Once proximal and distal controls are obtained, careful dissection of the injury can commence. The complete circumference of the vessel should be inspected with special attention to the often overlooked back wall. Injuries that can be repaired with simple lateral sutures should be fixed immediately, including venous injuries. Massive destruction of the femoral vein, however, should result in ligation rather than a complicated and time-consuming repair, which will likely thrombose soon afterward anyway. Similarly, in a dying patient with massive tissue destruction, the superficial femoral artery may also be ligated with relatively good outcome if the profunda femoral artery is intact. Subacute bypass (after resuscitation in the intensive care unit) can be used to rescue a limb that becomes ischemic from superficial femoral artery ligation.

For anything other than a simple lateral arteriography, you should consider temporary shunting instead of complicated definitive repair in a severely compromised patient. For practical purposes, a complicated repair is any repair that requires graft material or saphenous vein. Your decision to shunt should be based on the patient’s physiologic status and the associated injury burden. A very sick patient, as evidenced by hypothermia, acidosis, or coagulopathy, should be shunted and returned to the operating room after these are corrected. Additionally, a heavy injury burden should prompt the surgeon to shunt and move on to treating other injuries. This is particularly a helpful strategy in mass casualty events and combat surgery. On the other hand, in a stable patient with good physiology, even the most complicated repairs can be undertaken immediately.

The general principles of vascular surgery hold true for complex arterial or venous reconstruction: Autologous conduit is generally better than artificial graft material, especially for the femoral vessels. Reconstruction with reversed saphenous vein (for interposition repairs) or saphenous vein patch for anterior wall injuries is simple and, if done well with technical expertise, will last a lifetime. Most complex vascular anastomoses can be easily made with running 4-0 or 5-0 polypropylene suture. You should pay special attention to any combined arterial and venous injuries. Adjacent suture lines should not be allowed to contact one another, and a vitalized tissue flap should be placed between these two to avoid fistula.

Consideration should be given to placing a muscle flap over any repair done with graft material particularly if it is partially or totally exposed. A sartorius muscle flap is a simple and very fast solution. Simply identify the sartorius muscle in the lateral side of the wound, and dissect along its circumference superiorly toward the anterior superior iliac spine where the tendinous attachment may be taken down. The muscle can then be rotated over into the groin to provide muscular coverage of vascular repairs. The muscle can be secured in place by tacking it to the inguinal ligament. Alternatively, if the vascular injury is more distal and the incision is already fairly distal, the sartorius can be dissected distally toward its attachment at the medial knee, divided, and placed over the repair. A grossly contaminated wound remains a relative contraindication to the use of graft material, and this should be a last resort under circumstances where the saphenous vein is not available or suitable. If the patient is undergoing a simultaneous laparotomy, for example, a short segment of internal iliac artery can be harvested instead of placing graft material in a contaminated wound.

If the patient has a multiply penetrated thigh (such as multiple stabs, gunshots, fragmentation from a grenade, or improvised explosive device with shrapnel), then an on-table angiogram should be performed once vascular control has been obtained, but before repair of the femoral injuries. Also completion angiogram is desirable after completing the repair to confirm good graft proximal and distal anastomosis. The simplest technique is to cannulate the femoral vessel as proximal as possible (but just distal to the point of proximal vascular control) with an 18 or 20 gauge angiocatheter or butterfly. The C-arm X-ray machine can then be brought over the field. The inflow should be occluded while injecting half-diluted intravenous contrast agent. Any commercially available iodinated contrast agent may be utilized that has at least 320 mg/mL of organically bound iodine such that the half-diluted injectate has approximately 160 mg/mL of iodine. Injectate with approximately 160 mg/mL of iodine is all that is required to opacify the femoral outflow from the inguinal ligament to Hunter’s Canal. Opacification of the vessels below the knee will require injectate with approximately 320 mg/mL of iodine as contrast agent. Generally, the C-arm should be activated in real time while injecting the contrast and the run recorded for playback. If possible, the digital subtraction technique should be utilized for the best pictures, although adequate imaging is certainly possible without this option. If a C-arm is not available, a simple flat plate X-ray may be used. Simply position the flat plate below the field, and arrange the X-ray machine appropriately over the plate. After occluding the inflow, inject half-diluted contrast agent, and shoot the X-ray approximately 6 s after injection. Be sure to include the entire thigh in the X-ray field. A radiolucent table is not necessarily required for this procedure, although it does eliminate the bothersome radiopaque metal bars visualized on most on-table angiograms done on a non-radiolucent table. These bars are generally a simple annoyance and do not affect the utility of the angiogram. If the bar does obscure the area of particular interest on the angiogram, it can simply be re-shot in a slightly different orientation. Once the procedure and injury repair are completed, the femoral vessel can be decannulated, and the puncture site is closed with a single 5-0 polypropylene stitch. Alternatively, if angiogram capabilities are not available, the entire length of the femoral vessels may be explored surgically with relative ease all the way to the adductor canal, albeit through a somewhat larger incision. In the absence of radiographic capability for a fragmentation wound or multiple penetrating wounds with unilateral pulse discrepancy, this maneuver is mandatory. The only instruments required are scissors and an educated hand.