Extensive Iliofemoral Intimal Injury after Handlebar Trauma Requiring Iliac Exposure and Saphenous Vein Interposition Grafting: A Case Report

Abstract

Blunt trauma caused by bicycle or motor-scooter handlebars is a rare mechanism of femoral artery injury. Three-wheelers, commonly operated with handlebars, are a frequent mode of transportation in Sri Lanka. This case report describes a 22-year-old male driver of a three-wheeler who presented with acute occlusion of the common femoral artery (CFA) after blunt handlebar trauma to the groin during a collision. Intraoperatively, the intimal injury extended from the CFA to the external iliac artery, necessitating iliac exposure and reconstruction with a reversed great saphenous vein interposition graft. Arterial perfusion was successfully restored. Although the postoperative course was complicated by iliofemoral deep vein thrombosis, limb salvage was achieved. This case highlights that handlebar trauma to the groin can result in arterial injury extending beyond the site of impact. Clinicians managing such injuries should be prepared to extend exposure to the iliac vessels and perform appropriate reconstruction when needed.

INTRODUCTION

Handlebar injuries account for approximately 5%-10% of all serious bicycle-related injuries [1]. Abdominal organs are commonly involved in these trauma cases when relatively immobile abdominal viscera are crushed against the vertebral bodies by an impacting handlebar. A similar injury mechanism can damage the femoral vessels at the groin because these vessels are relatively fixed and superficial at this location [1,2]. However, such injuries are extremely rare and can lead to delayed diagnosis [3-5].

This case report describes a 22-year-old male who developed a femoral artery injury secondary to an impact from the handlebar of a three-wheeler. The patient presented with Rutherford grade 2A acute limb ischemia and underwent open vascular repair. Intraoperatively, we found an intimal injury to the common femoral artery (CFA) at the site of impact. This injury extended beyond the inguinal ligament into the external iliac artery (EIA), necessitating a pararectal incision for adequate vascular exposure.

Written informed consent was obtained from the patient before publication of this case report, and the study was exempt from approval by the Institutional Ethics Review Board of the Teaching Hospital Kurunegala.

CASE

A 22-year-old male patient was transferred to the emergency department following a road traffic accident. He was the driver of a three-wheeler that collided with a motorcar. The three-wheeler toppled over, and he sustained a crush injury to the left groin caused by the handlebars. Following the accident, he was taken to the nearest hospital and then transferred to our facility within 3 hours of the incident because of left leg pain and numbness with absent pedal pulses.

On examination, the patient was obese, conscious, and alert. Vital parameters, including pulse rate and blood pressure, were within normal limits. The left groin was bruised and swollen, and the left leg was colder than the right. Pedal and popliteal pulses were absent in the left leg, and deep palpation of the femoral pulse was not possible because of pain. Pulse examination of the contralateral limb was normal. The left foot was numb, but toe and ankle movements were intact. A Doppler probe over the anterior and posterior tibial arteries at the ankle failed to detect pulsatile blood flow. Suspecting an arterial injury, we performed duplex ultrasonography (DUS), which revealed absent flow in his left CFA and EIA, with no evidence of deep vein thrombosis (DVT). Subsequently, computed tomography angiography (CTA) confirmed occlusion of the EIA and CFA (Fig. 1). There was no clear evidence of a dissection flap. Soft tissue edema was observed in the groin, indicating the site of the primary injury. No obvious femoral venous injury was observed (Fig. 2).

Fig. 1.

Reconstructed computed tomography angiography showed occlusion of the left common femoral artery and external iliac artery (yellow arrow).

Fig. 2.

Axial computed tomography image showed a nonopacified femoral artery (red arrow) with a patent femoral vein (blue arrow) at the contused left groin.

Suspecting blunt trauma to the CFA, the patient was taken to the operating room for exploration. The time between injury and surgical intervention was approximately 12 hours. Limb viability was confirmed with serial examinations during this period. On-table mapping of the great saphenous vein (GSV) showed a 2.5 mm vein in the right lower limb and a 4.0 mm vein on the left. After circumferential control of the common, superficial, and deep femoral arteries, systemic heparinization was performed using 5,000 units of unfractionated heparin. A longitudinal arteriotomy was performed on the CFA. Intimal inspection revealed complete denudation at the proximal CFA (Fig. 3A), which extended into the EIA. Maximum exposure of the EIA through the groin and extension of the arteriotomy failed to demonstrate healthy intima. Therefore, we exposed the common, external, and internal iliac arteries via a pararectal incision. Healthy intima was identified at the mid-EIA, and a decision was made to replace the damaged artery with an interposition graft. The ipsilateral GSV was harvested, reversed, and used as an interposition graft (Fig. 3B). Pedal pulses returned immediately upon reperfusion. The total duration of ischemia was approximately 14 hours. Calf fasciotomy was deemed unnecessary because there was no concern regarding limb viability at the time of reperfusion. Additionally, the absence of significant calf swelling suggested a low risk of post-reperfusion compartment syndrome.

Fig. 3.

(A) Denuded endothelium was observed in the common femoral artery (CFA) at the trauma site (yellow arrow). (B) An interposition vein graft extended from the external iliac artery to the CFA.

The patient was started on low-dose aspirin and discharged on postoperative day 5. Until discharge, pharmacologic prophylaxis for DVT was provided using subcutaneous low-molecular-weight heparin. He developed superficial groin wound dehiscence, which was managed conservatively. Two weeks after the surgery, he presented with worsening swelling and pain in the left lower limb. Good pedal pulses were palpable, suggesting graft patency; however, DUS showed iliofemoral DVT. He was started on apixaban 5 mg twice daily, which was continued for 3 months for provoked DVT. At the 3-month follow-up, the patient was fully functional, free of claudication, and employed. DUS surveillance of the vein graft confirmed good patency.

DISCUSSION

Blunt trauma is a rare mechanism of vascular injury, especially in the absence of bony fractures [4,6]. Such an injury can occur in the femoral vessels at the groin after handlebar impact. Deutsch et al. [7] first described this injury pattern and coined the term ‘motor scooter handlebar syndrome’. Since its first description, only a limited number of similar cases have been reported worldwide [5]. The rare nature of this type of injury can lead to missed or delayed diagnosis [4]. Three-wheelers are a common mode of transportation in Sri Lanka, and these vehicles are maneuvered using a handlebar, similar to a motor scooter. The patient described in this case report presented with a thrombosed femoral artery secondary to blunt trauma caused by the impact of a three-wheeler handlebar on the groin.

The femoral artery is superficial and relatively fixed at the groin owing to its branches, surrounding connective tissue, and the femoral sheath. Because of this fixation, it is prone to injury when the vessel is compressed against the superior pubic ramus or femoral head by forceful, direct handlebar impact [4,8]. The most common mechanism of vessel occlusion in these cases is intimal injury, which can progress to thrombosis [5,8]. In our patient, the circumferential endothelial denudation extended from the upper CFA to the mid-EIA. This was similar to the case described by Yoshimura and Hamamoto [4], who hypothesized that post-traumatic intimal necrosis or retraction was the reason for endothelial loss over such a length [4]. Contusion of the vessel, intramural hematoma, and subintimal fibrosis are other patterns of vessel wall damage that have been described as a result of blunt trauma to the femoral artery [9].

The presentation and timing of patients with motor scooter handlebar syndrome have been highly variable across studies. Pain, swelling, and bruising of the groin are commonly observed at the time of the injury. In contrast to penetrating vascular trauma, massive bleeding, an expanding hematoma, a thrill, or a bruit over the injured vessel is typically absent. The absence of peripheral pulses is a highly specific physical finding. However, up to 25% of those with extremity vascular trauma have palpable pulses [9]. In patients with typical symptoms of acute limb ischemia, such as pain, paresthesia, and motor weakness, the diagnosis can be made with adequate physical examination aided by imaging studies. Duplex ultrasonography and CTA are the imaging modalities of choice. In patients who lack specific symptoms, the diagnosis can be missed unless there is a high degree of clinical suspicion and awareness of this injury pattern [1,8,9]. Patients with a missed diagnosis can present with ischemic claudication of the affected lower limb [6,8].

In our patient, the interval from injury to revascularization was 14 hours. Traditionally, a reperfusion time window of 6 hours has been suggested to achieve optimal outcomes after acute occlusion of extremity arteries [10]. However, time is not the sole determinant of limb viability [11]. Our patient likely had reasonable collaterals and we ensured that the blood pressure was maintained. Serial examinations were performed to confirm limb viability during the ischemic period, allowing adequate time for imaging and revascularization in a controlled operating room setting.

Blunt trauma–induced femoral artery injury has largely been treated using open revascularization [9]. Common treatment options include interposition grafting and bypass procedures using autologous conduits or prosthetic grafts. When the injury is limited, arteriotomy followed by tacking of the damaged intima and patch closure, or direct end-to-end repair after excision of the damaged segment, are suitable options [4]. When grafts are required, the great saphenous, femoral, jugular, and arm veins have been used. Alternatively, prosthetic material such as polyester and polytetrafluoroethylene can be used. However, there is no consensus on the optimal conduit [9]. Availability and size matching are key determinants of autologous conduit selection. Although our patient’s left GSV was approximately 2 mm smaller in diameter than the EIA, we used it as the interposition graft because we did not have a prosthetic graft of an appropriate size. Classic trauma surgery advocates the use of venous conduits from the noninjured limb, but we proceeded with the ipsilateral GSV because of its larger diameter. We decided against femoral vein harvesting because of the patient’s unfavorable body habitus.

Selected patients with blunt femoral artery trauma without limb-threatening ischemia can be managed conservatively with anticoagulation [12]. Endovascular stenting is an infrequently used option for this type of injury [13]. Minimal morbidity is an advantage of this approach. However, the long-term patency of stents in young patients may be an issue, especially if the stent crosses the inguinal ligament [4]. By contrast, interposition vein grafts for vascular trauma have excellent long-term patency rates [14]. Although there was a diameter mismatch between the vein graft and the native artery in our case, early postoperative results were favorable, and continued duplex surveillance is planned.

The patient’s postoperative recovery was complicated by DVT in the injured lower limb. At the time of evaluation of the original injury, there was no evidence of venous injury, either clinically or radiologically. At discharge, the affected limb was not disproportionally swollen. We believe that DVT was a provoked event after discharge, as the patient presented with worsening limb swelling and new-onset limb pain 2 weeks after the operation. DVT was likely triggered by obesity and poor mobility at home. The postoperative period is a hypercoagulable state due to the associated inflammatory response, which may have been an additional contributory factor [15].

In summary, motor scooter handlebar syndrome is a rare mechanism of femoral artery injury. Unless there is a high degree of suspicion, such injuries can be missed, especially in patients who lack typical acute limb ischemia symptoms. Clinical acumen, in conjunction with imaging, can aid diagnosis. Most patients with this type of injury require revascularization, and open surgical techniques are the preferred approach, with endovascular stenting and conservative management reserved for selected patients.

Funding Statement

FUNDING None.