Ischemia with endovascular balloon during disarticulations and amputations of limbs

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.