Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa.
J Vasc Surg. 2013 Oct;58(4):1037-42. doi: 10.1016/j.jvs.2013.04.035. Epub 2013 Jun 6.
Traditional treatment of acute arterial complications associated with total knee arthroplasty (TKA) and total hip arthroplasty (THA) has generally included arteriography followed by open surgery. The purpose of this study was to describe our evolution from open surgery to preferential endovascular treatment for acute arterial complications of TKA and THA.
We analyzed our computerized database registry and patient charts for vascular interventions associated with TKA and THA at a hospital with a large volume of orthopedic surgery to determine changing trends in endovascular intervention for these complications.
Between 1989 and 2012, 39,196 TKA (26,374 total: 23,205 primary; 3169 revisions) and THA (12,822 total: 10,293 primary; 2529 revisions) were performed. Vascular surgery consultation was provided for the treatment of acute ischemia, hemorrhage, ischemia with hemorrhage, and pseudoaneurysm formation. All interventions were performed within 30 days of joint replacement. A total of 49 (0.13%) acute arterial complications occurred over the 23-year period: 37 (76%) associated with TKA and 12 (24%) with THA. Arterial injury was detected on the same day as the orthopedic procedure in 28 patients, between postoperative days 1 and 5 in 18 patients, and between postoperative days 5 and 30 in three patients. The arterial complications caused ischemia in 28 patients (58%), hemorrhage in six (12%), ischemia with hemorrhage in six (12%), and pseudoaneurysm in nine (18%). Treatment included solely endovascular intervention in 12 (25%), failed endovascular treatment converted to open surgery in one (2%), and open surgery alone in 36 (73%) patients. Before 2002, only 6% (2/32; 2 TKA) of patients were successfully treated with endovascular intervention compared with 59% (10/17; 9 TKA, 1 THA) after June 2002 (P = .0004). There was no mortality, and limb salvage was achieved in all patients.
Although the majority of acute arterial complications after TKA and THA are diagnosed on the day of surgery, a high clinical awareness for acute arterial injury should also be present in the postoperative period. Although not always feasible, endovascular management is now our preferred treatment for injuries associated with TKA or THA. This offers substantially shorter time to vascular restoration, with less morbidity than open repair, and equivalent satisfactory outcomes.
传统的全膝关节置换术（TKA）和全髋关节置换术（THA）相关急性动脉并发症的治疗方法一般包括动脉造影，然后进行开放性手术。本研究的目的是描述我们从开放性手术到 TKA 和 THA 急性动脉并发症的优先血管内治疗的演变过程。
我们分析了一家大型骨科手术医院的计算机化数据库登记和患者病历，以确定这些并发症的血管内介入治疗的变化趋势。
1989 年至 2012 年间，共进行了 39196 例 TKA（26374 例：23205 例初次手术；3169 例翻修手术）和 12822 例 THA（10293 例初次手术；2529 例翻修手术）。血管外科会诊用于治疗急性缺血、出血、缺血伴出血和假性动脉瘤形成。所有干预措施均在关节置换后 30 天内进行。在 23 年的时间里，共发生 49 例（0.13%）急性动脉并发症：37 例（76%）与 TKA 相关，12 例（24%）与 THA 相关。28 例患者在骨科手术当天发现动脉损伤，18 例患者在术后第 1 天至第 5 天之间，3 例患者在术后第 5 天至第 30 天之间。动脉并发症导致 28 例患者（58%）发生缺血，6 例（12%）发生出血，6 例（12%）发生缺血伴出血，9 例（18%）发生假性动脉瘤。治疗包括单纯血管内介入治疗 12 例（25%），1 例（2%）血管内治疗失败转为开放性手术，36 例（73%）患者仅行开放性手术。2002 年 6 月前，仅 6%（2/32；2 例 TKA）的患者经血管内介入治疗成功，而 2002 年 6 月后（10/17；9 例 TKA，1 例 THA）成功率为 59%（P=0.0004）。无死亡病例，所有患者均保留肢体。
尽管 TKA 和 THA 后大多数急性动脉并发症在手术当天即可诊断，但术后也应高度警惕急性动脉损伤。尽管并非总是可行，但血管内治疗现在是我们治疗 TKA 或 THA 相关损伤的首选方法。这大大缩短了血管恢复的时间，与开放性修复相比，发病率更低，且结果满意。
