65

Review

Diagnostic workup and endovascular

treatment of popliteal artery trauma
Cheong J. Lee1, Rory Loo1, Max V. Wohlauer1, and Parag J. Patel2
1
Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, USA
2
Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, USA

Summary: Although management paradigms for certain arterial trauma, such as aortic injuries, have moved towards an en-
dovascular approach, the application of endovascular techniques for the treatment of peripheral arterial injuries continues
to be debated. In the realm of peripheral vascular trauma, popliteal arterial injuries remain a devastating condition with sig-
nificant rates of limb loss. Expedient management is essential and surgical revascularization has been the gold standard.
Initial clinical assessment of vascular injury is aided by readily available imaging techniques such as duplex ultrasonography
and high resolution computed tomographic angiography. Conventional catheter based angiography, however, remain the gold
standard in the determination of vascular injury. There are limited data examining the outcomes of endovascular techniques
to address popliteal arterial injuries. In this review, we examine the imaging modalities and current approaches and data re-
garding endovascular techniques for the management popliteal arterial trauma.

Keywords: Popliteal artery, trauma, endograft

Vasa 2019.48:65-71.

Introduction from rhabdomyolysis is a well-documented phenomenon

due to nephrotoxic byproducts of muscle necrosis and the
The popliteal artery is the second most frequently injured potential to develop other adverse systemic consequences
lower extremity vessel [1, 2]. Among civilian populations, of popliteal arterial trauma must be considered in the man-
popliteal artery injuries comprise 19 % of all extremity ar- agement algorithm [5, 13]. In essence, timing and sequence
terial injuries [3–5]. The overall incidence of popliteal ar- of interventions are paramount to preserve local limb and
tery injuries remains low, however; and only account for systemic physiological function when popliteal or other pe-
approximately 0.2 % of traumatic arterial injuries [1,  5]. ripheral arterial trauma is encountered.
Regardless, popliteal arterial injuries remain the most Open repair, by way of interposition or extra-anatomic
limb-threatening and challenging of all lower extremity bypass using autologous or prosthetic conduit or direct re-
peripheral vascular trauma with limb loss rates approach- pair using vein or prosthetic-based patch patches, is the
ing up to 50 % [1,  2,  4]. Treatment difficulties stem from current gold standard for management of popliteal artery
the fact that the popliteal artery is a true end artery with trauma [1, 4, 14]. Surgical repair, however, can be particu-
poor collateral supply. Furthermore, lesion location and larly difficult based on lesion location in a constrained en-
complex anatomy of the popliteal trifurcation and its vari- vironment that limits accessibility of the vessel [2]. In ad-
ability lends itself to iatrogenic neurovascular injury dur- dition, the degree of associated soft tissue damage can
ing vessel repair [6, 7]. severely distort native anatomy further adding difficulty to
Time to repair and revascularization are essential deter- the operation. These inherent technical challenges with
minants of limb-salvage. Amputation rates are reported to surgical repair, which can increase morbidity and delay
be less than 10 % for injuries with vascular intervention valuable reperfusion time, necessitate the evaluation and
implemented within 6 hours, and rises to 50 % when de- potential adoption of endovascular techniques in select
layed greater than 6 hours [2, 5, 8–11]. Various contexts of cases of popliteal artery trauma.
the injury: associated orthopedic trauma, remote organ in-
juries, patient stability are factors that can delay manage-
ment. When delays occur, prolonged ischemic periods neg- Assessing injury to the popliteal artery
atively affect limb-salvage rates. Furthermore, development
of acute compartment syndrome is a fearsome consequence Blunt and penetrating injuries to the popliteal artery with
of ischemia-reperfusion that requires prompt surgical de- “hard signs” of vascular compromise (i. e. significant bleed-
compressive fasciotomies of the leg; delays can lead to per- ing, absent pulses, motor/sensory deficit) require immedi-
manent disability or limb loss [8,  12]. Acute kidney injury ate operative intervention if the patient is not threatened by

© 2018 Hogrefe Vasa (2019), 48 (1), 65–71

https://doi.org/10.1024/0301-1526/a000756
 66 C. J. Lee et al., Endovascular repair of popliteal artery trauma

other more pressing systemic injury. If vascular injury is arterial injuries can progress to vessel occlusion or pseu-
suspected but physical examination is questionable, dedi- doaneurysm formation [1, 8, 10]. Thus, the authors of the
cated imaging should be the next step in the algorithm in present review suggest that all blunt injuries to the knee
the management of extremity trauma (Figure 1). The con- with significant bony injury including ligamentous injury
text of the peripheral injury determines what imaging mo- (especially the posterior cruciate ligament), require a for-
dality should be first line, for instance if other traumatic mal imaging evaluation of the vasculature.
injuries are present and require axial computed tomo-
graphic (CT) imaging, CTA would be logical. Non-invasive
modalities such as duplex ultrasound (DUS) is also readily Non-invasive assessment modalities
available and maybe used in isolated peripheral trauma or
in situations where patient is too critically ill for the CT Some argue that ongoing pulse examination alone is ade-
scanner. In our institution, we prefer CTA as first-line mo- quate to detect popliteal artery injuries. Others suggest that
dality given that a multi-detector row CTA (MDCTA) unit the risk of missing a popliteal injury is too high. The largest
is available adjacent to the emergency room trauma bay. study by Stannard et al. examining pulse examination
Regardless of context, the decision for immediate opera- showed that patients without hard signs could be managed
tive management is often more clear with penetrating inju- by frequent clinical examination [18]. Positive predictive
ries around the popliteal fossa, however; blunt mechanisms value (PPV) was 90 % and negative predictive value (NPV)
may produce “softer signs” of popliteal arterial injury. was 100 %. Sensitivity was 100 % and specificity was 99 %.
Knee dislocations and other mechanisms of blunt trau- Although the results were impressive, the authors fell short
ma are frequently associated with popliteal artery inju- of proposing an algorithm. Instead, they suggested adop-
ries, with a prevalence between 23 % and 32 % [2,  9, 15– tion of a tailored protocol accepted by each respective insti-
18]. Anatomically, the popliteal artery is tethered at the tution. On the other hand, a meta-analysis by Barnes et al.
entry to the adductor hiatus and at the tendinous arch of showed that abnormal pulse examination had an overall
the soleus. These fixed points are prone to damage in dis- sensitivity of 79 % and specificity of 91 % for popliteal ar-
tractive injuries [7, 18]. Along with knee dislocations, frac- tery injury [19]. Though acceptable, reliability on physical
tures of the distal femur, proximal tibia, and tibial plateau examination alone may delay the diagnosis of small pseu-
Vasa 2019.48:65-71.

fractures often lead to stretch injuries of the popliteal ar- doaneurysms or intimal tears that lend themselves to a nor-
tery and intimal disruptions [5,  9, 10,  18]. Following re- mal initial clinical examination but evolve into limb-threat-
duction, whether spontaneously or by intent, the artery ening issues. Based on data that will be reviewed in the
can regain pulsatility. Regardless, the clinician should not section on DUS, the authors of the manuscript have adopt-
miss an opportunity to thoroughly investigate the vascula- ed a liberal ultrasound policy for any suspected peripheral
ture. Intimal disruptions and other distracting popliteal vascular injury despite an initial normal clinical exam.

Lower extremity injury

with suspected vascular
injury

Multidisciplinary
evaluation with vascular
surgery

Hard signs of vascular Soft signs of vascular

injury or severe ischemia injury/ABI < 0.9

Computed tomographic
angiography/duplex
ultrasonography

No or Short Long No or
noncclusive segment segment noncclusive
injury injury injury (> 2 cm) injury

Primary surgi-
Immediate open surgical Observation Consider Figure 1. Assessment algorithm in the evalua-
cal or consider Bypass
exploration with repair or and medical endovascular tion of peripheral vascular trauma.
endovascular surgery
bypass management repair
repair
ABI: Ankle brachial index.

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 C. J. Lee et al., Endovascular repair of popliteal artery trauma 67

Reliance on ankle brachial index (ABI) assessment alone computed tomographic angiography (CTA) due to com-
remains controversial. There is abundant evidence to sug- pounding issues such as underlying renal failure or contrast
gest that an ABI of < 0.9 is sensitive in identifying signifi- hypersensitivity.
cant vascular trauma, although a normal ABI does not ex- Other benefits of DUS from a surgical perspective in-
clude occult injuries. In a well recited series by Johnsen et clude precise localization of the injured segment for tar-
al., ABI of less than 0.9 had a sensitivity of 87 % and speci- geted exploration and evaluation of both the deep and su-
ficity of 97 % for arterial injury [20]. When occult, non- perficial venous systems to assist with operative planning.
flow-limiting arterial injuries were excluded from the anal- Concomitant assessment of the saphenous venous systems
ysis, the sensitivity and specificity rose to 95 % and 97 %, as a potential vascular conduit in the event that an open re-
respectively. Many authors claim the risk of progression vascularization is required is another advantage of DUS.
with occult injuries are negligible. Sadjadi and colleagues
experience demonstrated that ABI > 0.9 was nearly 100 %
specific in predicting safe discharge of the patient [21]. In Computed tomographic angiography and
that study, only 1 of 182 patients who was discharged with catheter angiography
an ABI of > 0.9 returned to the hospital with delayed com-
partment syndrome. ABI is an important initial assessment Multi-detector row helical CTA has established an essen-
tool along with physical examination that allow improved tial role in the evaluation of peripheral trauma when there
triaging of patients toward more involved imaging. In ac- is concern for vascular involvement. There are distinct ad-
cordance with other guidelines, the authors of the present vantages to MDCTA, for one CTA is readily available in
review patient with an abnormal physical examination most centers and nowadays offers rapid, high-resolution
and/or an ABI < 0.9 should have additional imaging per- assessment of peripheral arteries that is comparable to the
formed to evaluate the presence of an arterial injury. more invasive catheter-based angiography [24, 25]. MDC-
Duplex ultrasonography (DUS) is an attractive means for TA in experienced, high-volume centers with established
assessing peripheral arterial injuries. Advantages include protocols for trauma, need not take longer than 10–20 min
portability with ability to perform the test at the bedside, for a study. In addition to vascular evaluation, CTA allows
rapid interpretation of results, cost-effectiveness, and lack superior bony or soft tissue assessment following trauma
Vasa 2019.48:65-71.

of ionizing-radiation or contrast. The disadvantages include compared to conventional angiography. CTA can be per-
operator dependency and the availability of a trained opera- formed along with other CT imaging protocols that may be
tor such as an RVT (registered vascular technologist) to per- required further facilitating the evaluation of the injured
form the studies. Regardless, DUS can play a crucial role in patients. There are several limitations to MDCTA when
the management of the injured patient. In one study exam- compared with catheter angiography, however, including
ining 319 potential vascular injuries, DUS demonstrated a distortion of images from foreign body induced beam
sensitivity of 95 % and a specificity of 99 % when used to scatter which may disrupt visualization of the injured ves-
assess for intimal tears, stenosis, occlusion, or pseudoaneu- sel. Particular to the popliteal artery and its outflow tibial
rysms utilizing both color and power doppler. Overall accu- arteries, streak artifacts from missile or bone fragments
racy was 98 %, closely approximating results of convention- can significantly obscure the degree of injury (Figure 2).
al arteriography in the evaluation of vascular trauma [22]. Sensitivity of MDCTA in meta-analysis are reported
In another prospective series of 200 patients with 225 ex- to be as high as 96 % with specificity greater than 99 %
tremity injuries reported by Fry and colleagues, DUS was when used in evaluating peripheral arterial trauma
nearly 100 % sensitive and 100 % specific compared with [25,  26]. CTA is also cost-effective comparative to con-
arteriography and/or operative exploration and had re- ventional angiography. One study found that the use of
placed conventional angiography in the diagnosis of vascu- MDCTA saves $ 12,922 in patient charges and $ 1,166 in
lar injuries [23]. In our institution, DUS is selectively em- hospital costs per extremity when compared to conven-
ployed in patients who are not suitable candidates for tional angiography [24]. One disadvantage to CTA is the

G Figure 2. CTA of the lower extremity following penetrating

trauma. This patient presented with a gunshot wound to the
right lower extremity. He did not have hard signs of vascular
compromise but his ABI was < 0.9 (A). CTA was obtained dem-
onstrating the missile adjacent to the above knee popliteal
artery (B). Beam scattering due to missile obscures the degree
A B C of injury to the popliteal artery and vein (C, D). Reconstitution
D E F of the popliteal artery with evident vasospasm noted immedi-
ately adjacent to missile (E, F). Thromboembolism remote
from the site of injury is noted in the geniculate popliteal
artery and tibioperoneal trunk (G). Reformatted image
illustrating extent of geniculate thromboembolic process.
CTA: Computed tomographic angiography.

© 2018 Hogrefe Vasa (2019), 48 (1), 65–71

 68 C. J. Lee et al., Endovascular repair of popliteal artery trauma

administration of iodinated contrast agents with poten- Embolization

tial for renal injury [27]. Studies examining the incidence
of contrast induced nephropathy in trauma patients is In general, lower extremity branch vessel embolization for
lacking and a recent meta-analysis has concluded that hemostasis has been shown to be safe and efficacious in a
studies to date do not support a strong causal relationship variety of trauma situations [37–39]. Embolization may be
between iodinated contrast use and renal failure in the
acutely ill patient [27]. In spite of the potential risks, CTA
is now a primary imaging modality for lower extremity C
vascular trauma that is well integrated in current treat-
ment guidelines [14, 25].
Catheter angiography remains the gold standard mo-
dality for diagnostic evaluation of patients with suspect-
ed lower extremity arterial injuries [8]. Historically, au-
thors have advocated for a liberal catheter angiography
policy in the treatment algorithm for peripheral artery
trauma as it provides valuable diagnostic information as
well as potential solutions [2,  8, 10,  28]. Angiography, A
however, is best applied selectively as it is resource inten-
B
sive. Mobilization of the appropriate team for angio-
graphic evaluation can also be time consuming as major-
ity of the patients presenting with peripheral vascular
injuries present at night or on the weekend [29]. There
are also inherent risks with intra-arterial contrast injec-
tion. A complication rate of 1 to 4 % have been reported
including access site hematomas and vessel occlusion
[30,  31]. Nevertheless, catheter based studies allow for
Vasa 2019.48:65-71.

superior imaging of the injured vessel when artefactual

distortion from foreign bodies obscure assessment with Figure 3. Infrapopliteal vascular injury is better characterized by con-
DUS or CTAs (Figure 3). Angiography can also better de- ventional catheter angiography in the setting of adjacent projectiles
that cause beam scatter (A, B). Patient presenting with gunshot wound
lineate the extent of injury to the vessel compared to oth-
to the lower extremity with significant bony injury surrounding the
er modalities (Figure 4). popliteal and infrapopliteal vasculature. Missile fragments in soft tis-
sue cause distortion of the vascular bed (C). Angiographic evaluation of
the patient demonstrates traumatic occlusion of the anterior tibial ar-
tery and focal injury to the tibioperoneal trunk (arrows).
Endovascular treatment

The role of endovascular therapy has dramatically evolved

A B C
in the setting of traumatic and non-traumatic emergen-
cies an over the past two decades [32]. Between 1994–
2003, 2.2 % of all traumatic vascular injuries were ap-
proached via endovascular repair, and the prevalence rose
to 5.9 % between 2007–2009 [32–34]. Although endovas-
cular repair is now the preferred approach for a number of Art.
B
situations such as blunt thoracic aortic injury treatment Vn.

[35], the application of endovascular techniques is less B D

well studied in peripheral vasculature. Endovascular ap-
Nv.
proaches have the theoretical advantage of being rapid
and minimally invasive, limiting both blood loss and ex-
pediting recovery [36]. Multiple studies have discussed
the efficacy of using endovascular approaches in traumat-
ic peripheral vessel injury [33]. But at present, indications
for endovascular management particularly in popliteal Figure 4. Complete avulsion of the popliteal artery demonstrated by
arterial segment are not well defined. As with other man- catheter angiography (A). CTA of a patient present with a posterior knee
agement paradigms, success of an endovascular approach dislocation who appeared to have a focal intimal flap of the popliteal
artery (arrows) (B). Catheter angiography demonstrating abrupt occlu-
is dependent upon proper patient selection. A patient with
sion of the popliteal artery with extravasation of contrast proximally
a focal geniculate popliteal injury and/or bleeding branch (arrow) concerning for avulsion of the vessel (C). Confirmed avulsion
injury that requires extensive and risk-ridden surgical ma- and complete transection of the popliteal artery at time of open explo-
neuvers to gain adequate exposure for open repair would ration. Hematoma surrounds the popliteal fossa structures.
be an ideal candidate for endovascular therapies. Art.: Popliteal artery; Nv.: Tibial nerve; Vn.: Popliteal vein.

Vasa (2019), 48 (1), 65–71 © 2018 Hogrefe

 C. J. Lee et al., Endovascular repair of popliteal artery trauma 69

accomplished by a variety of agents which are chosen for a A B

specific desired outcome. Liquid embolic agents such as
glues function through mechanical obstruction via polym-
erization. Upon contact with ionic mediums such as blood,
cyanoacrylate glues form flexible polymers that obstruct
the target vessel. Unpredictable dispersion can occur with
glues and non-target vessel occlusion is the most com-
monly encountered complication with the use of glue or
other liquid based embolic agents.
Depending on the situation, glues maybe indicated over
agents that cause permanent occlusion such as metallic
coils. There is insufficient evidence to support one type of
embolization medium over another, and most reported cas-
es involve selective embolization as opposed to the main
vessel occlusion methods. In the present practice, the au-
thors of this manuscript prefer detachable micro-coils for
occlusion of branch vessel hemorrhage off the popliteal
artery, pseudoaneurysms, or arteriovenous malformations
arising from the popliteal artery (Figure  5). Non-detacha-
ble, traditional coils may have higher incidence of non-tar- Figure 5. Angiographic images demonstrating successful treatment of
get vascular occlusion and distal tibial embolization leading an arteriovenous fistula following a gunshot wound to the left popliteal
fossa (A). Arteriovenous communications arising from collateral branch-
to unwanted ischemic complications. One drawback of coils
es of the distal below knee popliteal artery and the anterior tibial artery
as embolic agents is that efficacy depends on normal coagu- (B). Successful embolization of the communicating fistulae using de-
lation. Coagulopathy in traumatic shock and abnormal pa- tachable micro coils.
tient hemodynamics may, in theory, impact the outcomes
of coil embolization.
Vasa 2019.48:65-71.

that required thrombolysis [17]. No patient in that study

Stents and stent grafts suffered stent migration, deformation, or fracture. These
series and other preliminary data illustrate promising re-
Conventional bare metal stents (BMS) are subject to sig- sults of endovascular management of popliteal artery trau-
nificant mechanical forces in the popliteal artery and are ma in the short term. More studies, including comparative
vulnerable to fracture [40]. Interwoven BMS stents and studies to open repairs, are needed to make definitive state-
stent grafts, however, have shown increased integrity and ments regarding the application of BMS and stent grafts in
fracture resistance compared to conventional BMS, and traumatic injuries to the popliteal artery. Regardless, the
have found accepted use in the popliteal artery in situa- senior author of this manuscript has used interwoven BMS
tions outside of trauma [41, 42]. The conclusions regard- to treat a focal traumatic intimal flap in the popliteal artery
ing interwoven BMS stents and stent grafts gathered from with success. More caution should be employed with stent
patients with atherosclerosis or aneurysmal conditions graft use in the popliteal artery as it may cause unwanted
may not completely translate to traumatic popliteal arteri- geniculate branch occlusion that serve as important collat-
al injury patients. But theoretically ideal situations of de- erals in the setting of acute device occlusion.
vice applicability may be with focal, short-segment arterial
disruptions, intimal injury, and occlusion [16,  17, 43,  44].
Current data of BMS stents and stent grafts in popliteal ar-
tery trauma are limited to sporadic case reports and series. Conclusions
Furthermore, device application was mainly in the setting
of blunt popliteal injuries. Popliteal artery injuries are devastating with high rates of
In one series by Piffaretti et al., ten patients with periph- limb loss. Prompt recognition is the key to limb salvage,
eral arterial injuries following blunt trauma treated with along with a multidisciplinary team effort that allows ex-
BMS or stent grafts with a technical success of 100 % [44]. pedient and thorough evaluation of the injured patient.
Late occlusion occurred in 1 popliteal artery stent graft Numerous diagnostic modalities are available to detect
which was later salvaged endovascularly. In total, the re- vascular injury associated with extremity trauma, includ-
ported limb salvage rate was 100 % after a mean follow up ing CTA and DUS, but a good physical exam and rapid
of 16 months [44]. In another recent series, 7 patients un- non-invasive assessment tools such as ABI begins the pro-
derwent BMS placement at times with combination of coils cess and can effectively guide appropriate triaging of the
for varying injuries to the popliteal artery. Technical suc- patient. Direct communication between surgical and in-
cess reported to be 100 % and during the follow up period terventional teams is essential to determine the appropri-
that averaged 21 months, 1 patient had stent thrombosis ate sequence and type of vascular intervention.

© 2018 Hogrefe Vasa (2019), 48 (1), 65–71

 70 C. J. Lee et al., Endovascular repair of popliteal artery trauma

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