能。结论　对晚期动脉损伤的救治 ,术前正确的对患者伤情进行评估 ,及时调整全身状态 ,应用激素减轻机体再灌注损伤 ,术后控制感染和防止急性肾功能衰竭 ,可以提高肢体成活率     

Recanalization of an Occluded Popliteal Artery following Posterior Knee Dislocation

Posterior knee dislocation results in popliteal artery injury in up to one-third of cases. Prompt recognition and treatment of arterial injury is essential for limb salvage. We report a case of complete occlusion of the popliteal artery following posterior knee dislocation treated with saphenous vein bypass without exclusion of the injured arterial segment. Follow-up duplex scanning demonstrated a patent vein graft and a patent ipsilateral popliteal artery. This report suggests that, in some instances, a traumatically occluded popliteal artery may recanalize, and that revascularization with a bypass graft may be the preferred method of repair, particularly in young patients.