Introduction

It is necessary to control the proximal arterial bleeding during surgery on distal peripheral arterial bed. The blood flow coming from the proximal area should be stopped to work on a bloodless area. The proximal arterial bleeding control is more important in wounds created by gunshot, stab or other penetrating tools. The prevention of blood loss and rapid intervention save the life of the victim. A lot of methods have been tried for proximal arterial bleeding control. Atraumatic vascular clamps, vessel rings, tapes rounding the vessels, intraluminally used tools, pneumatic tourniquets have been used frequently for this aim (₁,₂,₃,₄,₅).

Material And Method

Patient selection

Surgical Technique

Patients who were scheduled for lower extremity arterial surgery were laid down on the table in the supine position. For upper extremity peripheral arterial surgery, the arms of the patient is abducted so that the palm of the hand is in upright position. Following general anesthesia, 8,5 French jugular vein percutaneous introducer sheath (Arrow: Arrow international inc., USA) was inserted through the common femoral artery in the lower extremity and the brachial or the axillary artery; depending on the site of injury; in the upper extremity. After that, 6 French Fogarty embolectomy catheter (Edwards Lifesclences inc., USA) was deployed through the introducer sheath (Picture). The balloon of the catheter was filled with saline solution and inflated after the catheter was pushed up to 20cm in the iliac arteries in patients with lower extremity lesions and proximal control of the bleeding was achieved. In patients with upper extremity lesions, the site of balloon occlusion depended on the site of injury as said before and bleeding was controlled by the same technique described above. Once the surgery of the distal vessels was completed, the Fogarty balloon was deflated and removed with the introducer sheath. The puncture site on the artery is detected ultrasonographically and compressed 20 minutes continuously. Finally, an elastic bandage is administered before the patient is transferred to the intensive care unit.

Figure 1

Picture 1: Jugular vein percutaneous introducer sheath and Fogarty embolectomy catheter.

Statistical analysis

Results

Of patients, 36 (95%) in group I and 28 (74%) in group II were male. The complications seen on the operation area were haematoma, embolism, atherocalcific plaque detachment, pseudoaneurysm, arteriovenous fistula, bleeding, infection, lymphore, wound-site healing problems and deep vein thrombosis. In group I, haematoma, which was seen in three patients (8%) was the most frequent complication. In group II, haematoma was seen in 8 patients (20%), bleeding in 8 patients (20%) and deep vein thrombosis in 7 (17%) patients. No pseudoaneurysm were seen in group-I and p=0.034 value was found between two groups regarding this type of complication. Lymphore was detected in 5 patients (%12.5) of group-II, p=0.034. The preoperative variables of the patients are listed in table-I. The complications seen at the site of proximal bleeding control are listed in table-II.

Figure 2

Table 1: Preoperative patient characteristics.

Figure 3

Table 2: Complications seen during proximal arterial bleeding control

Discussion

In vascular surgery, it is very crucial to obtain a dry field while operating the distal arterial segment. Parallel to the advances in medicine, various techniques and instruments have been developed for this purpose and most of them are still being widely used. The easiest and well known technique to control the bleeding is direct deployment of atraumatic vascular clamps on the proximal artery. However endothelial injury is a major concern due to the time of clamping and tissue damage caused by the pressure of the instrument itself (₆,₇). Previous experimental studies have showed the correlation between pressure caused by the clamp and degree of the tissue damage (₇,₈). A scale was used showing the degree of damage starting from adventitia and advancing to the intima. This damage scale revealed the fact that; the closer the injury to the intima, the higher chance of thrombus formation as a result of increased accumulation and adhesion of thrombocytes (₈). Other studies done on non-atherosclerotic vessels have shown permanent hystologic and morphologic changes on the arterial wall which are well correlated with clamping time, even in presence of maximum care of the participants (₉). The amount of damage is nearly twofold in veins when compared to arteries (₁₀). Tapes around vessels, pneumotic tourniquets and vascular rings have all resulted in a lesser degree of endothelial injury (₁₁,₁₂). Instruments that are used externally often cause intimal injury especially in calcific vessels. This has led investigators to search for an intraluminal device or technique to stop the bleeding. The most commonly used types of such devices are Nelaton catheter, umbilical vein feeding catheter and Fogarty catheter. Of all these well known instruments, Fogarty embolectomy catheter is widely used for this purpose. To do so; proximal artery is visualized initially and vascular tapes are turned around both proximal and distal proximal vessel segments. Following arteriotomy, Fogarty catheter is introduced to the proximal artery and bleeding is controlled after inflating the balloon of the catheter. But this procedure is time consuming and time is very precious especially in cases of gunshot and stab wounds. So, main goal should be rapid control of bleeding while managing the injured site. For such cases we prefer advancing a Fogarty catheter through a jugular vein percutaneous sheath introducer (Arrow: Arrow international, inc., USA) with the lowest rate of mortality and morbidity described so far. Arrow sheath provides safe and rapid passage for the Fogarty catheter. Proximal control of the bleeding can be fully achieved with this technique in both upper and lower extremity. Dislocation of the atherosclerotic plaque is another problem that is seen with the classical approach. In our study, 3 patients (%7.5) from group-II suffered such complication as a result of classical extra or intraluminal applications, whereas none of the patients in group-I had this problem with the technique we described above. The particles from the dislocated plaque also causes further trouble such as thromboembolus and each attempt in order to control proximal bleeding might be an extra surgical stress for the patient. These factors, altogether, contribute to increased rates of morbidity and hospital costs. Haematoma (%20) and bleeding (%20) were common findings in group-I. No pseudoaneurysm were seen in group-I and p=0.034 value was found between two groups regarding this type of complication. In order to prevent pseudoaneurysm, after removing the Fogarty and Arrow catheters, the puncture site was detected with the aid of a Doppler probe and pressure was applied manually for 20 minutes with the probe itself (₁₃). Patients who are operated for such arterial lesions may have problematic wound healing and infection since they usually have metabolic comorbidities. So such patients might benefit further from our technique as a result of limited incision because there is only a puncture on the proximal site and compression with the doppler probe prevents vascular complications. Infection was seen only in 1 patient (%2.63) in group-I who had a gunshot wound and an infection originating from skin over the distal vascular graft. But in group-II there were 4 patients (%10) with wound site infection and half of these were at the proximal site. Patients of group-I in which Arrow and Fogarty catheters were used had the chance to get up on their feet earlier and as a result, deep vein thrombosis were seen only in 2 patients (%5.26). On the other hand, 7 of the patients (%17,5) from group-II suffered deep vein thrombosis probably related to delayed mobilization and damage to the vein itself caused by classical applications for bleeding control as we described above. Moreover, DVT in group-I was originating from the distal site of the surgical field, rather than the proximal site. Only 1 patient (%2.5) who had a previous CABG operation 8 months before died during surgery because of cardiac instability in group-II. In addition to the complications above, lymphore was detected in 5 patients (%12.5) of group-II, p=0.034. Lymphore contributes to morbidity primarily by delaying wound healing and secondarily increasing the infection.

Advancing a Fogarty catheter through percutaneous jugular vein introducer sheath is a safe, easy and time saving way of controlling proximal bleeding during peripheral arterial surgery where it may be troublesome especially in cases of emergency.

Correspondence to

Nezihi KUCUKARSLAN, MD GATA Askeri Hastanesi Kalp ve Damar Cerrahisi ABD. 06018 ETLIK/ ANKARA/ TURKEY Tel: 00903123045271- 00905335185364 Fax: 00903123045200 E-mail: nkucukarslan@gata.edu.tr; nezihimd@hotmail.com