Native vs. synthetic grafts in lower extremity vascular trauma: Lessons from two rural case presentations

Abstract

Introduction

Trauma to the extremities is a common injury that demands a comprehensive evaluation of vascular structures. Prompt identification and timely intervention improve clinical outcomes; severe injuries frequently lead to complications and potential limb loss. Revascularization delays greater than 8 h post-injury markedly increase amputation risk. This report describes successful management strategies for lower extremity vascular injuries by comparing native and synthetic graft applications.

Case presentations

Two patients with lower extremity vascular injuries are detailed. Case 1: a 54-year-old female with blunt trauma to the right leg that resulted in femoropopliteal occlusion successfully underwent a saphenous vein graft (SVG) bypass. Case 2: a 28-year-old female presented 27 h post-road traffic collision with a left thigh injury and total transection of the superficial femoral artery. Revascularization was achieved via femoropopliteal extra-anatomic bypass using an expanded polytetrafluoroethylene (ePTFE) vascular graft. Both patients were discharged 2 weeks post-surgery with favorable outcomes.

Clinical discussion

Case 1 emphasizes the importance of prompt diagnosis and intervention. Case 2 demonstrates limb salvage potential despite delayed presentation. The choice between autologous SVGs (superior biocompatibility, long-term patency) and synthetic ePTFE grafts (readily available, higher re-occlusion risk) dictates postoperative management, particularly in terms of anticoagulation therapy.

Conclusions

This report illustrates successful open surgical bypasses for femoropopliteal occlusion and ruptured superficial femoral artery. It underscores the importance of timely intervention and differing postoperative management methods for autologous SVGs and synthetic ePTFE grafts. An algorithmic approach to diagnosis and treatment, alongside surgeon comprehension of therapeutic options, is paramount for optimal outcomes.

Highlights

• •Timely revascularization is critical for favorable limb salvage outcomes.
• •Native vein and synthetic grafts are viable options in vascular trauma.
• •Graft choice dictates the specific postoperative anticoagulation strategy.
• •Successful limb salvage is possible even with delayed presentation.

1. Introduction

Trauma to the extremities is a common injury in surgical interventions and emergency department settings and has considerable societal health repercussions [1]. Accurate assessment of these injuries requires a comprehensive evaluation of all functional components of the affected limb (vascular structures, soft tissues, bones, and nerves), both in isolation and in combination [2]. A high index of suspicion for an associated vascular injury is crucial, where the presence of “hard signs,” such as pulsatile hemorrhage or pulselessness, necessitates immediate surgical intervention [3]. Common trauma mechanisms include penetrating and blunt strikes, high-energy and low-energy impacts, crushing forces, and bending or twisting movements [4,5].

Complications associated with severe injuries are frequently observed, and prompt identification and intervention are crucial for improving clinical outcomes. Serious injuries to the lower extremities can compromise functional outcomes and precipitate chronic infection, degenerative joint disease, abnormal gait, potential limb loss, and prolonged pain [4,5]. A delayed diagnosis resulting from the oversight of a hard sign can lead to limb loss. The timing of revascularization is critical, as delays beyond 8 h post-injury present a greater than 80 % amputation risk, whereas vascular reconstructions performed within 8 h post-injury have excellent limb salvage rates [6].

Vascular trauma constitutes approximately 3 % of traumatic injuries. Injuries to the vasculature of the extremities may occur as isolated events or concomitantly with significant trauma and represent 1–2 % of emergency department (ED) patients and nearly 50 % of arterial injuries. The lower extremities are more often afflicted than the upper extremities within the adult population [7]. These traumas affect all vessels distal to the iliofemoral junction, including the common femoral artery, superficial femoral artery, femoral vein, greater saphenous vein, and tibial artery [1]. In the lower extremity, the popliteal artery and superficial femoral artery are most frequently injured in blunt and penetrating traumas, respectively [8]. Clinically apparent distal ischemia or pulse deficit is noted in more than 90 % of femoral arterial injuries and most blunt popliteal injuries, and the duration of ischemia consistently predicts amputation [9]. Primary repair or anastomosis of popliteal injuries is not typically possible, and an interposition graft is necessary. Autologous saphenous vein grafts (SVGs) and synthetic expanded polytetrafluoroethylene (ePTFE) grafts have distinct benefits and limitations for vascular interventions. Autologous SVGs have superior biocompatibility (reducing the risk of thrombosis and intimal hyperplasia) and long-term patency rates compared to synthetic options [10,11]. Synthetic ePTFE grafts can be manufactured and are readily available for patients without suitable autologous vessels; however, they have a higher failure rate due to rapid re-occlusion caused by intimal hyperplasia, especially in small-diameter applications [12].

This case report illustrates the successful performance of open surgical bypass for both femoropopliteal occlusion and ruptured superficial femoral artery by presenting a comparative analysis of native and synthetic grafts for managing lower extremity vascular injuries in a rural setting. The results underscore the critical need for meticulous monitoring of anticoagulation therapy following revascularization and the differing postoperative management strategies for autologous SVGs and synthetic ePTFE grafts. Furthermore, the importance of an algorithmic approach to diagnosis and treatment is emphasized, alongside the necessity for surgeons to comprehend the limitations and benefits of available therapeutic options. This case report is presented according to the 2025 SCARE guidelines [13].

2. Case presentation

2.1. Case report 1

A 54-year-old female presented to the accident and emergency department with a painful right leg that became considerably more aggravated 2 h after immediate reduction and debridement were performed by the orthopedic team. This initial intervention related to an open lacerated wound at the right popliteal area and dislocation of the right femur and tibia fibula joint, which were acquired by contact with a falling cabinet that the patient was cleaning underneath while in a squatted position.

Upon physical examination, sutured lacerated wounds measuring 8 × 9 cm with no active bleeding were noted, vital signs were normal, and a Glasgow Coma Scale of 15 was reported. Despite substantial distracting injuries, ED practitioners promptly recognized the absence of peripheral pulses in the right foot and notified the on-call vascular team. Clinical evaluation revealed normal pulsations within the left lower extremity and notably reduced pulsations in the right popliteal, posterior tibial, and anterior tibial arteries. Ankle-Brachial Index (ABI) values of 0.4 and 1.0 were recorded for the right and left legs, respectively, with the right accompanied by an incomplete sensorimotor deficit below an unstable knee joint. A CT Angiogram (CTA) was performed, delineating the arterial vascular pathology and confirming deep venous thrombus (Fig. 1).

Fig. 1.

A CT Angiogram showed deep venous thrombus occlusion from right popliteal region 1 to popliteal region 3 along 12 cm (arrow).

Following a case evaluation involving vascular surgery, trauma and orthopedics, radiology, and anesthesiology, informed consent was received, and emergency surgical revascularization of the right lower extremity was performed. The contralateral great saphenous vein (GSV) was identified and delineated via ultrasound for use as a vascular conduit. Under general anesthesia with prophylactic intravenous ceftriaxone (1 g), a urinary catheter was placed, and the patient was positioned supine. Both lower extremities were prepared using 2 % alcoholic chlorhexidine gluconate.

The standard medial approach used for suprageniculate popliteal exposure involved a longitudinal skin incision along the anterior margin of the sartorius muscle in the distal third of the thigh. The popliteal artery was exposed by retracting the vastus medialis and sartorius muscles anteriorly and posteriorly, respectively, to allow visualization of the neurovascular bundle. For infrageniculate popliteal exposure of the anterior tibial artery, a longitudinal skin incision was made 2 fingerbreadths lateral to the anterior edge of the tibia and was deepened between the tibialis anterior and extensor hallucis longus muscles to expose the artery superficial to the interosseus membrane. The approximately 25 cm long contralateral GSV was harvested and used as a bypass from the superficial femoral artery (SFA) to the anterior tibial artery using a Prolene 6.0 suture (Fig. 2). Inflow and backflow were rigorously evaluated and purged before final patch anastomosis. Upon bypass completion, a triphasic anterior tibial artery signal was present.

Fig. 2.

Bypass starting from the right distal superficial femoral artery (SFA) (white arrow) to the right anterior tibial artery (ATA) using a contralateral great saphenous vein graft (yellow arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Postoperatively, the patient was managed in the intensive care unit for 3 days on continuous intravenous heparin (target APTT 2.0–4.0) before switching to aspirin (75 mg once daily) and antibiotics. Sensory deficits were resolved, motor function returned, and the patient was medically fit for discharge by day 14 with palpable pedal pulses. Subsequent CTA of the lower limb confirmed contrast flow from the SFA to the popliteal artery, ATA, and distal pedal arteries with no thrombus or occlusion (Fig. 3).

Fig. 3.

A CT Angiogram post-operatively showed contrast filled GSV bypass from the distal SFA to the right ATA.

2.2. Case report 2

A 28-year-old female sustained a traumatic injury to her left thigh as a consequence of a lateral strike by a motor vehicle. The patient presented for medical attention 27 h post-injury, at which time she was conscious and oriented and hemodynamically stable.

Local examination revealed a deformed, swollen, and tense left thigh with absent peripheral pulses and unrecordable oxygen saturation on the affected limb. A large open lacerated wound on the anterior thigh of approximately 10 cm in circumference with exposed bone had been sutured in the ED but showed active bleeding. The fractured extremity was initially stabilized with a Thomas splint but not subjected to prompt intervention. Radiographic imaging showed a comminuted fracture in the proximal one-third of the left femur, concomitant with lesions of the thigh musculature and subcutaneous tissue. Computed tomography angiography (Fig. 4) revealed a total transection (cut-off) of the right superficial femoral artery from the proximal one-third to the distal one-third.

Fig. 4.

A CT Angiogram showed deep venous thrombus occlusion from right popliteal region 1 to popliteal region 3 along 12 cm (arrow).

Within 3 h of initial presentation, the patient was transported to the operating theater for further evaluation and surgical intervention lasting approximately 5 h. Initially, the orthopedic surgeon stabilized the fracture using external fixation for both proximal and distal fragments. Through an anterior approach addressing the open laceration, the vascular team noted ruptured superficial femoral arteries, while the deep femoral artery, femoral vein, and associated nerve structures remained intact.

A left longitudinal skin incision was made overlying the femoral artery in the groin of the affected limb. The landmark halfway between the pubic symphysis and the anterior superior iliac spine was used to guide placement due to the absent femoral pulse. Dissection proceeded to the common femoral artery using Bovie electrocautery and Metzenbaum scissors. The proximal profunda femoris and superficial femoral arteries were encircled with Silastic vessel loops, and any side branches were ligated with silk suture. A longitudinal skin incision for suprageniculate popliteal exposure was made along the anterior border of the sartorius in the distal third of the thigh, exposing the suprageniculate popliteal artery by retracting the sartorius muscle posteriorly and the vastus medialis muscle anteriorly to visualize the neurovascular bundle.

A 6 mm diameter, 50 cm length expanded polytetrafluoroethylene (ePTFE) vascular graft (IMPRA® ePTFE, catalogue number F5006C, Bard Peripheral Vascular, Inc., Tempe, AZ, USA) was prepared for femoropopliteal extra-anatomical bypass using end-to-side anastomosis with Prolene 6–0 suture (Fig. 5). Following completion of the repair, the Acland clamp test was performed to evaluate both antegrade and retrograde flow. Ultrasound Doppler guidance confirmed a triphasic waveform in the popliteal artery, and distal pulses became palpable and oxygen saturation levels were restored within minutes.

Fig. 5.

A) Extraanatomical proximal bypass using ePTFE graft (yellow arrow) from the proximal left common femoral artery (white arrow), and B) Extraanatomical distal bypass using ePTFE graft (yellow arrow) to the left popliteal artery (blue arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Intraoperatively, the patient received a bolus of heparin at 5000 IU. Postoperatively, a continuous heparin infusion at 18 IU per kg of body weight via syringe pump was maintained for 24 h, targeting an activated partial thromboplastin time (APTT) range of 2.0 to 4.0, for 5 days. The patient was subsequently discharged with a recommendation of 75 mg aspirin once daily for 3 months. A repeat Doppler ultrasound at the 3-month mark demonstrated a favorable triphasic flow pattern within the popliteal artery.

3. Discussion

The two cases offer valuable insights into the contemporary management of severe lower extremity vascular injuries, particularly highlighting the contrasting approaches to graft selection and the importance of timely intervention, especially within a rural healthcare context. Vascular injuries of the extremities may occur as isolated events or concomitantly with trauma and injuries to other organ systems [7]. In the lower extremity, the popliteal and superficial femoral arteries are most frequently injured in blunt and penetrating traumas, respectively. Clinically apparent distal ischemia or pulse deficit occurs in more than 90 % of femoral arterial injuries and most blunt popliteal injuries, and the duration of ischemia consistently predicts amputation [9].

Case 1 involved a 54-year-old female who sustained a right leg injury from blunt trauma, specifically a falling cabinet, resulting in a femoropopliteal occlusion associated with an open lacerated wound and dislocation of the knee joint. Her prompt presentation and diagnosis, facilitated by the quick recognition by the ED practitioners of the absence of peripheral pulses in the right foot despite substantial distracting orthopedic injuries, allowed for revascularization within the crucial 8-h window. This rapid intervention contributed to the favorable outcome and limb salvage. The decision to utilize an autologous great saphenous vein graft (SVG) for femoropopliteal bypass in this patient aligns with established preferences due to the superior biocompatibility (reducing the risk of thrombosis and intimal hyperplasia) and historically excellent long-term patency rates when compared to synthetic options [10,11]. Postoperatively, the patient received continuous intravenous heparin for 3 days before being transitioned to aspirin. This antiplatelet strategy is a common approach for native vein grafts to maintain patency and prevent thrombotic complications, given that traumatized vessels often have no underlying atherosclerotic disease. The successful resolution of sensory deficits, return of motor function, and palpable pedal pulses within 2 weeks demonstrates the efficacy of the approach.

In contrast, Case 2 involved a 28-year-old female who presented with a left thigh injury from penetrating trauma, specifically a traffic collision that resulted in a total transection of the superficial femoral artery. A critical distinguishing factor in this case was the delay in presentation, which occurred 27 h post-injury. This prolonged ischemic time was well beyond the recommended 8-h window for optimal limb salvage and placed the patient at a substantially higher risk for amputation. Despite this challenging initial presentation, successful revascularization was achieved using an ePTFE vascular graft via a femoropopliteal extra-anatomical bypass. An ePTFE graft is generally chosen when autologous vessels are not suitable or available, or when immediate access to a native conduit is not feasible in an emergency setting. While synthetic grafts are readily available, they are associated with higher failure rates due to rapid re-occlusion, particularly in small-diameter applications [12], and poor integration with host tissue can lead to complications at the anastomotic sites [10]. The postoperative anticoagulation regimen in Case 2 involved continuous heparin infusion for 5 days (as opposed to 3 days for Case 1) followed by aspirin for 3 months, which aligns with existing evidence. The Dutch Bypass Oral Anticoagulants or Aspirin (BOA) trial [14] indicated that while oral anticoagulants enhanced patency of native vein grafts, aspirin demonstrated superior efficacy in promoting the patency of prosthetic grafts relative to anticoagulation. The favorable outcome, with restored distal pulses and oxygen saturation intraoperatively, and triphasic flow at 3 months follow-up, underscores the potential for successful limb salvage despite delayed presentation provided aggressive and meticulous surgical management is employed. However, this case also serves as a reminder of the dramatically increased risks and potential for adverse outcomes associated with delays in presentation and revascularization.

Both cases emphasize the importance of close monitoring of anticoagulation therapy following revascularization and delineate the distinctions in postoperative care between autologous SVGs and synthetic ePTFE grafts. While the decision to use systemic anticoagulation post-trauma can be complex and may be contraindicated in cases of polytrauma and hemorrhagic shock, the graft material chosen plays a crucial role in determining the appropriate antithrombotic strategy. Recent evidence from the American Association for the Surgery of Trauma Multicenter PROspective Observational Vascular Injury Treatment (PROOVIT) registry [15] revealed no significant difference in outcomes between anticoagulated and non-anticoagulated patients following traumatic vascular surgery, suggesting that individualized assessment is key. The outcomes of these cases further reinforce the need for a heightened level of suspicion regarding associated vascular injury, coupled with a comprehensive clinical examination (differentiating “hard signs” from “soft signs”), and the prompt utilization of imaging techniques such as CTA to delineate arterial vascular pathology.

Complications arising from traumatic vascular surgical interventions can be catastrophic. First, lower extremity compartment syndrome may manifest as a consequence of reperfusion following a period of ischemia, and swelling can result from the initial injury or edema induced by venous trauma. A low threshold for the execution of preemptive fasciotomy should be maintained in patients who have experienced vascular injuries. Second, graft failure is a technical complication that can be mitigated through shunt placement, thereby minimizing the duration of ischemia [16]. These cases collectively demonstrate that with meticulous surgical technique, appropriate graft selection, and tailored postoperative management, successful limb salvage can be achieved even in complex trauma scenarios. The importance of an algorithmic approach to diagnosis and treatment and a thorough understanding of the limitations and benefits of available therapeutic options remains paramount for achieving optimal outcomes when managing vascular injuries of the extremities.

4. Conclusion

This case report details the successful performance of open surgical bypass for both femoropopliteal occlusion and ruptured superficial femoral artery. The distinct outcomes of these cases underscore the critical role of timely intervention (Case 1) and the potential for limb salvage even with delayed presentation (Case 2). Our findings emphasize the importance of meticulous monitoring of anticoagulation therapy following revascularization and highlight the differing postoperative management strategies for autologous SVGs and synthetic ePTFE grafts. Furthermore, these cases reinforce the significance of an algorithmic approach to diagnosis and treatment, alongside the necessity for surgeons to comprehend the limitations and benefits of available therapeutic options in managing vascular injuries of the extremities.

Author contribution

JC: study concept and surgical therapy for this patient. JC and MW: Data collection and Writing-Original draft preparation. PD and RS: senior author and the manuscript reviewer. NH and MF: Editing and Writing. All authors read and approved the final manuscript.

Patient consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical Approval was waived by the authors institution.

Guarantor

Patrianef Darwis, R. Suhartono, and Mulawardi

Provenance and peer review

Not commissioned, externally peer-reviewed.

Sources of funding

None

Research registration

N/A

Declaration of competing interest

No conflict of interest