Salvage of Long Segment Artery Defect of Lower Limb by Long Segment Vein Graft Associated with a Polytetrafluoroethylene Graft Conduit Protection -- A Case Report

長段下肢血管缺損透過靜脈移植及聚四氟乙烯人造血管之血管重建－個案報告

李聖聯(Sheng-Lian Lee) ； 邱文寬(Wen-Kuan Chiu) ； 李紹榕(Shao-Jung Li) ； 王先震(Hsian-Jenn Wang) ； 陳杰峰(Chiehfeng Chen)

《臺灣整形外科醫學會雜誌》 29卷2期 (2020/06) Pp. 126-133

摘要

Background: Severe injury to the extremities is a life-threatening event which may lead to a myriad of disabilities. Before considering amputation, physicians should always evaluate if revascularization and replantation are achievable after thoroughly assessing the status of the patient's injury and hemodynamic condition. However, the therapeutic plan is often complicated by the presence of several factors, such as an advanced age, a degloving wound, involvement of a neurovascular injury or comminuted fracture, prolonged ischemia time, and concomitant diseases. Materials and Methods: Herein, we present a geriatric patient who suffered from a high-energy traumatic injury. A massive degloving wound with severe detachment of skin, subcutaneous fat, and muscle were seen over the patient's left lower limb. Her circulation was disrupted at the popliteal level, and segmental loss of popliteal artery was seen during emergent surgery. We restored the arterial perfusion of patient's traumatized limb with an autologous vein graft, but there was not enough soft tissue to cover the vein graft. A polytetrafluoroethylene (PTFE) graft was deployed outside of great saphenous vein graft for temporally conduit protection. Results: The patient underwent a series of reconstructive surgeries within 2 months after the incident. The swelling of her left lower limb subsided gradually, and the PTFE graft was removed on post injury day 21 as the vein graft was able to be covered by muscle flap and skin graft. Computed tomography angiography showed good patency of the vein graft on the 9^(th) month after the accident. The functional outcome of the patient's limb was greatly preserved in one-year follow-up. Conclusion: In our case, the vascular reconstruction was successfully achieved, and the function of the traumatized limb was also well preserved. This case report shows that the polytetrafluoroethylene graft can play a big role in temporarily protecting the vein graft when there is insufficient soft tissue coverage.

關鍵字

popliteal artery injury ； vascular reconstruction ； emergency vascular injuries ； polytetrafluoroethylene (PTFE) graft

並列摘要

背景：嚴重的肢體外傷對於年長病患來說是一件威脅生命的重大事件，它可能對病患帶來各種程度上的失能。因此在進行截肢手術前，應謹慎評估是否存在任何傷口重建的方法。但往往臨床上會面臨很多影響治療決策的因素，其中包含病患的年紀，傷口是否為脫襪性傷口，傷口是否牽涉到血管受傷或是粉碎性骨折，過長的缺血時間與病患本身的慢性疾病。材料及方法：我們在這呈現一位年長女性，其左下肢在遭遇公車後輪碾壓後，被送至急診室。事故發生後，他的左下肢為脫襪性創傷合併開放性骨折的狀態，手術中發現她的膝膕動脈已被截斷且有部分喪失。我們利用對側的大隱靜脈將斷裂的血管銜接，由於傷口的面積過大且周邊組織腫脹嚴重，重建的血管缺乏足夠的軟組織保護，因此我們在銜接的血管外置放聚四氟乙烯人造血管作為保護。結果：病患在事故發生的兩個月內進行了多次傷口重建手術。隨著傷口腫脹程度漸漸消退，我們將聚四氟乙烯人造血管移除並使用腓腸肌皮瓣將移植的靜脈包覆。事故發生9個月後的電腦斷層血管攝影顯示重建的血液循環通暢，且病患患肢的功能在追蹤的一年內復原狀況良好。結論：在此個案中，我們不僅完成了血管重建，還幫助病患保留了患肢的功能。透過此個案我們明白，聚四氟乙烯人造血管對於缺乏足夠周邊組織保護的開放性外傷傷口，其可暫時性提供有效的血管保護作用。