86

Review

Vascular handlebar syndrome with

blunt injury of common femoral
artery
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Report of two cases and systematic review of the literature

Loukia Alexopoulou-Prounia1 , Stavros K. Kakkos1, Vasiliki Mystakidi1 ,
Ioannis Ntouvas1, Pantelis Kraniotis2 , and Eleni Sintou3
1
Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
2
Department of Radiology, University of Patras Medical School, Patras, Greece
3
Department of Anesthesiology, University of Patras Medical School, Patras, Greece

Summary: Vascular handlebar syndrome with blunt injury of the common femoral artery is a rare vascular trauma
mechanism, with high possibility of being missed or delayed. We present two cases of vascular handlebar syndrome treated in
our hospital and a systematic review of the literature using MEDLINE and SCOPUS databases. Literature review identified
20 similar cases. The median age of patients was 18 years, and in vast majority males in gender. In most cases, the common
femoral artery injury was an intimal flap and lumen occlusion with intramural thrombosis followed by transection and intimal
injury without occlusion or thrombosis. The median time between injury and diagnosis/treatment was half an hour. Clinical
presentation ranged from asymptomatic to acute limb ischemia. The grade of acute ischemia was mostly Rutherford class I
(n=14), while acute IIa (n=4), chronic ischemia (n=3), and no ischemia (n=1) were also noticed. The correct diagnosis was
revealed by clinical examination only (n=1), or by the combination of clinical and imaging techniques including computed
tomography angiography (n=7) and duplex ultrasonography (n=4) or both (n=10). Management of the handlebar trauma
syndrome injuries was surgical in most cases. Outcome was favorable in all patients. Vascular handlebar syndrome is
extremely rare and high suspicion is required for early diagnosis and definitive treatment, as the early management is
effective and crucial for averting the devastating consequences. An individualized approach to the vascular trauma patient
is to be applied with considerations taken to the age of the patient, the mechanism of the injury, the anatomy of the lesion,
and symptomatology of the case.

Keywords: Handlebar syndrome, vascular injury, blunt trauma, common femoral artery, limb ischemia

Introduction Therefore it is of great importance to carefully evaluate

Handlebar trauma syndrome is a rare and often missed or
delayed blunt arterial injury in which the common femoral
artery (CFA) suffers a direct blow by the handlebar of a
motorcycle or bicycle as the rider falls forwards, in the
absence of penetrating injury or underlying fracture. It
was first described by Deutsch et al. in 1968, as the
motor-scooter handlebar syndrome [1]. A common site
for these injuries is at the level of the inguinal ligament,
where the common femoral artery is superficial and follows
through from the anterior to the superior pubic ramus and
femoral head. As such, it is prone to compression against
the underlying osseous structures.
The importance of blunt trauma is delayed vascular
stenosis or occlusion with little symptomatology at the time
of the injury in contrast to penetrating trauma which cre-
ates bleeding and expanding hematoma [2]. A blunt injury
can be asymptomatic for a while and so be overlooked.
and follow-up the patients, particularly for pediatric patient
population since diminished blood flow to a limb can create
discrepancies in limb length and limb growth [2].
As shown from the systematic search in MEDLINE and
SCOPUS there is no prior systematic review of the litera-
ture. The aim of this article is to report two interesting cases
of vascular handlebar trauma syndrome and blunt trau-
matic injury of CFA caused by the steering bar (handlebar)
of a bicycle and to perform a systematic review the litera-
ture as this syndrome may be rare.
Patients and methods
Case report A
An acute limb ischemia was caused to a 15-year-old
male student 2 hours after striking his left groin on a bicycle

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 L. Alexopoulou-Prounia et al., Vascular handlebar syndrome
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Figure 1. A sizable hematoma is observed in patient’s left groin and
upper thigh. The limb was pale in comparison with the other one.
handlebar. He was transferred from his local hospital and
on presentation he was in no apparent distress; past medi-
cal history was unremarkable. On physical examination, he
had a normal heart rate and pressure, as for the system
review there were not any findings worthy to be mentioned
except from the injured area and limb. During the overview
of the injured area a sizable hematoma was observed in his
left groin, the limb was pale in comparison with the other
one and had no pulses (Figure 1). Sensory and motor func-
tions were intact. Doppler examination indicated flow only
in the posterior tibial. A subsequent lower extremity com-
puted tomography angiography (CTA) revealed thrombosis
on the distal portion of the left CFA (Figures 2A and 2B).
Patient was transferred to the operating room, where
CFA thrombosis due to an intimal flap was found followed
by thrombectomy and passage of a 4Fr Fogarty catheter
distally, which did not retrieve any clots. The distal intimal
flap was tagged with 6-0 polypropylene sutures and the
arteriotomy was closed with a PTFE patch (GOREÒ ACU-
SEAL cardiovascular patch, W. L Gore & Associates, Flag-
staff, Ariz, USA; Figure 3). Postoperative course was
uneventful, and the patient was discharged home on the
second postoperative day with palpable peripheral pulses.
Ó 2023 Hogrefe
87
Case report B
The second case refers to a 21-year-old male college stu-
dent who had an accident with his bicycle which led to left
groin blunt injury by the handlebar and acute ischemia of
his left limb. The patient was stable with good motor func-
tion and sensation of his injured limb. On physical exami-
nation of the lower extremities the left leg was pale and
there was a bruise on the left groin. On palpation the limb
was cold and peripheral pulses were absent. On Doppler
examination there were no flow, neither dorsal nor the
posterior tibial artery. Lower extremity CTA showed an
obstruction at the level of the left CFA, exactly distal to
the inguinal ligament (Figure 4). Immediately the patient
was transferred to the operating room. During the opera-
tion a hematoma was found in the area, the CFA was
bruised and pulseless. An arteriotomy was performed
which showed thrombi and remnants of the endothelium,
all removed. The arteriotomy was closed with a GOREÒ
ACUSEAL cardiovascular patch. Immediately after the
operation, there were good Doppler signals in the periph-
eral arteries. The following day, Doppler signals became
monophasic on re-examination and there was suspicion
for embolism of popliteal and lower leg arteries, confirmed
on angiography (Figure 5). Embolectomy with a Fogarty
catheter was performed in a second operation through an
above the knee popliteal artery exploration, which led to
the immediate restoration of pulses in the lower leg.
Literature search
On March 14th, 2022, we conducted an up-to-date litera-
ture search on MEDLINE and SCOPUS electronic data-
bases using the keywords “handlebar trauma syndrome”,
“blunt trauma of common femoral artery”, “thrombosis
of common femoral artery due to blunt trauma”, with no
date limit, to identify articles reporting similar cases as
the two case reports, followed by a manual search of the
reference list of the full-text articles to identify additional
Figure 2. (A) and (B) CT angiography
reveals thrombosis on the distal
portion of the left common femoral
artery (arrow).
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Figure 3. Intraoperative figure showing the common femoral artery
bifurcation. The arteries were controlled with vascular clamps (prox-
imal clamp barely visible) and explored through a longitudinal
arteriotomy followed by removal of the local thrombus and parts of
the dissected intima. A large part of the CFA is denuded from its
intima. The distal intimal flap is marked with an arrow. CFA: common
femoral artery, SFA: superficial femoral artery.
trials. Studies not including humans or published in lan-
guages other than English were excluded. The study selec-
tion process was outlined using a PRISMA flow-diagram.
For each article included in the study, raw data were
entered into the table of datasheets.
Results
The literature review, with the criteria above mentioned,
identified 447 articles in total. After removing duplicate
records, 379 remained; their title and abstract was screened
and 365 were considered irrelevant, which left 14 records.
We obtained and reviewed the full text of these 14 records,
which were assessed for eligibility following criteria: injury
mechanism relevant to blunt trauma caused by the steering
Vasa (2023), 52 (2), 86–96
L. Alexopoulou-Prounia et al., Vascular handlebar syndrome
wheel of a bicycle or other similar vehicles (motor scooter,
motorcycle, all-terrain vehicle, etc.) and the injured artery
was the CFA. We excluded two records due to eligibility
reasons above mentioned.
Data such as age, gender, mechanism of vascular injury,
symptoms, treatment and other equivalent data, were con-
stituted as elements of comparison and study, that is why
they were not considered to the selection criteria. Seven
additional records identified through hand searching of
the reference list of the retrieved articles were added so
that the total number of relevant records was 19. The final
research sample consisted of 19 articles [2, 3, 4, 5, 6, 7, 8, 9,
10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20], describing 20 eligible
cases. The selection methodology is illustrated in a flow
chart (Figure 6). After adding our two patients, 22 cases
were included in our study.
Presentation and clinical characteristics of the 22 cases
are summarized in Table I. Most of the patients were chil-
dren or young adults, with a median age of 18 years and a
range of 9–51 years. The vast majority were males, only
one female case was found. The vehicles causing the acci-
dent were bicycle (n=14), motorcycle (n=4), motor scooter
(n=3), and all-terrain vehicle (n=1). The vascular injury was
most of the times CFA intimal injury with occlusion (n=18,
82%), CFA transection (n=3, 14%) and intimal injury with-
out occlusion or thrombosis (n=1, 4%) being less common.
Clinical presentation ranged from asymptomatic to acute
limb ischemia symptoms. Ischemia was most of the times
acute, Rutherford grade I (n=14) or Rutherford grade IIa
(n=4), while chronic (n=3) or no ischemia (n=1) were also
reported. In most cases (18 out of 22), the presentation
was acute limb ischemia with pain, numbness, pallor, or
low temperature of the limb, with lack of distal flow on clin-
ical examination (pulselessness) or on Doppler examina-
tion. Other presentations included local pain and
claudication (4 out of 22) as primary symptoms. In cases
of chronic clinical characteristic, calf claudication was
Figure 4. (A) and (B) CT angiography
reveals obstruction (arrows) at the
level of the common femoral artery,
exactly after the inguinal ligament.
Ó 2023 Hogrefe
 L. Alexopoulou-Prounia et al., Vascular handlebar syndrome 89

was provided in one case. Our data shows a wide range of

time until diagnosis from 0 hours to 8 months. The diagno-
sis was confirmed by either clinical or combinations of clin-
ical examination and imaging features including Duplex
ultrasonography (DUS) and CTA. In 10 cases (45%) all
the above-mentioned techniques were used during the
diagnostic process. In the remaining cases, clinical and
CTA (n=6), clinical and DUS (n=4), DUS and CTA (n=1),
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and clinical examination alone (n=1) revealed the traumatic

injury. Management of the arterial injuries was surgical in
most cases (21 out of 22). Vascular reconstruction with a
prosthetic graft interposition was used in 6/21 cases
(29%) including PTFE and Dacron grafts, a saphenous vein
graft was used in 8/21 cases (38%), the hypogastric artery
in 1/21 cases (5.5%), a synthetic cardiovascular patch graft
in 2/21 cases (11%), a prosthetic patch not otherwise spec-
ified in 1/21 case (5.5%), primary closure in 3/21 cases
(16.5%). For the single case not surgically managed, antico-
agulation therapy was used for 30 days. The procedure out-
come was favorable in all cases with limb salvage rate being
100%. There are two cases where the patient required mul-
tiple operations until reaching a favorable outcome.

Figure 5. Digital subtraction angiography reveals embolism of left

popliteal artery and tibioperoneal trunk (arrow).

always the predominant symptom leading the patient seek-
ing for medical help.
In Table II, interval to diagnosis, examination revealing
the correct diagnosis and treatment choice and outcome
are presented. The median time until the diagnosis was half
an hour in a total number of 21 cases; no such information
Discussion
In the current report, we describe two cases of vascular
handlebar trauma syndrome and blunt traumatic injury of
CFA caused by the handelbar of a bicycle and present a
systematic review of the literature. A favorable outcome
was mostly observed, likely a result of limited vascular

Identification of studies via databases and registers Identification of studies via other methods
Identification

Records removed before

Records identified from:
Records identified from: screening:
Reference list of retrieved
MEDLINE (n = 317) Duplicate records removed
articles (n = 7)
SCOPUS (n = 130) (n = 68)

Records screened Records excluded

(n = 379) (n = 365)

Reports sought for retrieval Reports not retrieved Reports sought for retrieval Reports not retrieved
(n = 14)
Screening

(n = 0) (n = 7) (n = 0)

Reports assessed for eligibility Reports assessed for eligibility

(n = 14) (n = 7)
Reports excluded:
Reports excluded: 0
Irrelevant (n = 2)
Included

Studies included in review

(n = 19)

Figure 6. PRISMA flow-diagram.

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 90 L. Alexopoulou-Prounia et al., Vascular handlebar syndrome

Table I. Clinical characteristics, type of injury and presentation of the 22 cases described in this review

First author (year) Age Gender Vehicle Vascular injury Ischemia grade* Presentation

Hadeed et al., 49 Male All-terrain-vehicle/ CFA, intimal injury-occlusion Acute IIa Acute limb ischemia
2005 [3] vehicle with handlebar on superimposed underlying
calcific atherosclerosis
Sarfati et al., 13 Male Bicycle CFA, intimal injury-occlusion Acute IIa Acute limb ischemia
2002 [4]
Sarfati et al., 9 Male Bicycle CFA, intimal injury-occlusion Chronic Thigh and calf claudication,
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2002 [4] absent pulses

Bean et al., 21 Male Motor scooter CFA, intimal injury-occlusion Acute IIa Acute limb ischemia
1968 [5]
Baker et al., 30 Male Motorcycle CFA, intimal injury-occlusion No ischemia Groin pain
1996 [6]
Hassan et al., 51 Male Motorcycle CFA, intimal injury-occlusion Acute I Acute limb ischemia with
2002 [7] diminished femoral pulses
Madan et al., 14 Male Bicycle CFA, complete transection Acute IIa Expanding hematoma,
2003 [8] absent distal pulses
Paling et al., 11 Male Bicycle CFA, intimal injury-occlusion Acute I Acute limb ischemia
1999 [9]
Waikittipong, 40 Male Motorcycle CFA, intimal injury-occlusion Chronic Numbness, pain and calf
2009 [10] claudication
Kioumehr et al., 15 Male Bicycle CFA, intimal injury with Chronic Pain and calf claudication
1989 [2] intramular thrombosis
Ophir et al., 21 Male Motor-scooter CFA, intimal injury Acute I Acute limb ischemia
1968 [11]
Chadha et al., 13 Unknown Motor-vehicle CFA, complete transection Acute I Acute limb ischemia
2003 [12]
Rose et al., 19 Male Bicycle CFA, occlusion Acute I Pain, swelling, ecchymosis
2016 [13]
Yoshimura et al., 18 Male Bicycle CFA, occlusion Acute I Numbness initially, then
2019 [14] claudication
Taneva Zaryanova 20 Male Bicycle CFA, complete transection Acute I Acute limb ischemia and
et al., 2017 [15] groin hematoma
Leo et al., 18 Male Motorcycle CFA, segmentary occlusion, and Acute I Pain and claudication
2012 [16] common femoral and iliac vein
occlusion due to hematoma
Jones et al., 10 Male Bicycle CFA, intimal injury-occlusion/ Acute I Pain and pallor
2016 [17] thrombus
Sandri et al., 23 Male Bicycle CFA, intimal injury-segmental Acute I Pain, ecchymosis and calf
2003 [18] thrombosis, total section of claudication
intima
Hussain et al., 11 Female Bicycle CFA and external iliac, Acute I Pain, lower temperature,
2021 [19] occlusion/thrombus intact motor function.
Patoulias et al., 11 Male Bicycle CFA, occlusion/thrombus Acute I Paleness, lower
2021 [20] temperature, reduced
muscle strength.
Case A, 2015 15 Male Bicycle CFA, intimal occlusion/ Acute I Acute limb ischemia
thrombus
Case B, 2010 21 Male Bicycle CFA, intimal injury-occlusion Acute I Acute limb ischemia

Notes. CFA: common femoral artery. *Ischemia grade in accordance with Rutherford classification for limb ischemia.

injury and the lack of atherosclerosis in a young population age [9, 24]. Lesions caused by blunt direct trauma may
group. easily be missed in young patients due to the lack of symp-
toms and the extensive pattern of collateral construction
Age and gender that may occur in this age.

Both pediatric and adult patients are included in cases of

handlebar trauma. In our study review, the male gender
is predominant. In the majority of the cases the patients
were 18 years-old or less. In children, blunt trauma repre-
sents 11–33% of all arterial injuries [9]. The predominance
of young males in such vascular trauma has been cited else-
where [21, 22, 23], as well as the importance of the young
Vehicle
Regarding vehicle type, bicycles, motorcycles, motor-scoo-
ters, and all-terrain vehicles have been associated with han-
dlebar trauma. Interestingly, blunt trauma with CFA injury
has also been reported in non-handlebar trauma cases.
Suliman et al. described a case of forced hip hyperextension

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 L. Alexopoulou-Prounia et al., Vascular handlebar syndrome 91

Table II. Interval to diagnosis, examination revealing the correct diagnosis and treatment choice and outcome of the 22 cases described in this
review

Interval to diagnosis and Examination revealed the

First author (year) intervention diagnosis Treatment Outcome

Hadeed et al., 2005 [3] 48 hours later Clinical and CT angiography PTFE bypass grafting, aorta Good
to SFA and jump graft to
deep femoral artery
Sarfati et al., 2002 [4] 5 hours later Clinical and CT angiography Hypogastric artery Good
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interposition grafting
Sarfati et al., 2002 [4] 10 weeks later Clinical and CT angiography Dacron bypass grafting Good
Bean et al., 1968 [5] 8 hours later Clinical and CT angiography Primary closure of Good
longitudinal arteriotomy
Baker et al., 1996 [6] Immediately anticoagulation, Doppler and CT angiography Saphenous vein patch Good
next day surgery angioplasty
Hassan et al., 2002 [7] Immediately Clinical, colour Doppler, CT Resection and primary end- Good
angiography to-end anastomosis
Madan et al., 2003 [8] Immediately Clinical and Doppler Interposition of prosthetic Good
graft between external iliac
and CFA
Paling et al., 1999 [9] Half an hour later Clinical (no pulses), Doppler, CT Saphenous vein patch Good
angiography angioplasty
Waikittipong, 2009 [10] 2 months later Clinical, CT angiography Interposition of PTFE graft Good
between external iliac and
superficial femoral artery
Kioumehr et al., 1989 [2] 8 months later Clinical (loud systolic bruit, no Saphenous vein bypass Good
pulses) and CT angiography grafting
Ophir et al., 1968 [11] 4 hours later Clinical Saphenous vein patch Good
angioplasty
Chadha et al., 2003 [12] 4 hours later Clinical (no pulses), Doppler, CT Primary end-to-end Good
angiography anastomosis
Rose et al., 2016 [13] Immediately Clinical, CT angiography Saphenous vein Good
interposition graft
Yoshimura et al., 2019 Later that day anticoagulation, Clinical, Doppler, CT Saphenous vein patch Good
[14] next day surgery angiography angioplasty
Taneva Zaryanova et al., Immediately Clinical, Doppler, CT Interposition of PTFE graft Good
2017 [15] angiography
Leo et al., 2012 [16] 3 days later Clinical, colour Doppler, CT Anticoagulation therapy Good
angiography only (duration: 30days)
Jones et al., 2016 [17] 2 days later Clinical and Doppler Common femoral artery Good
patching
Sandri et al., 2003 [18] Immediately, 24 hours later Clinical and Doppler Saphenous vein Good
surgery interposition graft
Hussain et al., 2021 [19] Immediately Clinical, Doppler, CT Resection of right CFA and Good
angiography an end-to-end anastomosis
with common femoral patch
angioplasty
Patoulias et al., 2021 Immediately Clinical and Doppler Resection and major Good
[20] saphenous vein
interposistion graft
Case A, 2015 2 hours later Clinical, Doppler, CT PTFE patch angioplasty Good
angiography
Case B, 2010 Immediately Clinical, Doppler, CT PTFE patch angioplasty Good
angiography
Notes. CT: computed tomography; CFA: common femoral artery; SFA: superficial femoral artery; PTFE: polytetrafluoroethylene.

and abduction which leaded to CFA injury [25]. Studies
have reported similar blunt trauma with CFA injury caused
by the fall of heavy objects on the pelvis or thigh [26, 27]. In
our review, we strictly included vascular handlebar syn-
drome caused by a vehicle as those mentioned above, sim-
ilar to our two cases.
The mechanism of the injury
Ophir et al. first described the mechanism of injury attribut-
ing the vascular injury in the formation of a tear at the CFA
intima leading to blood flow mediated dissection of the torn
intima and thrombus formation along the denuded artery
[11]. More specifically, the handlebar of a motorcycle or
bicycle as the rider falls forwards strikes the groin, causing
a direct blow at the level of the inguinal ligament. A seem-
ingly trivial injury can result in significant force being
applied to the artery [10]. The mechanism is that of blunt
force over the femoral vessel as it is compressed on the
bony pelvis [25]. It is the location and position of the CFA
that renders it vulnerable to injury from high-impact
trauma, as the one mentioned [1, 12, 16, 28]. At the level

Ó 2023 Hogrefe Vasa (2023), 52 (2), 86–96

 92
of the inguinal ligament, the femoral neurovascular bundle,
thus the femoral artery seems to be relatively immobile as it
passes anterior to the superior pubic ramus and femoral
head to its most superficial position. The CFA maintains
a fixed position in the groin area in the fibro-osseus canal
formed by its multiple branches, periadventitial connective
tissue, and the femoral sheath. This immobility renders the
CFA more vulnerable to compression against the underly-
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ing osseous structures [3, 4, 10, 12, 16, 25].
The mechanism of vascular occlusion
In our review, the vascular injury was most of the times
CFA intimal injury with occlusion (n=18, 82%). Blunt forces
or excessive stretching of the arterial wall can lead to struc-
tural changes and then to a gradual but progressive occlu-
sion [14, 29]. The outer layers of a healthy artery are more
elastic than the intima which presumably accounts for the
selective layer rupture on blunt trauma [5]. The intimal tear
or the intramural dissection owing to a blunt trauma has the
potential to mechanically obstruct the arterial flow. A pro-
posed mechanism is that of shearing forces transmitted
through the affected vessel so that a tear in the endothe-
lium and other layers of the intima is formed. The piece
of intima still attached to the media project into the lumen
of the artery as an intimal flap, which can then lead to the
thrombosis of the vessel [3, 11, 30]. The vascular occlusion
is presumably either by thrombus formation entirely as
Byun et al. described [29] or, by intimal dissection and
downward prolapse associated with some thrombus forma-
tion as in the case of Bean et al. [2, 5] and Yoshimura and
Hamamoto [14]. Whether only occlusion due to the pro-
lapse of inner arterial layers or thrombosis following the
vessel injury, or both take place, the upcoming blood flow
obstruction occurs in either case.
The presence of an atherosclerotic plaque may predis-
pose toward intimal disruption when subjected to shearing
forces due to not only intimal weakening but also loss of
compliance and elasticity that occur [3]. In cases of preex-
isted peripheral arterial disease (PAD) even a moderate
speed compressive trauma can lead to an intimal split.
What is more, as the upcoming physiological adaptation
to PAD is to remodel and increase the collateral blood sup-
ply to the extremity suffered, when blunt trauma occurs,
collateral circulation may mitigate acute interruption of
axial flow after the main vessel has been damaged. As a
result, there may be negligible or no signs of acute limb
ischemia, as in the cases of Karachentsev [23] and Peck
and Rasmussen [31].
Intimal disruption and vascular
transection
Although it was originally described as leading to vessel
thrombosis, intimal damage owing to a blunt trauma may
also result in subintimal hemorrhage, complete transec-
tion, partial avulsion, complete artery stenosis, aneurysmal
Vasa (2023), 52 (2), 86–96
L. Alexopoulou-Prounia et al., Vascular handlebar syndrome
or pseudo-aneurysmal dilation [25, 32]. For blunt trauma
and CFA injury, intimal disruption is the most common
type of vascular damage, followed by intramural hema-
toma, subintimal fibrosis and simple contusion [3, 4, 16,
33]. In our study, CFA transection occurred in 3 cases
(14%). As before mentioned, the relatively sharp anterior
lip of the acetabulum lies posterior to the CFA. Conse-
quently, a direct impact in the inguinal region with a blunt
surface can result in the CFA being crushed against the
anterior lip of the acetabulum, leading to complete transec-
tion of the CFA, without any associated bony injury as
Chadha et al. described [12].
In blunt vascular trauma, complete transection may lead
to retraction, vasoconstriction, and thrombosis of the ves-
sel, presenting with limiting hemorrhage, as in the case of
Suliman et al. [23]. In the case reported by Yoshimura
et al. it was presumed that the damaged intima had necro-
tized or retracted because of the complete circumferential
dissection leading to thrombosis and obstructive blood flow
[14]. Partial lacerations of the injured vessel may result in
persistent bleeding as well, a potentially much more severe
condition for the patient, especially when large vessels as
the CFA are involved [25].
Clinical presentation
Blunt arterial injury in the absence of associated bone frac-
ture has been usually overlooked leading to devastating
consequences. In case the patient is presented with classic
signs of acute limb ischemia on initial assessment, the diag-
nostic approach is unchallenging for an expert. However,
there are cases where signs indicative of the need for fur-
ther clinical and imaging examination are not apparent,
and therefore they are neglected. During physical examina-
tion the presence of signs of acute limb ischemia, including
pain, decreased or absent pulses, pallor, coolness, or paral-
ysis suggest possible vascular injury. In acute peripheral
artery occlusion, clinical presentation usually begins sud-
denly with symptoms as severe groin pain and swelling,
often accompanied by ecchymosis and hematoma, cool-
ness, and loss of normal color [3, 16, 34]. While the most
common sign of vascular injuries is pulse deficits, in 25%
of the cases normal pulses may be present on the initial
examination [3, 34]. Thus, diagnosis of vascular injury sec-
ondary to blunt trauma might be missed on initial exam in
the presence of a normal pulse [3].
Of all the cases reported, in 18 out of 22, the patients are
presented with signs and symptoms of acute limb ischemia
such as pulse deficit on clinical and DUS examination, pain,
numbness, pale skin color, and low temperature of the
limb. When the presentation was as above mentioned,
the diagnosis was made in a short amount of time; immedi-
ately or few hours after the incident. It is highly rare for the
right diagnosis to be made before complete occlusion of the
injured vessel occurs. In two of the studied cases, the inju-
ries were detected in the immediate postinjury phase
before ischemic symptoms emerged [6, 13]. Both of these
cases were presented with local swelling and associated
Ó 2023 Hogrefe
 L. Alexopoulou-Prounia et al., Vascular handlebar syndrome
thrill and bruit [6, 13]. For patients presenting no signs
indicative of vascular injury in the initial examination, per-
sistent pain and claudication revealed the vascular injury
within a certain amount of time after the incident. In all
cases of chronic clinical characteristics, calf claudication
was always the predominant symptom. In some cases,
authors have documented normal distal pulses in the
immediate postinjury phase in patients who developed
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complete arterial occlusion hours later [1, 6, 11, 33]. The
clinical diagnosis of these injuries is more challenging. It
has been noticed that in young patients is more often for
the symptoms to emerge 2–3 days after the traumatic event
because of more efficacious collateral development com-
pared to the older ones [16].
Examination that revealed the diagnosis
As mentioned above, during the physical examination of a
trauma patient such as the one injured by the handlebar of
a bicycle, certain injury patterns should prompt considera-
tion of associated arterial injuries. Early recognition of
these patterns raises the awareness of the clinician to con-
tinue with further investigation and more specialized test-
ing until confirming the diagnosis. Importance of a high
index of suspicion when consulting a patient with blunt
trauma has been mentioned in the literature [33]. Even in
the absence of clinical signs indicative of vascular injury
and acute limb ischemia, further evaluation with ankle bra-
chial pressure index (ABPI) measurement, DUS or angiog-
raphy should be made. Angiletta et al. suggested that the
physical examination should always be associated with a
DUS [15, 35] and when a low ABPI of the affected limb is
detected, CTA or conventional catheter-based angiography
should also be considered [34, 35]. An ABPI less than 1.0 is
an important clinical index that indicates that further
examination is required [8, 34]. In this review, we noticed
that the ABPI is not always mentioned as part of the clinical
vascular examination. CTA and magnetic resonance
angiography may have potential utility in evaluating for
such injuries, but their use for this specific application has
yet to be reported [33].
Jones et al. used only DUS as a non-invasive first-line
imaging test [17]. Duplex scan is not only a non-invasive
technique, but it is also a costless and timeless method.
Jones et al. suggested that DUS is an accurate technique
especially for emergency physicians who are familiar and
routinely use point-of-care ultrasonography (POCUS) to
identify the femoral vessels during venipuncture [17].
Ophir et al. reported that correct diagnosis is only possible
after arteriotomy. After the arteriotomy follows the evacu-
ation of the clots and careful examination for intimal con-
tinuity. Since “arterial spasm” may easily be mistaken
with intimal occlusion and dissection, the arteriotomy pro-
vides an inside look so it is easier to identify exactly the inti-
mal injury and traumatic detachment [11].
Based on the few published data, CTA seems to be the
preferred diagnostic tool, as it is accurate in evaluat-
ing peripheral arterial injuries and operative planning
Ó 2023 Hogrefe
93
[13, 33, 36]. In the majority of the reviewed cases, it was
the CTA that confirmed the diagnosis and demonstrated
the exact location of the vascular injury, in order to
plan the best surgical approach and management, underly-
ing the utility of this examination technique.
Interval to diagnosis and intervention –
the response time
The median time from the time of the accident until the
diagnosis and intervention was half an hour in a total num-
ber of 22 cases. Interval to diagnosis and intervention was
between the range of 0 hours and 8 months. Among the
22 cases, 9 of them (41%) were treated immediately, 7 of
them (32%) were treated hours later and 6 of them (27%)
were treated days to months after the initial incident.
As it was above mentioned due to the nature of the
injury, symptoms of blunt traumas may not become
apparent for hours or even days. In the presence of distal
pulses during the initial evaluation with no hard signs of
vascular injuries, it is easy for cases to be missed [33]. In
our review, in 5 out of 22 cases no vascular symptoms
were reported in the initial evaluation, and the patients
presented weeks or even months after the initial injury
[2, 4, 11, 16, 17]. A high index of suspicion should be main-
tained in the context of a history of handlebar trauma since
an early and meticulous clinical assessment can prevent
any unfortunate outcome.
The pediatric population has a good innate collateraliza-
tion pathway in the pelvic area and a greater capacity for
the development of collaterals. Stanton et al. described an
11-year-old patient with an extensive pattern of collaterals
within 48 hours after the trauma [24]. As such, the delayed
presentations may be more common in this specific patient
population. Thus, children may remain asymptomatic until
a period of growth spurt or resume more rigorous physical
activity [37]. A delay in the diagnosis in a young-age
patient, can impair growth-plate function, resulting in
limb-length discrepancy and permanent gait abnormalities
[4]. In contrast, older patients do not develop easily and
early enough such a rich network of collateral vessels. Nev-
ertheless, for those suffering from arterial disease, revascu-
larization already exists making it more challenging to be
diagnosed. In our study review, in 5 out of 22 cases the
response time was days, weeks or months after the initial
trauma [2, 4, 11, 16, 17]. In four of these cases, the age of
the patient was 18 years or less [4, 11, 16, 17]. This fact
comes in line with the above-mentioned speculation that
the pediatric population has a greater chance to be missed
in the initial examination.
Our review results regarding the interval to diagnosis
and treatment highlight the facility with which the use of
standard diagnostic tools can be expanded in the diagnosis
of an unusual injury complex. The simple maneuver of a
thorough clinical examination and the use of the DUS in
patients with handlebar trauma history can result in rapid
and precise identification of the vascular injury.
Vasa (2023), 52 (2), 86–96
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Treatment options
In our review, among the 22 cases, the vast majority (21 out
of 22) of the cases were treated by various open surgical
techniques. Regardless of the chosen surgical technique,
the limb salvage rate was 100% and the subsequent devel-
opment of the limb was normal in all cases. Literature
seems to advocate open primary surgery for the manage-
ment of these injuries; however, endovascular and conser-
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vative medical management have also been used [16, 35].
Surgical treatment
Ophir et al. early in 1968, suggested that if the syndrome is
recognized early enough, it can be corrected by simple arte-
riotomy, while a more complicated bypass grafting proce-
dure may be necessary in cases of late diagnosis [11]. After
arteriotomy, it is critical to proceed with extracting the
potential thrombus and replace the traumatized segment
completely ensuring that the artery-to-artery or artery-to-
vein- or artery-to-graft anastomosis is performed using a
healthy vessel edge and no tension [32]. Excision of the dam-
aged segment and end-to-end anastomosis is considered
when an arterial sleeve is resected or a regarding small size
arterial segment is removed [3, 11]. Another technique is the
removal of the detached intima and anchoring the distal torn
edge with patch graft closure of the arteriotomy site [11].
Direct arterial repair may be the preferred operative
approach in cases where small segments are injured, how-
ever, the extent of the arterial damage may preclude such
a primary repair [3]. The length of the artery affected, the
mobility of the segments and the severity of the injury deter-
mine the choice of method in the individual case [3, 11]. In
case a long arterial segment is injured, management requires
interposition of an autogenous or prosthetic graft [3]. In our
two reported cases, open surgery was the most appropriate
option as well. In both cases, the main anatomical issue
was the large intimal flap with a preserved media and adven-
titial layer of the vessel wall, rendering segmental replace-
ment not necessary. Thus, we performed patch repair
considering that the adventitia was strong enough to prevent
the formation of a late pseudoaneurysm.
The choice of the optimal arterial substitute, vein versus
prosthetic graft, remains controversial [15, 25, 38]. In our
study, a prosthetic graft or patch was used in 7 out of the
21 surgically treated cases, including PTFE and Dacron
grafts, a saphenous vein graft or patch was used also in 8
cases, the hypogastric artery in 1 case, no graft and primary
closure in 3 cases, and prosthetic graft and patch not other-
wise specified in 2 cases. When grafting is required, an
autogenous conduit is a preferable procedure. In most
cases, the greater saphenous vein is used, but also the use
of veins from the arms or even the jugular vein, has been
reported in the literature [15]. However, we should notice,
that the length as well as the diameter of the vessel are
important factors for choosing the most appropriate graft
in relation to circumstances [15]. For instance, when larger
grafts are needed, the superficial femoral vein may be
Vasa (2023), 52 (2), 86–96
L. Alexopoulou-Prounia et al., Vascular handlebar syndrome
preferred. What is more, in cases that require avoiding
the danger of an additional incision, given the probable sur-
rounding veins, contusion, and the emergency nature of the
case, a prosthetic graft constitutes an optimal option [15].
Suliman et al. also noticed that according to the literature,
most venous grafts ultimately thrombose regardless of
repair technique [25]. However, the femoral vein which is
usually the one used as a vein graft, is a vessel of high flow
with great patency. In two cases of our review, a prosthetic
supported PTFE graft was chosen because of its noted per-
formance in the aorto-femoral position along with its resis-
tance to compression.
Conservative treatment
In our review, we found only one case non-surgically man-
aged, in which the patient was successfully treated with anti-
coagulation therapy for 30 days [16]. Successful conservative
treatment of an isolated CFA intimal injury caused by com-
pression by the board has also been reported by Carter
et al. In this case, the CFA was injured due to compression,
presenting an intimal tear with no extravasation or obstruc-
tion revealed by the CTA. The patient was successfully trea-
ted with anticoagulation treatment. Apart of these two cases,
the standard of care is considered to be groin exploration
with arterial repair, while heparinization has been employed
successfully while awaiting the surgical repair to prevent
thrombogenesis and arterial occlusion [6, 33, 39].
Treatment considerations in the pediatric
population
In our review, most cases occurred in patients 18 years-old
or less. The importance of the young age of such patients
has been mentioned in the literature, since it should be
taken under consideration when deciding the optimal treat-
ment approach. Previous studies have suggested that when
treating the pediatric patient population, rapid limb growth,
the small vessel size and the tendency to restenosis are
some of the factors that should be well considered [15,
35]. The principles of arterial reconstruction in children
seem to be equal to those in adults. Where possible end-
to-end anastomosis should be performed, and in cases
needed a venous graft or patch can be used [24]. Autolo-
gous grafts are frequently preferred because the long-term
patency of synthetic grafts in children is not known [4, 14].
Some restrictions in the use of autogenous grafts such as
inadequate diameter to accomplish a meaningful bypass
or the risk of future aneurysmal changes, limit the range
of their use similarly to the adult population. In such an
event, synthetic grafts are to be considered. Successful
use of synthetic grafts in younger children has been
reported, but it remains unclear whether synthetic or autol-
ogous grafts are better [4]. According to Paling and
Viersma, the use of prosthetic grafts is not recommended
in regard to the expected growth, although some investiga-
tors describe the use of Dacron grafts [9]. What is more,
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 L. Alexopoulou-Prounia et al., Vascular handlebar syndrome
bypass with the anastomosis below the knee should be
avoided because this could lead to limb disparity, which
can also occur if stenosis remains after reconstruction
[9]. With all these in mind, the long-term efficiency of pros-
thetic grafts in pediatric extremity injuries is unknown,
thus, when grafting is required, the literature agrees on
generally favor autogenous conduits [4, 9, 14, 24]. In our
reported cases, synthetic grafts were preferred over autoge-
https://econtent.hogrefe.com/doi/pdf/10.1024/0301-1526/a001054 - Friday, March 08, 2024 5:12:53 PM - IP Address:2800:370:cb:88d0:8861:6fbd:2dc6:cae4
nous grafts. Even though, the one patient was only 15 years-
old, we concluded to this choice of graft since the patient’s
body size was almost the same as that of an adult.
The role of endovascular intervention in the pediatric
population has previously been documented more as a tem-
porizing measure for revascularization rather than a treat-
ment option [35, 37]. Angiletta et al. treated a 13-year-old
patient with the use of a stent in the distal superficial
femoral artery, after estimating that vessel’s caliber at the
time of injury was of inappropriate size for traditional
surgical reconstruction [35]. The main disadvantage of
endovascular interventions in pediatric patients is similar
to the disadvantage of prosthetic grafts. Because of the con-
stant growth of the child’s organs and tissue, the conse-
quent enlarging of the vessels will not conform with the
fixed stent length and diameter. This may predispose to
complications such as restenosis, stent fracture, stent dislo-
cation and acute to chronic ischemia and lower limb length
discrepancies due to increased caliber of the treated artery
[14, 35, 37]. As a result, future vascular reconstruction may
be required [37].
Rarity of cases
In a retrospective study of our hospital including patients
with arterial trauma for the 30-year period between 1989
and 2018, blunt trauma accounted for 29% of the cases
(83 cases out of 285), and 22% (65 cases out of 285) if
excluding the iatrogenic causes. What is more, only 2 of
these cases were caused due to handlebar syndrome corre-
sponding to a rate of 3.5% for such cases, underlying the
rarity of the syndrome [40].
Limitations
The syndrome is rare, so our review research identified a
limited amount of cases which were included. Thus, a lim-
ited number of cases were used to extract generalized con-
clusions. Nevertheless, we believe that our reasonable and
well justified conclusions may contribute to better under-
standing and treating such cases.
Conclusions
In conclusion, we reported two interesting cases of vascular
handlebar syndrome with blunt injury of the common
Ó 2023 Hogrefe
95
femoral artery and conducted a review of the literature of
this specific syndrome. It mainly concerns males of young
age and children. Clinical presentation ranges from acute
limb ischemia to complete lack of signs. It is the high index
of suspension that can lead to thorough clinical and imag-
ing evaluation averting the devastating consequences of
delayed diagnosis of such vascular injury. The treatment
is often proportional to the extent of the injury and the
age of the patient. Surgical treatment is often required,
sometimes with vascular reconstruction using autogenous
or synthetic graft. Conservative approach has also been dis-
cussed. Regardless of the chosen treatment, early recogni-
tion and appropriate treatment are necessary elements for
a good outcome, rescue, and normal development of the
limb.
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History
Submitted: 07.02.2022
Accepted after revision: 11.01.2023
Published online: 26.01.2023
Conflict of Interest
The authors certify that there is no conflict of interest with any
financial organization regarding the material discussed in the
manuscript.
ORCID
Loukia Alexopoulou-Prounia
https://orcid.org/0000-0002-0118-4150
Vasiliki Mystakidi
https://orcid.org/0000-0002-4344-6243
Pantelis Kraniotis
https://orcid.org/0000-0001-9149-1586
Eleni Sintou
https://orcid.org/0000-0001-5365-9712
Correspondence address
Loukia Alexopoulou-Prounia
Department of Vascular Surgery
University Hospital of Patras
Zafeiriou 4
17122 Athens
Greece
loukia_ale07@yahoo.gr
Ó 2023 Hogrefe