Objective Limb disarticulation has been widely performed since the
18th century, especially in war surgery. Actually is infrequently done
in orthopaedic and vascular surgery, and it is associated with a high
mortality rate because of frequent comorbidities. Disarticulation
usually is reserved for patients with malignant tumours or gangrene
from severe artherosclerosis. During disarticulation, hemodynamic
stability can be altered by hemorrhagic events in the femoral or
humeral arteries. We propose an endovascular technique for proximal
control of the artery to reduce blood loss during disarticulation. Our
experience today is limited at hip disarticulation.
Material and methods The vascular access was percutaneous at the
common femoral artery of the healthy limb. A 6 French (Fr) introducer
sheath was placed using the Seldinger technique. Under
fluoroscopic control, with a portable vascular C-arm capable of digitally
subtracter angiogram and roadmap angiography, a 0.035 inch
hydrophilic guide wire was crossed aver into the opposite side iliac
artery through a 5F contra angiographic catheter placed at the aortic
bifurcation. After a diagnostic angiography the guide wire was
replaced with an Amplatz 0.0035 inch, 260 cm long, super stiff guide
wire. Then, a 7 9 20 mm Ultra-thinTM SDS balloon catheter was
placed in the external iliac artery and systemic heparinization with
2500 UI was performed. The balloon catheter was inflated and femoral
pulsation ceased immediately. After proximal, endovascular
occlusion, hip disarticulation was accomplished without any hemorrhagic
complication. At the end of procedure, the balloon was deflated
and removed. Hemostasis of the surgical field completed the procedure.
The femoral access in the healthy common femoral artery was
controlled with a 6 Fr Angio-seal percutaneous hemostatic system.
Results and discussion In hip disarticulation, hemostatic tourniquets
cannot be used of the location of the operating field. Therefore,
control of bleeding is a major issue in this procedure. Various techniques
have been proposed, femoral vessels and nerves were attached before the disarticulation. The use of semi-compliant balloon catheters
for endovascular occlusion avoids injury to the endothelium of
the vessel wall during balloon inflation. However preoperative
assessment, with color-duplex scanning and plain abdominal radiographs,
is mandatory; coexisting atherosclerosis often is present
especially in elderly patients, and severe wall calcification can lead to
vessel rupture and retroperitoneal hematoma, or even balloon catheter
rupture. Moreover, color-duplex scanning and radiographs will help
in choosing the landing-zone for balloon inflation.
Conclusions Endovascular balloon assistance is a simple, safe and
effective technique in preventing major arterial bleeding during
amputation or disarticulation and can be routinely used