How are the femoral artery and its branches managed during an above knee amputation?

Management of Femoral Artery and Branches During Above-Knee Amputation

During an above-knee amputation, the femoral artery should be ligated proximally, with careful management of collateral vessels to ensure adequate stump perfusion and prevent wound complications. 1

Arterial Anatomy and Surgical Considerations

Preoperative Assessment

• Evaluate femoral pulse quality - diminished or absent femoral pulses significantly increase risk of wound complications 2
• Consider preoperative arteriography for patients with diminished femoral pulses to assess:
  • Common femoral artery patency
  • Profunda femoris artery (deep femoral) patency
  • Presence of stenosis or occlusion 2

Intraoperative Management

1. Femoral Artery Ligation:

   • Identify and isolate the femoral artery
   • Ligate the superficial femoral artery with non-absorbable suture
   • Ensure adequate proximal stump length for potential revision if needed

2. Profunda Femoris Management:

   • Preserve the profunda femoris artery whenever possible as it provides critical collateral circulation to the stump
   • Avoid injury to profunda branches during dissection 1

3. Collateral Vessel Considerations:

   • Identify and preserve major collateral vessels
   • Carefully ligate smaller branches to prevent bleeding
   • Maintain adequate tissue perfusion via collateral circulation 1

Inflow Revascularization Considerations

High-Risk Situations Requiring Revascularization

Consider inflow revascularization prior to amputation in patients with:

• Acute thrombosis of a prior combined inflow/outflow procedure
• Occlusion of the superficial femoral artery with occluded/stenotic deep femoral artery and no palpable femoral pulse
• Flat pulse volume recordings at high thigh level 3

Revascularization Options

1. Common Femoral Endarterectomy:

   • Recommended for significant common femoral artery disease
   • Provides durable results with 78.5% primary patency at 7 years 1

2. Bypass Procedures:

   • Aortobifemoral bypass for significant aortoiliac disease
   • Iliac endarterectomy or iliofemoral bypass for unilateral disease
   • Use autogenous vein when possible for any bypass procedure 1

Preventing Stump Complications

Risk Factors for Poor Healing

• Diminished or absent femoral pulse
• Hypertension
• Failed bypass procedure to the groin
• Stenosis or occlusion of common femoral or profunda femoral artery 2

Surgical Techniques to Improve Outcomes

1. Adequate Tissue Perfusion:

   • Ensure patent common femoral artery (present in 86% of successful through-knee amputations) 4
   • Consider prophylactic inflow revascularization in high-risk patients 3

2. Novel Approaches:

   • For cases with femoral artery occlusion, retrograde trans-amputation embolectomy of common, superficial, and deep femoral arteries may be considered to improve inflow 5

Postoperative Considerations

Monitoring and Management

• Assess stump perfusion regularly in immediate postoperative period
• Monitor for signs of ischemia (coolness, pallor, pain)
• Consider antiplatelet therapy unless contraindicated 1

Follow-up Care

• Regular evaluation for return or progression of ischemic symptoms
• Check femoral pulses and ABI in remaining limb
• Monitor wound healing and address complications promptly 1

Pitfalls and Caveats

• Failure to assess femoral inflow adequacy preoperatively can lead to stump gangrene with high mortality (28.5%) 3
• Ignoring profunda femoris artery status may result in inadequate collateral circulation to the stump
• Attempting revascularization after stump necrosis has developed carries high mortality 3
• Primary hip disarticulation may be preferable in patients with multiple risk factors for poor healing 2

By ensuring adequate arterial inflow and proper management of the femoral artery and its branches during above-knee amputation, surgeons can significantly improve wound healing outcomes and reduce complications.