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Acute lower limb ischemia after arterial injury secondary to femoral hernia repair
Isquemia aguda de extremidad inferior tras lesión arterial secundaria a hernioplastia crural
Miriam Tellaeche de la Iglesiaa,
Corresponding author
miriam.tellaeche@gmail.com

Corresponding author.
, Arkaitz Perfecto Valeroa, Antonio Rebollo Garcíaa, Elena Aranda Escañoa, Ana Apodaka Díezb
a Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Cruces, Barakaldo, Vizcaya, Spain
b Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Cruces, Barakaldo, Vizcaya, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Vascular injury secondary to a suture is an uncommon but potentially serious situation in femoral hernia surgery&#46; It normally occurs on the femoral vein &#40;FV&#41;&#44; and it is rare for it to occur on the femoral artery &#40;FA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a case of acute ischemia of the lower limb after femoral hernia repair&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient is a 54-year-old woman&#44; with no relevant clinical history&#46; She presented an uncomplicated right femoral hernia&#44; which was treated as outpatient surgery using an anterior approach&#46; A Lichtenstein hernia repair was performed with cylindrical polypropylene mesh fixed with one polypropylene n 0 stitch to the lower side of the inguinal ligament&#59; the procedure apparently proceeded without incident&#46; 72<span class="elsevierStyleHsp" style=""></span>h after the procedure&#44; the patient reported coldness&#44; paresthesia and progressive functional limitation of the ipsilateral lower limb&#46; On examination&#44; no pulses were palpable&#44; she presented limited dorsiflexion of the foot &#40;grade 0 of the Medical Research Council &#91;MRC&#93; muscle strength scale&#44; paresthesia and decreased distal sensitivity&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Given the suspicion of acute arterial ischemia&#44; computed tomography angiogram &#40;CT-angiogram&#41; was performed &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#44; which revealed obstruction of the right common FA with posterior recanalization&#59; the superficial and deep FA were permeable&#44; and another obstruction was found in the third portion of the popliteal artery and the origin of the tibioperoneal trunk&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">With the finding of an occlusive thrombus in the lumen of the common FA&#44; urgent surgery was indicated&#46; Upon manual release of the artery&#44; a mechanical obstacle was palpated in the iliofemoral transition that corresponded with the stitch of the hernia repair cone anchored to the adventitia of the vessel&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Transfemoral thromboembolectomy was performed with a 4<span class="elsevierStyleHsp" style=""></span>Fr Fogarty catheter&#44; releasing the point of the stenosis and closing the arteriotomy with interrupted 5&#47;0 polypropylene stitches to recover perfusion of the limb&#46; Closed fasciotomies of the anterior and posterior compartment of the calf were also performed for the anticipated treatment of post-perfusion edema&#46; However&#44; during the postoperative period&#44; the patient presented compartment syndrome&#44; requiring extension of the anterior fasciotomy&#46; She was discharged on the sixth day after the second intervention with ischemic sequela upon dorsiflexion of the foot against gravity &#40;grade 3 MRC&#41;&#46; After 6 months of rehabilitation and follow-up&#44; she currently presents no motor limitations &#40;grade 5 MRC&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">When performing femoral hernia repair&#44; the sutures are close to the arteriovenous bundle&#44; superficial to the iliac artery and veins&#46; The proximity to these structures implies the possibility of iatrogenic injury&#46; In-depth knowledge of the inguinal anatomy is essential to try to avoid unexpected vascular injuries&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The FA passes through the lateral part of the femoral ring and the FV through the medial part&#46; At the medial level of the ring&#44; the transverse fascia attaches to the femoral adventitia&#44; covering the space between the vessels&#44; and is called the femoral septum&#46; In turn&#44; this is a weak point where hernias can appear&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Venous injury is much more common than arterial injury due to its more medial position&#46; The artery can be injured when the transverse fascia is included in the stitches used to close the medial aspect of the internal inguinal ring&#46; Care must be taken when setting the needle-penetration depth and assessing the proximity of the external iliac artery &#40;EIA&#41;&#44; which can become trapped&#44; causing stenosis&#44; or be injured by direct puncture or avulsion of one of its branches&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In our case&#44; the suture trapped the adventitial layer on the anterior side of the artery&#44; causing stenosis that led to secondary thrombosis of the common FA and a distal embolism&#46; Postoperative analgesia and the slow progression of functional limitation disguised the symptoms of ischemia&#44; delaying diagnosis for up to 3 days&#44; which initially led to a neurological sequela despite optimal limb revascularization&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinical suspicion should guide the correct diagnosis and treatment of these lesions&#46; The loss of pulses or the weakness of the femoral pulse compared to the contralateral limb after inguinal surgery should lead to suspicion of a possible arterial lesion&#44; and symptoms of sudden claudication with coldness and paresthesia are highly suggestive of ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Urgent evaluation by a vascular surgeon will avoid potential neuromotor sequelae or even loss of the limb&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the event of bleeding due to direct injury to the artery&#44; randomly applied hemostatic stitches should be avoided&#46; It is recommended to dissect and correctly expose the artery in order to reliably identify the point of injury and make the repair properly under direct vision&#44; using non-stenosing vascular sutures or patch angioplasty depending on the size of the defect&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Arterial injury after surgery for femoral hernia is a rare but serious complication&#46; It is important to explore the diagnosis of ischemia in patients after recent femoral hernia repair who present absence of pulses in association with coldness&#44; paleness&#44; paresthesia or motor dysfunction of the ipsilateral limb&#46; Proper diagnosis and treatment of a vascular injury minimizes the subsequent consequences of ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span>"
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Article information
ISSN: 21735077
Original language: English
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