Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 115-118

Acute limb ischemia secondary to popliteal artery thrombosis following total knee arthroplasty – Limb salvage by endovascular therapy


Department of Cardiology, ASRAM Medical College, Eluru, Andhra Pradesh, India

Date of Web Publication3-May-2018

Correspondence Address:
Dr. Iragavarapu Tammi Raju
Department of Cardiology, ASRAM Medical College, Eluru, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_72_17

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  Abstract 


Popliteal artery thrombosis is a very rare complication in total knee arthroplasty (TKA) surgery, which is more commonly caused by indirect mechanism than direct mechanism. If not treated early, it leads to limb amputation and rarely may lead to mortality. Although bypass grafting is the mainstay of treatment done in many cases, endovascular therapy is a potential alternative in acute setting for limb salvage. There are only few case reports of endovascular therapy in this setting. We report a case of acute limb ischemia due to popliteal artery thrombosis immediately after TKA which is salvaged by endovascular therapy with endoluminal thrombosuction and balloon inflation only.

Keywords: Acute limb ischemia, endovascular therapy, popliteal artery occlusion, total knee arthroplasty


How to cite this article:
Raju IT. Acute limb ischemia secondary to popliteal artery thrombosis following total knee arthroplasty – Limb salvage by endovascular therapy. Indian J Vasc Endovasc Surg 2018;5:115-8

How to cite this URL:
Raju IT. Acute limb ischemia secondary to popliteal artery thrombosis following total knee arthroplasty – Limb salvage by endovascular therapy. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2019 Oct 20];5:115-8. Available from: http://www.indjvascsurg.org/text.asp?2018/5/2/115/231853




  Introduction Top


Injury to the popliteal vessels during total knee arthroplasty (TKA) is rare, with a reported incidence of 0.03%–0.17%, which deserves attention as consequences may be disastrous, with mortality up to 7% and amputation up to 42%.[1],[2] Thrombotic occlusion is caused by an indirect mechanism such as joint manipulation or tourniquet application and presents as limb ischemia. Arterial laceration or transection is caused by a direct penetrating injury and may present as intraoperative hemorrhage, pseudoaneurysm, arteriovenous fistula, and recurrent hemarthrosis. Although bypass surgery is done in many cases as a preferred present-day approach, endovascular therapy can also be a potential therapy for limb salvage in this setting.


  Case Report Top


A 55-year-old female with no conventional risk factors for atherosclerosis was suffering from bilateral arthritis of knee joint from 10 years. She was on long-standing steroids for arthritis and underwent TKA in the standardized approach. The surgery was performed through a standard midline approach and a median parapatellar arthrotomy. The tourniquet time was around 90 min for each limb with 280 mmHg. Arthroplasty was done separately for two limbs with 1-week gap in between. Preoperative pulses were normal and status of immediate postoperative pulses were normal as evaluated by orthopedician. On the 1st postoperative day (POD), she developed numbness and pain in the left lower limb below the knee. Her left limb below the knee was cooler than the right limb and capillary refill time was prolonged. Neurologic examination revealed moderate weakness in the left lower limb distal muscles and moderate nerve paresthesia with no dorsiflexion or plantar flexion of the ankle joint. Vascular evaluation revealed a normal pulse on the right and a palpable left femoral pulse but no palpable pulse in the left popliteal, posterior tibial, and dorsalis pedis arteries. Arterial Doppler was done immediately which showed thrombus in the popliteal artery with no audible signals on both arterial and venous Doppler below the popliteal artery.

After evaluation, she was found to be in Rutherford IIb acute limb ischemia. We did a peripheral angiogram in digital subtraction angiography through the right femoral artery (antegrade approach) which showed thrombotic occlusion of the popliteal artery P1 segment [Figure 1]. There was no contrast extravasation. We considered various treatment modalities such as thrombectomy using Fogarty catheter and bypass grafting if necessary by vascular surgeon, intra-arterial thrombolysis, and balloon angioplasty with or without stenting.
Figure 1: Popliteal artery thrombotic total occlusion

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As our center is a peripheral center without vascular surgery team which is required in this situation, we planned for endovascular therapy after explaining the patient and attenders about the pros and cons. In view of postoperative situation <24 h, catheter-directed thrombolysis (CDT) into the surgical site may lead to hemorrhagic complications. Hence, we planned to go ahead with thrombosuction and balloon angioplasty if necessary. Intravenous heparin 5000U was given at the beginning of the endovascular therapy and additional doses thereafter keeping activated clotting time around 250 s. We exchanged 5 Fr Judkins Right (JR) with 6 Fr JR guiding catheter. Initially, we tried balanced middleweight (BMW) wire (0.014) to cross the lesion, but the wire buckled and could not cross the lesion. Then, we used a 0.018” Terumo wire (a straight tip made into j tip) which crossed the lesion, and then, we passed BMW wire across the lesion tracking the Terumo wire. Dottering of the lesion was done with a balloon. After dottering, there is faint opacification of popliteal artery. As we do not have mechanical thrombectomy/percutaneous aspiration devices, we did manual thrombus aspiration with the guiding catheter and the aspiration device (Thrombuster III, Kaneka Medics, Osaka, Japan, used for the coronary arteries) [Figure 2]. Check angiogram showed faint filling in the popliteal artery. Intra-arterial nitroglycerin was given, but no significant improvement in flow. There is no leak or evidence of rupture in popliteal artery. Hence, low-pressure balloon inflation was done with 4 × 23 balloon [Figure 2] (keeping a covered stent in standby). Thrombosuction was repeated. Check angiogram showed brisk flow in popliteal artery and slow filling of both tibial arteries [Figure 3]. Left great toe saturation was 98%. As the saturation was stable at 98%, we did not dilate further for fear of distal embolization.
Figure 2: Thrombosuction by Thrombuster catheter and ballooning by 4 × 23 balloon

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Figure 3: Filling of popliteal, anterior tibial, and posterior tibial arteries

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Postprocedure, she was given anticoagulation with low molecular weight heparin (LMWH) overlapping with Vitamin K antagonists (VKA), cilostazol, and antiplatelets. On the POD 2 numbness decreased, limb is warm and pulses were feebly felt in dorsalis pedis and posterior tibial arteries. On the POD 5, all pulses of the left lower limb were normally felt. Arterial Doppler showed good flow in both anterior and posterior tibial arteries. There is foot drop with no signs of ischemia. International normalized ratio was 2.5. LMWH was discontinued and she was discharged on VKA and splint for foot drop. Anticoagulation was discontinued after 6 months. Follow-up arterial Doppler of the left lower limb after 3, 6, and 9 months is normal with the triphasic flow in all the arteries.


  Discussion Top


The main complications of TKA include venous thromboembolism, nerve and blood vessel damage, infection, bleeding, wound complications, and orthopedic complications such as fracture and instability.[3] Popliteal artery injury and subsequent arterial thrombosis after TKA is rare, its incidence has been reported to be 0.03%–0.17%.[1],[2] The proximity of the popliteal artery to the posterior tibial surface renders it vulnerable to injury. Most of postoperative vascular injuries are caused by tourniquet application which result in damage of calcified vessels leading to thrombosis or embolization of calcified plaques and other causes include joint manipulation, dislocation, intrajoint protrusion of cement or screws, or excessive retraction [4],[5] When the artery is damaged by blunt injury, platelet thrombus formation is induced by membrane damage, intimal flap, flexion injury of internal media, intramural hemorrhage, and spasm.[6] The moments of TKA surgical procedure during which popliteal artery can be damaged are (1) at the tibial cut, (2) at the posterior cut of the femoral condyles, (3) during the application of retractor for anterior dislocation of the tibia, and (4) during placement of the knee in hyperextension after the cuts and before the application of the hardware.[7] In fact, chronic lower extremity arterial insufficiency is estimated to exist in 2% of patients undergoing TKA.[8] Parvizi et al. in a series of 11 vascular complications after TKA found that in 9 of them the popliteal artery was thrombozed due to an indirect mechanism. Some authors recommend that in patients with ankle/brachial index <0.3 arthroplasty should be performed without the application of a tourniquet.[9]

Early diagnosis and accurate initial therapy are essential for ischemic limb salvage. The presentation is often acute with serious consequences such as limb loss and mortality as mentioned above if it is not repaired early. It is generally recognized that 4–6 h after the onset is the golden time of reperfusion therapy for acute arterial occlusion. In a report by Green and Allen, 86% of the patients required amputation if the surgery was performed more than 8 h after interruption of popliteal arterial blood flow in situ ations of arterial injury due to trauma and dislocation of knee.[10] Management of popliteal artery thrombosis requires urgent revascularization either by vascular surgery or endovascular therapy. A previous study reported that thrombectomy for revascularization alone was insufficient and 71% of patients required a lower extremity bypass graft (Above-knee to below-knee popliteal artery saphenous vein bypass grafting). In this study, 33% cases had preexisting atherosclerotic disease in injured segment.[11]

In our case, we have considered the pros and cons of various treatment modalities such as thrombectomy using Fogarty catheter by vascular surgeon, intra-arterial CDT, balloon angioplasty with or without stenting [Table 1]. As this patient was a postoperative case, we avoided CDT at the operative site, as it is a relative major contraindication.[12] Repeated surgical intervention with above-knee to below-knee popliteal artery saphenous vein bypass grafting (if necessary) by vascular surgeon is not available at our center and shifting to a nearby higher center may take long time which endangers the limb further. Hence, we planned for endovascular therapy. As initial thrombosuction showed partial filling of popliteal artery without any evidence of rupture, we did low pressure balloon angioplasty. After ballooning and repeat thrombosuction, there is good filling of popliteal and slow filling of both tibial arteries with good saturation of left great toe (98%). Compartment syndrome (more common after thrombolytic therapy)[13] and distal embolization are the two important complications to be taken care of after reperfusion of acute limb ischemia. Even though we did not thrombolyze the patient, we kept a close watch on the development of symptoms till the discharge of patient and also in follow-up. However, the patient did not had any signs and symptoms suggestive of compartment syndrome. Slow flow can be due to embolization by dottering or ballooning which leads to occlusion of the distal vessels, which can be managed with continuing thrombolytic infusion with a microcatheter or by microtibial balloon embolectomy.[14] But in our case, there was no distal total occlusion and saturation was persistently around 98%, hence we have not given any thrombolytic therapy keeping in view of postoperative status and stopped the procedure at this stage avoiding further dilatation for more better flow which may further impede the flow. She was discharged on appropriate anticoagulation (VKA) regimen and cilostazol. She had foot drop which could be due to damage of peroneal nerve because of ischemia and hence recovered lately with physiotherapy and splint support with minimal residual deficit. Her left lower limb arteries were well felt on follow-up after 9 months also.
Table 1: Pros and Cons of various treatment modalities in acute limb ischaemia after total knee arthroplasty

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Endovascular therapy has been increasingly performed for the management of acute arterial occlusions, particularly in the lower limb in the recent days. However, a considerably higher restenosis rate is one of the major concerns related to balloon angioplasty and stenting in this approach. However, it would be unrealistic to assume these limitations of endovascular angioplasty in the elective setting should limit its utility in the emergency setting. Because this minimally invasive revascularization has significant benefits in the emergency setting in the places where there is no vascular surgery, such as in our case. There are only a few case reports regarding balloon angioplasty in this situation.[15] Supera stent is the Food and Drug Administration (FDA) approved stent for deployment in the chronic diseases of popliteal artery because of its very low risk of fracture.[16],[17] There is no evidence or case reports of its use in acute setting, hence we used clinical judgment in not deploying the stent as it is a thrombotic lesion and also the implant may lead to stent crush and disastrous consequences.

Preoperative arterial Doppler was not done for this patient since the patient had good peripheral pulsations. Retrospectively, we thought the cause of thrombosis might be due to early atherosclerotic plaque rupture due to long-standing steroid usage for pain relief, though there is no evidence on imaging.[18] Hence, after analyzing the case, we were in sighted about the need for arterial Doppler in the cases who are at risk of atherosclerosis which may add on the cost of TKA but worth outweighing the risk of vascular complication postoperatively. Measuring ankle brachial pressure index can be an easy, economical, and an objective preoperative vascular study for atherosclerosis but may give disfigured values in inelastic vessels of patients with diabetes.[19]


  Conclusion Top


Although the technique of endovascular intervention is promising, long-term outcome and complication rates have not been clarified. Given the relative shortness of time from the onset of arterial occlusion to complete revascularization and taking bleeding complications postsurgery into consideration, endovascular treatment should be considered as a treatment option for popliteal artery occlusion after TKA. Endovascular therapy with balloon angioplasty needs further evaluation as an alternative therapy in acute limb ischemia secondary to postoperative arterial occlusion in patients with prohibitive surgical risks.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Mahmood A, Hardy R, Garnham A, Samman Y, Sintler M, Smith SR, et al. Microtibial embolectomy. Eur J Vasc Endovasc Surg 2003;25:35-9.  Back to cited text no. 14
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Imanaka T, Fujii K, Fukunaga M. A case of acute thrombotic occlusion of the popliteal artery occurring immediately after the total knee arthroplasty recanalized by ballooning alone. J Cardiol Cases 2013;8:190-2.  Back to cited text no. 15
    
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Werner M, Paetzold A, Banning-Eichenseer U, Scheinert S, Piorkowski M, Ulrich M, et al. Treatment of complex atherosclerotic femoropopliteal artery disease with a self-expanding interwoven nitinol stent: Midterm results from the Leipzig SUPERA 500 registry. EuroIntervention 2014;10:861-8.  Back to cited text no. 16
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Willenberg T, Diehm N, Zwahlen M, Kalka C, Do DD, Gretener S, et al. Impact of long-term corticosteroid therapy on the distribution pattern of lower limb atherosclerosis. Eur J Vasc Endovasc Surg 2010;39:441-6.  Back to cited text no. 18
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