IPC22. Vascular Complications During Total Knee Arthroplasty: Understanding Relative Risks and High Morbidity for Popliteal Artery Injury

Total knee arthroplasty (TKA) is the most commonly performed operation in the United States; 700,000 TKAs are performed annually with a projected growth to 3.4 million procedures by 2030. Vascular injuries during TKA are rare with popliteal artery injury rates around (0.057%), with reported amputation rates as high as 42%. With these volumes, most vascular surgeons will be involved with the care of these patients during their career. This report seeks to demonstrate the incidence of injury, and morbidity associated with these injuries, and to describe the postoperative sequela that can complicate these repairs. We performed a retrospective chart review of a single center’s experience from 2011 to 2018 covering a high-volume orthopedic center. All cases in which vascular surgery was consulted intraoperative or in the postoperative period were included in this study. There were a total of eight iatrogenic vascular injuries over this 7-year period, during which approximately 40,000 TKAs were performed. Two were isolated popliteal vein injuries, and two were delayed presentations associated with geniculate artery pseudoaneurysms. There were four instances of popliteal artery injury, all of which attempts were made at intraoperative primary repair and all of which required secondary interventions. These secondary interventions included one surgical bypass, two stent placements for acute thrombosis, and one stent placement for delayed finding of pseudoaneurysm. This high intervention rate is likely owing to the challenging and limited visualization from an anterior exposure when called into intraoperatively to repair a damaged vessel. Given the 100% reintervention rate with direct repair at the time of injury, consideration should be given to routinely performing intraoperative imaging to confirm adequate primary repair. The patients with highest risk for popliteal artery injury include revision surgery (25%), and patients with a history of posterior knee dislocation (38%). Vascular injury during TKA is rare, and management of nonpopliteal artery injuries are generally well-tolerated; however, when a direct injury to the popliteal artery is encountered we recommend immediate postoperative follow-up with angiography to evaluate the quality of the repair and if needed for therapeutic intervention.