Delayed Occlusion of the Left Superficial Femoral Artery Following High-Energy Lower Extremity Trauma: A Case Report

Abstract

Background:
Peripheral vascular injury is a serious but sometimes underrecognized complication in patients with high-energy extremity trauma. Intimal disruption of the artery may lead to delayed thrombosis and subsequent limb ischemia if early signs are missed. Prompt recognition and timely surgical management are crucial to optimize limb salvage outcomes.

Case Presentation:
A 19-year-old male sustained bilateral femoral fractures and an open right tibial fracture with palpable distal pulses following a motorcycle collision. Initial management included debridement and open reduction with internal fixation of the right tibia. Two days postoperatively, the patient developed pallor, coldness, and loss of distal pulses in the left leg. Computed tomographic angiography demonstrated distal superficial femoral artery (SFA) occlusion. Twenty hours after symptom onset, the patient underwent exploration and revascularization with a 4.5-cm. PTFE interposition graft, accompanied by fasciotomy and external fixation of the femur. Subsequent debridement of necrotic posterior compartment muscle was required. Definitive fixation with intramedullary nails was later performed, and the limb was successfully salvaged. The patient achieved partial weight-bearing ambulation upon recovery.

Discussion:
This case highlights the importance of serial vascular examinations in trauma patients, as palpable pulses do not exclude vascular injury. In the presence of hard signs of vascular injury, immediate surgical intervention should be prioritized over advanced imaging to prevent treatment delay with few exceptions such as patient with multilevel injury. Assessment of ischemic severity using Rutherford classification may be unreliable in cases with concomitant nerve injury. Partial muscle necrosis does not always necessitate amputation if viable tissue remains. Multidisciplinary collaboration among trauma, vascular, and orthopedic teams, together with effective communication with the patient’s family, is essential to optimize outcomes and mitigate reperfusion-related complications.

Conclusion:
Delayed arterial occlusion can occur even in the presence of initially palpable pulses. Serial assessment and coordinated multidisciplinary management are key to achieving successful limb salvage and minimizing morbidity in vascular trauma.