Outcome of complex venous reconstructions in patients with trauma

Small saphenous vein aneurysm diagnosis and treatment

Venous aneurysms are rare, particularly those arising from the superficial venous system. Current limited evidence suggests that congenital weakness of the vein wall, degenerative changes, trauma and inflammation are among potential causes. Surgical management has been the mainstay treatment modality of venous aneurysms. Surgical approaches and techniques should be tailored on a case-by-case basis, taking into consideration aneurysm location, size, shape and presence of complications (ie, rupture or thrombosis). In this report, we present a male patient in his late thirties who presented with right leg swelling and achiness 2 years following right lower extremity blunt trauma and was found to have a 3 cm small saphenous vein aneurysm extending to the saphenopopliteal junction. The patient was successfully treated with excision of the aneurysm via a posterior approach. This case report adds to the current literature and may help to define future treatment recommendations.

Predictive factors of amputation in infra-inguinal vascular trauma: a monocentric experience

OBJECTIVES

Infra-inguinal vascular injuries (IIVI) are emergencies involving both functional and vital prognosis. The choice between saving the limb or doing a first-line amputation is difficult even for an experienced surgeon. The aims of this work are to analyze early outcomes in our center and to identify predictive factors for amputation.

M METHODS

Between 2010 and 2017, we reviewed retrospectively patients with IIVI. The main criteria for judgement were: primary, secondary and overall amputation. Two groups of potential risk factors of amputation were analyzed: Those related to the patient: age, shock, ISS score; those related to the lesion: mechanism, above or below the knee, bone lesions, venous lesions and skin decay. A univariate and multivariate analysis were performed to determine the risk factor(s) independently associated with the occurrence of amputation.

RESULTS

57 IIVI were found in 54 patients. The mean ISS was 32,3 ± 21. A primary amputation was performed in 19%, and secondary in 14% of cases. Overall amputation rate was 35% (n=19). Multivariate analysis reveals that the ISS is the only predictor of primary (p=0.009; OR:1.07; CI:1.01-1.12) and global (p=0.04; OR:1.07; IC:1.02-1.13) amputation. A threshold value of 41 was selected as a primary amputation risk factor with a negative predictive value of 97%.

CONCLUSIONS

The ISS is a good predictor of the risk of amputation in IIVI. A threshold of 41 is an objective criterion helping to decide for a first-line amputation. Advanced age and hemodynamic instability should not be important in the decision tree.

Early Outcomes of Complex Vascular Reconstructions in Lower Extremities Using Spiral and Panel Vein Grafts

BACKGROUND

Spiral saphenous vein grafts (SSVG) or paneled vein grafts (PVG) can be used when the diameter of the autologous great saphenous vein does not match the vessel that needs to be repaired. This study aimed to present early results of complex vascular reconstruction with SSVGs and PVGs in the lower extremities.

METHODS

From May 2019 through January 2021, 6 SSVGs and 3 PVGs were used for vascular reconstruction in 9 patients. Patient data were collected retrospectively, including age, gender, cause of vascular pathology, target vessels, concomitant injury, surgical method, additional surgical methods, and hemodynamic status. The Kaplan-Meier method was used to calculate the rate of freedom from reintervention.

RESULTS

Among these patients, 7 had trauma, 1 had graft infection, and 1 had vascular reconstruction after tumor excision. The mean duration of follow-up was 6 ± 6.6 months (range 1-19 months). The rate of freedom from reintervention for any reason was 77.8% at 1 year. Two patients underwent amputation after vascular reconstruction with patent vascular reconstructions. One of the 2 amputations was performed because of infection, and the other was due to ischemia >24 hr. The success rate of reconstruction was 100%, and the primary patency rate was 100%. The rate of limb salvage was 77.8%. There was no death, bleeding, embolism, skin ulcers, graft-related complication, or aneurysmal dilation during follow-up.

CONCLUSIONS

SSVG and PVG were associated with low infection rates and satisfactory short-term patency rates. Both 2 grafts may be good choices when there is a diameter mismatch in vascular reconstructions.

Review article: History of venous trauma

ABSTRACT

This is a literature review on the history of venous trauma since the 1800s, especially that to the common femoral, femoral and popliteal veins, with focus on the early 1900s, World War I, World War II, Korean War, Vietnam War, and then civilian and military reviews (1960-2020). In the latter two groups, tables were used to summarize the following: incidence of venous repair versus ligation, management of popliteal venous injuries, patency of venous repairs when assessed <30 days from operation, patency of venous repairs when assessed >30 days from operation, clinical assessment (edema or not) after ligation versus repair, incidence of deep venous thrombosis after ligation versus repair, and incidence of pulmonary embolism after ligation versus repair.There is a lack of the following in the literature on the management of venous injuries over the past 80 years: standard definition of magnitude of venous injury in operative reports, accepted indications for venous repair, standard postoperative management, and timing and mode of early and later postoperative assessment.Multiple factors have entered into the decision on venous ligation versus repair after trauma for the past 60 years, but a surgeon's training and local management protocols have the most influence in both civilian and military centers. Ligation of venous injuries, particularly those in the lower extremities, is well tolerated in civilian trauma, although there is the usual lack of short- and long-term follow-up as noted in many of the articles reviewed.

LEVEL OF EVIDENCE

Review article, levels IV and V.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries

Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Adult Human Vein Grafts Retain Plasticity of Vessel Identity

BACKGROUND

The spiral saphenous vein graft is an excellent choice for venous reconstruction after periphery vein injury, but only few cases have been reported. We implanted a segment of a single saphenous vein into both the popliteal vein as a venous vein graft and into the popliteal artery as an arterial vein graft at the same time in a trauma patient; we then had an extraordinary opportunity to harvest and examine both patent venous and arterial vein grafts at 2 weeks after implantation.

METHODS

A spiral saphenous vein graft was made as previously described and implanted into the popliteal vein and artery as interposition grafts; because of the patient's serious injuries, an amputation was performed at day 18 after vascular reconstruction. The grafts were harvested, fixed, and examined using histology and immunohistochemistry.

RESULTS

Both grafts were patent, and there was a larger neointimal area in the venous graft compared to the arterial graft. There were CD31- and vWF-positive cells on both neointimal endothelia, with subendothelial deposition of α-actin-, CD3-, CD45-, and CD68-positive cells. There were fewer cells in the venous graft neointima compared to the arterial graft neointima; however, there were more inflammatory cells in the neointima of the venous graft. Some of the neointimal cells were PCNA-positive, whereas very few cells were cleaved caspase-3 positive. The venous graft neointimal endothelial cells were Eph-B4 and COUP-TFII positive, while the arterial graft neointimal endothelial cells were dll-4 and Ephrin-B2 positive.

CONCLUSIONS

The spiral saphenous vein graft remains a reasonable choice for vessel reconstruction, especially in the presence of diameter mismatch. Both the venous and arterial grafts showed similar re-endothelialization and cellular deposition; the venous graft had more neointimal hyperplasia and inflammation. At an early time, endothelial cells showed venous identity in the venous graft, whereas endothelial cells showed arterial identity in the arterial graft.

CLINICAL RELEVANCE

Veins can be used as venous or arterial vein grafts but venous grafts have more neointimal hyperplasia and inflammation; vein grafts acquire different vessel identity depending on the environment into which they are implanted.

Hyaluronic acid-heparin conjugated decellularized human great saphenous vein patches decrease neointimal thickness

Although the science of implantable materials has advanced therapeutic options in vascular surgery, graft failure is still a problem in need of a durable solution. With the development of coating and decellularization techniques, coated prosthetic grafts have become an option; however, whether decellularized human saphenous vein can be conjugated and implanted is not known. Human great saphenous vein (GSV) was harvested and decellularized and hyaluronic acid (HA)-heparin was conjugated to the GSV; water contact angles (WCA), morphology, and sulfur element change were measured before and after heparin bonding. GSV patches were implanted into the rat inferior vena cava and aorta; patches were harvested (Day 14) and analyzed. HA-heparin was successfully conjugated to the decellularized human GSV with altered morphology and reduced WCA. The HA-heparin coated decellularized GSV patch was anti-thrombotic in vitro, and significantly decreased neointimal thickness both in patch venoplasty and angioplasty in a rat model. Both CD90 and nestin positive cells participated in neointima formation. These data show that HA-heparin coated human GSV patches decrease neointimal thickness when used both in venoplasty and arterioplasty. Tissue engineered decellularized human GSV is a promising vascular prosthesis.

Impact of ligation versus repair of isolated popliteal vein injuries on in-hospital outcomes in trauma patients

BACKGROUND

Popliteal vascular injuries are common and frequently associated with limb loss. Although many studies have evaluated the treatment and outcomes of popliteal artery injuries (PAI), there is little available evidence regarding popliteal venous injuries (PVI). As such, substantial debate remains regarding the benefit of repair over ligation of PVI. The objectives of this study were to compare in-hospital outcomes of repair versus ligation of isolated PVI, as well as to determine nonvascular factors associated with worse outcomes.

METHODS

Patients in the National Trauma Databank from 2007 to 2014 with at least one PVI were evaluated. First, patients with concomitant PVI and PAI were compared with patients with isolated PVI. Second, outcomes were compared between ligation and repair of isolated PVI. To limit the impact of concomitant injuries and focus on the impact of venous injury management, we defined isolated PVI as cases without concomitant PAI and with Abbreviated Injury Scale severity score of less than 3 for all body regions other than lower extremity. Patients dead on arrival and those with less than 18 years of age were excluded. The primary outcomes were in-hospital mortality, amputation, and in-hospital amputation-free survival (AFS). Secondary outcomes included lower extremity compartment syndrome, fasciotomy, acute kidney injury, pulmonary embolism, deep venous thrombosis, and inferior vena cava filter placement.

RESULTS

Overall, 1819 patients (0.03%) had a PVI and after exclusion 1213 met the criteria for initial analysis. Of those, 308 had isolated PVI, and 905 had combined PVI and PAI. Patients with combined PVI and PAI had higher rates of amputation (15.2% vs 6.8%; P < .001), fasciotomy (64.5% vs 30.8%; P < .001), compartment syndrome (14.8% vs 8.8%; P = .006), and a lower AFS (82.9% vs 91.8%; P < .001) than patients with isolated PVI. There was no difference in in-hospital mortality, amputation, or in-hospital AFS between ligation and repair of isolated PVI. On multivariable logistic regression of isolated PVI, ligation was not independently associated with in-hospital AFS, amputation, or mortality.

CONCLUSIONS

Ligation of isolated PVI was not an independent predictor of in-hospital mortality, lower extremity amputation, or in-hospital AFS. Ligation also did not result in higher rates of fasciotomy, acute kidney injury, or pulmonary embolism.

Presentation patterns and prognosis of 109 isolated venous injuries in 99 patients

Objectives

To identify outcome predictors of isolated venous injuries (VIs).

Methods

Retrospective analysis of prospectively collected information.

Results

A total of 99 patients with 109 isolated VI were included. All-cause mortality was 18/99 (18%) and mortality related to the VI was 10/99 (10%). On multivariate analysis, independent predictors of all-cause mortality included age (odds ratio – OR – 1.06, p = 0.042), external cause – trauma and foreign body retention – of VI (OR 34.62, p = 0.002) and the number of red blood cell units transfused intraoperatively (OR 2.10, p < 0.001), while independent predictors of VI-related mortality included external cause of VI (OR 47.60, p = 0.001) and the number of red blood cell units transfused intraoperatively (OR 1.72, p = 0.003).

Conclusions

VIs due to external causes have a high mortality rate. On the other hand, VIs due to internal causes (iatrogenic injuries during a surgical procedure) are managed promptly and have a very low mortality related to the VI.

Factors Contributing to Morbidity after Combined Arterial and Venous Lower Extremity Trauma

The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.

Is It Really Mandatory to Harvest the Contralateral Saphenous Vein for Use in Repair of Traumatic Injuries?

Since the transition time in surgical technique of vascular repair to current civilian practice, the great saphenous vein (GSV) remains unarguably the preferred conduit for surgical reconstruction in the lower extremity. With qualities such as accessibility, expendability, and long-term durability, it is easy to understand the enthusiasm with using the GSV in arterial or venous vascular injuries. However, the question does arise whether these detailed benefits of the GSV warrant harvest from an uninjured limb for vascular reconstruction on an injured limb. For those ardent followers of surgical dogma, harvest of contralateral vein from the uninjured lower extremity traumatic vascular repair is mandated. Unfortunately, this principle is not supported by high-quality data and remains folklore at best.

Venous thromboembolism after major venous injuries: Competing priorities

BACKGROUND

Venous thromboembolism (VTE) after major vascular injury (MVI) is particularly challenging because the competing risk of thrombosis and embolization after direct vessel injury must be balanced with risk of bleeding after surgical repair. We hypothesized that venous injuries, repair type, and intraoperative anticoagulation would influence VTE formation after MVI.

METHODS

A multi-institution, retrospective cohort study of consecutive MVI patients was conducted at three urban, Level I centers (2005-2013). Patients with MVI of the neck, torso, or proximal extremities (to elbows/knees) were included. Our primary study endpoint was the development of VTE (DVT or pulmonary embolism [PE]).

RESULTS

The 435 major vascular injury patients were primarily young (27 years) men (89%) with penetrating (84%) injuries. When patients with (n = 108) and without (n = 327) VTE were compared, we observed no difference in age, mechanism, extremity injury, tourniquet use, orthopedic and spine injuries, damage control, local heparinized saline, or vascular surgery consultation (all p > 0.05). VTE patients had greater Injury Severity Score (ISS) (17 vs. 12), shock indices (1 vs. 0.9), and more torso (58% vs. 35%) and venous (73% vs. 48%) injuries, but less often received systemic intraoperative anticoagulation (39% vs. 53%) or postoperative enoxaparin (47% vs. 61%) prophylaxis (all p < 0.05). After controlling for ISS, hemodynamics, injured vessel, intraoperative anticoagulation, and postoperative prophylaxis, multivariable analysis revealed venous injury was independently predictive of VTE (odds ratio, 2.7; p = 0.002). Multivariable analysis of the venous injuries subset (n = 237) then determined that only delay in starting VTE chemoprophylaxis (odds ratio, 1.3/day; p = 0.013) independently predicted VTE after controlling for ISS, hemodynamics, injured vessel, surgical subspecialty, intraoperative anticoagulation, and postoperative prophylaxis. Overall, 3.4% of venous injury patients developed PE, but PE rates were not related to their operative management (p = 0.72).

CONCLUSION

Patients with major venous injuries are at high risk for VTE, regardless of intraoperative management. Our results support the immediate initiation of postoperative chemoprophylaxis in patients with major venous injuries.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Giant Spontaneous Greater Saphenous Vein Aneurysm

Venous aneurysm, a rare venous anomaly, poses increased risk of distal thromboembolic event. Superficial venous aneurysm, such as greater saphenous vein aneurysm, is an uncommon subset with nonspecific symptoms and often a delay in diagnosis. Symptomatic patients or patients with a thromboembolic event may benefit from surgical intervention with low morbidity. This case report describes an isolated spontaneous greater saphenous vein aneurysm which was successfully ligated and resected for symptomatic relief and prevention of distal thromboembolism.

Prosthetic Grafting and Arteriovenous Fistula for the Surgical Management of a Common Femoral Vein Injury Using a Staged Approach

A 27-year-old female patient was referred due to an edematous left lower extremity. Both saphenous veins had been ablated with an endovenous laser procedure used to treat varicose veins. Venography revealed that the left common femoral vein had been divided and that thrombosis was present at the site of division. No veins were available around the thighs. The patient was treated using a staged procedure. During the first stage, a ringed polytetrafluoroethylene graft was used to repair the common femoral vein, and an arteriovenous fistula was constructed from the femoral artery to the graft using a short segment of cephalic vein to increase graft patency. The edema was relieved postoperatively and the graft was patent. During the second stage, which was performed 6 months later, the fistula was occluded by coil embolization. The staged procedure described herein provides an alternative for venous reconstruction when autologous vein is unavailable.

Use of Cryopreserved Small Aortic Homografts for Large Vein Replacement

Total obstruction, stenosis, or ligation of any large vein is associated with significant morbidity. No synthetic grafts can adequately replace large veins, particularly in areas subjected to motion (flexion or extension). Artificial prosthetic materials usually occlude within a short period.

Since 1987, the author has used cryopreserved allografts of small aortas varying from 1 to 1.7 cm in diameter to replace large vein channels in the upper or lower body. These allografts provide a manageable, pliable conduit with normal endothelium. He implanted grafts bridging gaps from 4 to 30 cm in length, in 14 patients (10 women, 4 men). Veins replaced were five iliac, three iliofemoral, and six subclavian-innominate. The long-term patency rate (follow-up 3 months to 10 years) is 93%.

The use of small aortic cryopreserved homografts for large vein replacement, particularly in mobile areas (groin, thoracic inlet, pelvis) is recommended. These grafts appear superior to any previous grafts used for the same purpose.

Abdominal vascular trauma

Abdominal vascular trauma, primarily due to penetrating mechanisms, is uncommon. However, when it does occur, it can be quite lethal, with mortality ranging from 20% to 60%. Increased early mortality has been associated with shock, acidosis, hypothermia, coagulopathy, free intraperitoneal bleeding and advanced American Association for the Surgery of Trauma Organ Injury Scale grade. These patients often arrive at medical centers in extremis and require rapid surgical control of bleeding and aggressive resuscitation including massive transfusion protocols. The most important factor in survival is surgical control of hemorrhage and restoration of appropriate perfusion to the abdominal contents and lower extremities. These surgical approaches and the techniques of definitive vascular repair can be quite challenging, particularly to the inexperienced surgeon. This review hopes to describe the most common abdominal vascular injuries, their presentation, outcomes, and surgical techniques to control and repair such injuries.

Common femoral vein reconstruction using internal jugular vein after blast injury

Common femoral vein traumatic injuries are rare. Surgical management is controversial and by nature case specific. In this report, we present an unusual case of an isolated common femoral vein injury from a gunshot blast repaired with an interposition internal jugular vein bypass. To our knowledge, this is the first reported case of an isolated common femoral vein reconstructed in this manner.

Vascular grafts

Autogenous vein is the conduit of choice in the surgical creation of bypasses of small-to-medium-caliber vessels in patients with peripheral occlusive arterial disease and will remain so for the near future. The success rate of bypasses using conduits of diameters greater than 6 mm has been excellent, whereas the majority of bypasses using smaller conduits fail within 5 years. In addition, due to a steep increase in rates of diabetes and decreasing cardiovascular mortality rates, increasing challenges are presented by this population. These facts have motivated much of the research in the cardiovascular arena over the past four decades, with improved techniques and new materials. Strategies to improve outcomes include the use of alternative materials including autologous, nonautologous and prosthetic grafts, utilizing different methods for their harvesting and preservation; tissue engineering, using either polymer- or biological-based scaffolds for cell seeding; endovascular methodologies; and gene therapy. This report presents an overview of the several options currently available in the management of patients with peripheral arterial occlusive disease, as well as the ongoing research directed towards the creation of an artificial engineered vessel, discussing experimental work in which endothelial cells have been seeded on different scaffolds and finally the potential application of gene therapy in the field of vascular reconstruction.

Management of traumatic popliteal vein injuries

PURPOSE

The aim of this study was to evaluate different repair methods of popliteal vein injuries, and to assess the relationship between early patency and surgical outcome.

METHODS

Thirty patients with popliteal vein injuries underwent surgical repair procedure at our hospital from March 2000 to April 2010. Patients who were haemodynamically unstable and those with massive bleeding from limb wounds were taken directly to the operating room. Stable patients underwent preoperative colour-flow duplex ultrasonography (CFDU).

RESULTS

Our study group consisted of 26 males and 4 females, ranging in age from 17 to 60 years with a mean age of 25.3 ± 5.9 years. The mechanism of trauma was penetrating in 27 patients and blunt in the remaining 3 patients. Treatment included primary venous repair in 11 cases, end-to-end anastomosis in 8, interposition vein graft in 10, and interposition polytetrafluoroethylene (PTFE) graft in 1. There were 26 patients with associated arterial injury, of which 4 cases had primary repair, 9 had end-to-end anastomosis, 11 had saphenous vein graft interposition, and 2 had PTFE graft interposition. Associated bone fracture was seen in 6 patients. There were no deaths. One patient required a below-knee amputation. Postoperative CFDU revealed thrombosed venous repair in 7 cases without any sequelae.

CONCLUSION

Popliteal venous injuries can be repaired with minimal downside and a good early patency rate. Additionally, transient venous patency allows for establishment of venous and lymphatic collateralisation. Alternatively, venous ligation should be considered only in unstable patients who refuse blood transfusion (Jehovah's witnesses). In these victims, adjuvant management may be required such as the use of fasciotomy and anticoagulation treatment.

Capillary leak syndrome in trauma: what is it and what are the consequences?

TICS is a complex disease that is clearly multifactorial in the traumatically injured patient (Fig. 2). Although systemic inflammation that occurs directly as a result of injury plays the most prominent role, the local tissue and organ injury effects of trauma not only cause local capillary leak and edema but also further amplify the SIRS response. High volume fluid administration and hypoproteinemic states further exacerbate the problem. All of this leads to organ dysfunction and failure, which is the third leading cause of death following injury. Strategies to treat TICS and attenuate its effects once it occurs by targeting inflammatory pathways have been wholly unsuccessful. The mainstay of therapy for TICS is prevention and minimization of its lethal effects. Newer resuscitation strategies such as hemostatic resuscitation and early goal-directed therapies are currently the best available strategies to combat TICS. Whether these result in better outcomes remains to be seen and the authors anxiously await the results of well-designed prospective trials.

Femoral vein injury and transposition techniques: a new approach to venous reconstruction in the setting of trauma

Femoral vein (FV) injury is infrequent but potentially serious. Venous repair is the procedure of choice and multiple technical options are performed. This article describes a novel venous reconstruction technique of transposition of the injured FV into the deep femoral vein (DFV) system. Two men, 26 years and 32 years old, were evaluated after suffering penetrating wounds to the inguinal region, resulting in proximal FV injuries. Both the patients were treated with a lateral venorraphy of the common FV and transposition of the FV to DFV (end-to-side anastomosis). Venous thrombectomy was not required; intravenous unfractionated heparin and local acting heparin were administered during surgery. Low molecular weight heparin therapy was routinely administered before intervention in combination with elastic compression stockings. Duplex ultrasound at 1 month and 6 months after the injury demonstrated patency and luminal integrity of the involved vein in both the patients. Clinical follow-up without duplex at 12 months and 18 months revealed no evidence of chronic venous insufficiency. In instances of penetrating injury to the proximal FV, transposition to the DFV represents a novel and effective alternative to establishing venous outflow from the extremity. This technique is relatively simple and presents good permeability in the medium term. However, possible and often tolerated ligation of penetrating FV injuries should be considered a last option.

Early Palma procedure after iliac vein injury in abdominal penetrating trauma

Ligation for penetrating abdominal vein trauma may have better outcome than a vascular reconstruction in an unstable patient. However, symptoms of chronic venous insufficiency may appear over time. We describe our surgical experience with 4 patients who underwent iliac vein ligation followed by venous bypass with a modified Palma derivation between 48 and 240 hours after sustaining penetrating abdominal trauma with concomitant iliac vein injury. Patients were assessed for venous symptoms and conduit patency with continuous wave Doppler and duplex scanning. One graft occluded acutely and the remaining three remain patent with functioning valves. In order to preserve venous outflow after severe iliac vein injury, we think that venous ligation as a part of damage control surgery followed by a modified Palma operation may prevent chronic symptoms of venous outflow obstruction without compromising an already injured patient.

The effect of vein repair on the risk of venous thromboembolic events: a review of more than 100 traumatic military venous injuries

BACKGROUND

The management of venous trauma remains controversial. Critics of venous repair have cited an increased incidence of associated venous thromboembolic events with this management. We analyzed the current treatment of wartime venous injuries in United States military personnel in an effort to answer this question.

METHODS

From December 1, 2001, to October 31, 2005, all United States casualties with named venous injuries were evaluated. A retrospective review of a clinical database was performed on demographics, mechanism of injury, associated injuries, treatment, outcomes, and venous thromboembolic events. Data were analyzed using the Fisher exact test, analysis of variance, and logarithmic transformation.

RESULTS

During this 5-year period, 82 patients sustained 103 named venous injuries due to combat operations. All patients were male, with an average age of 27.9 years (range, 20.3-58.3 years). Blast injuries accounted for 54 venous injuries (65.9%), gunshot wounds for 25 (30.5%), and motor vehicle accidents for 3 (3.6%). The venous injury was isolated in 28 patients (34.1%), and 16 (19.5%) had multiple venous injuries. The venous injury in two patients was associated with acute phlegmasia, with fractures in 33 (40.2%), and 22 (28.1%) sustained neurologic deficits. Venous injuries were treated by ligation in 65 patients (63.1%) and by open surgical repair in 38 (36.9%). Postoperative extremity edema occurred in all patients irrespective of method of management. Thrombosis after venous repair occurred in six of the 38 cases (15.8%). Pulmonary emboli developed in three patients, one after open repair and two after ligation (P > .99).

CONCLUSION

In the largest review of military venous trauma in more than three decades, we found no difference in the incidence of venous thromboembolic complications between venous injuries managed by open repair vs ligation. Blast injuries of the extremities have caused most of the venous injuries. Ligation is the most common modality of treatment in combat zones. Long-term morbidity associated with venous injuries and their management will be assessed in future follow-up studies.

Civil and war peripheral arterial trauma: review of risk factors associated with limb loss

We sought to analyze the early results of civil and war peripheral arterial injury treatment and to identify risk factors associated with limb loss. Between 1992 and 2001, data collected retrospectively and prospectively on 413 patients with 448 peripheral arterial injuries were analyzed. Of these, there were 140 patients with war injuries and 273 patients with civil injuries. The mechanism of injury was gunshot in 40%, blunt injury in 24%, explosive trauma in 20.3%, and stabbing in 15.7% of the cases. The most frequently injured vessels were the femoral arteries (37.3%), followed by the popliteal (27.8%), axillary and brachial (23.5%), and crural arteries (6.5%). Associated injuries, which included bone, nerve, and remote injuries affecting the head, chest, or abdomen, were present in 60.8% of the cases. Surgery was carried out on all patients, with a limb salvage rate of 89.1% and a survival rate of 97.3%. In spite of a rising trend in peripheral arterial injuries, our total and delayed amputation rates remained stable. On statistical analysis, significant risk factors for amputation were found to be failed revascularization, associated injuries, secondary operation, explosive injury, war injury (p < .01) and arterial contusion with consecutive thrombosis, popliteal artery injury, and late surgery (p < .05). Peripheral arterial injuries, if inadequately treated, carry a high amputation rate. Explosive injuries are the most likely to lead to amputations, whereas stab injuries are the least likely to do so. The most significant independent risk factor for limb loss was failed revascularization.

Management and short-term patency of lower extremity venous injuries with various repairs

BACKGROUND

Although several methods of repair of extremity venous injuries have been shown to be efficacious, patency rates have varied significantly from center to center.

METHODS

A retrospective review was made of treatment outcomes of adult and pediatric patients with major venous injuries of the lower extremity.

RESULTS

From 1997 to 2002, 82 patients sustained 86 major lower extremity venous injuries. Venous injuries were treated with primary repair in 27, complex repair in 37 (autogenous vein, 10, and ringed polytetrafluoroethylene [PTFE], 27) and ligation in 20. Prior to repair, temporary intraluminal venous shunts were used in 18 patients. Follow-up duplex imaging or venography or both were performed on 42 extremities at a mean of 10.9 +/- 7.1 days after repair with an overall patency rate of 73.8% (primary repair 76.5%; autogenous vein graft 66.7%; and PTFE 73.7%).

CONCLUSIONS

Overall early patency rate of venous repairs performed by an experienced trauma team is similar irrespective of the type of repair. The use of temporary intraluminal shunts is acceptable in selected circumstances, while ringed PTFE grafts are reasonable alternatives when the contralateral saphenous vein is too small.

Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss

PURPOSE

We sought to analyze the results of lower limb arterial injury (LLAI) management in a busy metropolitan vascular unit and to identify risk factors associated with limb loss.

PATIENTS AND METHODS

Between 1987 and 1997, prospectively collected data on 550 patients with 641 lower limb arterial injuries were analyzed.

RESULTS

The mechanism of LLAI was gunshot wounds in 46.1%, blunt in 19%, stabbing in 11.8%, and shotgun in 9.1%. The most frequently injured vessel was the superficial femoral artery (37.2%), followed by the popliteal (30.7%), crural (11%), common femoral (8.7%), and deep femoral (5.3%) arteries. In 3.4% of cases, there was a combined injury on either side of the knee (ipsilaterally). Associated injuries included bony injury in 35.1% of cases, nerve injury in 7.6%, and remote affecting the head, chest, or abdomen in 3.6%. Surgery was carried out on 96.2% of cases with a limb salvage rate of 83.8% and a survival of 98.5%. In spite of a rising trend in LLAI, our total and delayed amputation rates remained stable. On stepwise logistic regression analysis, significant (P <.01) independent risk factors for amputation were occluded graft (odds ratio [OR] 16.7), combined above- and below-knee injury (OR 4.4), tense compartment (OR 4.2), arterial transsection (OR 2.8), and associated compound fracture (OR 2.7).

CONCLUSION

LLAI carries a high amputation rate. Stab injuries are the least likely to lead to amputations, whereas high-velocity firearm injuries are the most likely to do so. The most significant independent risk factor for limb loss was failed revascularization.

Successful reconstruction of stripped superficial femoral vein

A 69-year-old man who had hemorrhagic shock after inadvertent stripping of the right superficial femoral-popliteal vein during surgery for greater saphenous vein varicosis in another hospital was referred to us. Phlebography revealed a ruptured popliteal vein with intact profunda femoris and common femoral veins. The stripped superficial femoral-popliteal vein brought in a jar was reimplanted. Phlebography performed during the patient's follow-up visits in our outpatient clinic 11 months postoperatively showed a patent femoral vein.

Gunshot injuries of the popliteal artery

BACKGROUND

Guidelines for the management of popliteal artery trauma emanate mainly from military experience. This study was undertaken to describe the management of popliteal injuries in a civilian vascular surgical unit with a large trauma workload.

METHODS

A retrospective review of records of patients treated between 1983 and 1997 was undertaken.

RESULTS

Some 117 popliteal artery gunshot injuries were treated (83 low velocity, 16 high velocity, 18 shotgun). Associated fractures occurred in 44 patients and 40 had popliteal vein injuries. Treatment of the arterial injury included vein graft interposition in 71, primary reanastomosis in 19, prosthetic graft interposition in four, lateral suture in one, vein patch in one and ligation in one patient; 84 fasciotomies were performed. No perioperative deaths occurred. There were 20 primary and 14 secondary amputations. Factors associated with amputation were high-velocity injuries, delay in revascularization in excess of 7 h, arterial transection, associated fracture, and compartment syndrome or muscle infarction.

CONCLUSION

Civilian popliteal gunshot injuries are attended by a high amputation rate. Prompt resuscitation and revascularization appear to be the only correctable factors that may improve limb salvage rates.

Results of reconstruction in major pelvic and extremity venous injuries

PURPOSE

Outcome and venous patency after reconstruction in major pelvic and extremity venous injuries was studied.

METHODS

We retrospectively reviewed 46 patients with 47 venous injuries.

RESULTS

Injuries were caused by penetrating trauma in 37 extremities, blunt trauma in 6 patients, and were iatrogenic in 4 patients. Pelvic veins were injured in 4 patients, lower-extremity veins were injured in 39 limbs in 38 patients, and upper-extremity veins were injured in 4 patients. Concomitant arterial injuries occurred in 37 patients. Venous repairs were mostly of the complex type and included spiral or panel grafts in 15 (32%) reconstructions, interposition grafts or patch venoplasty in 19 (40%) reconstructions, end-to-end and lateral repair in 11 patients, and ligation in 2 patients. Two patients underwent early amputation. Early transient limb edema occurred in 2 patients, and postoperative venous occlusions were documented in 4 patients. Full function was regained in 39 (81%) extremities. No variable, including 4 retrospectively applied extremity injury scores (mangled extremity severity score [MESS], limb salvage index [LSI], mangled extremity syndrome index [MESI], predictive salvage index [PSI]), correlated with outcome. High values on all 4 scores were significantly associated with reexplorations (P <.02), which were done in 8 patients for debridement (5), arrest of bleeding (2), and repair of a missed arterial injury (1). Follow-up of 28 +/- 6 months on 27 patients (57%; duplex scan in 18, continuous-wave Doppler and plethysmography in 9, and venography in 3) showed 1 occlusion 6 weeks after the injury and patency of all other venous reconstructions.

CONCLUSION

Reconstructions of major venous injuries with a high rate of complex repairs result in a large proportion of fully functional limbs and a high patency rate. A high extremity injury score predicts the need for reexploration of the extremity. Mostocclusions occur within weeks of injury, and the subsequent delayed occlusion rate is very low.

Long-term follow-up of a superficial femoral vein injury: a case report from the Vietnam Vascular Registry

We report a 29-year follow-up of a high-velocity superficial femoral vein injury sustained during the Vietnam War that was treated by emergent ligation. After years of suffering recurrent ulceration from chronic venous insufficiency, this patient underwent axillary vein valve transfer with improvement in his venous hypertension. Long-term follow-up of patients with deep venous injuries is necessary to avoid complications from chronic venous insufficiency.