Acute Surgical Management of Vascular Injuries in Hip and Knee Arthroplasties

Christopher M. Melnic, MD; Marilyn Heng, MD, MPH, FRCSC; Santiago A. Lozano-Calderon, MD, PhD

Disclosures

J Am Acad Orthop Surg. 2020;28(21):874-883. 

In This Article

Acute and Initial Management and Assessment

Two key pillars are noted for successful management of acute surgical complications of major arterial or venous bleeding. The first is to remain calm but diligent to not lose control of the situation, the room, and the staff. Second, clear channels of communication should exist to work jointly with anesthesia, nursing, and scrub technician team members. Of note, before any hip or knee procedure, we recommend that a detailed vascular examination be done in the preoperative holding area noting the presence and quality of the dorsalis pedis and posterior tibialis pulses. This allows for appropriate postoperative comparison.

Once a vascular injury is recognized, the initial step is to apply firm pressure in the area of bleeding. If the vascular injury occurs while drilling a screw hole, a screw should be placed immediately. Simultaneous communication with anesthesia is essential to confirm patient stability for hemodynamic status, and to ensure whether appropriate peripheral venous access is present and that blood and/or blood products are available because of the imminent need of transfusion. In the setting in which a vascular surgeon is available, a STAT intraoperative consult should be called. If the patient is stable and appropriate equipment (Table 1) and nursing/scrub tech readiness is available, it is reasonable to explore and assess the extent of the injury (complete or partial laceration) and its nature (venous, arterial, or both). If the lesion occurred during a TKA and a tourniquet is not being used, the application of a sterile tourniquet, while awaiting the vascular surgeon arrival to the room, will assist in better local control of the bleeding if it is arterial in nature. If the bleeding is of venous origin, a sterile tourniquet may worsen the amount of bleeding. Therefore, our recommendation is to assess the type of bleeding rather than applying a tourniquet in a reflexive manner. Finally, the time on injury or application of the tourniquet should be recorded because all the members of the team, especially the vascular surgeon, need to be aware of the limb ischemia time. Ideally, a visible place to everyone such as a white board in the room is recommended. If the facility does not have a vascular surgeon readily available, the application of a compression dressing in a sterile fashion without or without sterile tourniquet with immediate transfer to a tertiary level facility should be arranged for definitive management. A good clinical practice is to write on the patient's dressing the ischemia start time and to contact directly the receiving team to discuss information necessary for patient handover. The same principles apply for vascular injury during THA except for the application of a tourniquet for obvious anatomic reasons.

In some cases, these measures are not sufficient to obtain control of the bleeding and hemodynamically stabilize the patient. In this scenario, the standard approach is to gain proximal and distal control of the vessels, prioritizing proximal control if the injury is arterial and distal control if the injury is venous. Achieving vascular control depends on the surgeon's background in training and the level of comfort with these surgical techniques. The following is a review and discussion of these surgical techniques.

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