Cross-Femoral Bypass Graft for Combined Iliac Arterial Venous Injury

Cross-Femoral Bypass Graft for Combined Iliac Arterial Venous Injury Marc P. Posner, MD, C. Gregory Alty, MD, H.M. Lee, MD, Richmond, Virginia

We report on the treatment of a patient who sustained combined arterial and venous injury to the left lilac vessels as a result of a gunshot wound. Repair was accomplished as a staged procedure following lifesaving ligation of both artery and vein, using extraanatomic, cross-femoral polytetrafluoroethylene (arterial) and saphenous vein (venous) bypass techniques, followed by prophylactic caval filter placement. Principles of management with respect to combined arterial venous vascular injury are discussed, with special reference to controversies surrounding repair of major venous injury. (Ann Vasc Surg 1991 ;5:286-290). KEY WORDS:

Cross-femoral bypass grafting; lilac artery; lilac vein; trauma.

One third of all civilian vascular injuries occur to the vessels supplying the lower extremity, and of these approximately 40% involve injury to major veins. Associated trauma to nearby structures, including bone, nerve, and soft tissue, occurs frequently and compounds the overall morbidity and mortality. Survival after combined injuries to the iliac artery and vein is in the range of 40-75%, depending upon the patient's hemodynamic presentation [1,2]. Extraanatomic bypass for chronic arterial insufficiency, originally developed for the high risk patient, has gained more widespread acceptance as an alternative to direct inline reconstruction since long-term results have been found to be almost as good [3,4]. Whereas the diagnostic and therapeutic approach to major extremity arterial injury has b e c o m e standardized and rather straightforward with resultant decreased limb loss, the same cannot be said o f major venous injury, where controversy and confusion persist as to whether to

From the Division of Vascular and Transplant Surgery, Department of Surgery, Medical College of Virginia, Richmond, Virginia. Reprint requests: Marc P. Posner, MD, Associate Professor of Surgery Division of Vascular~Transplant Surgery, Department of Surgery, Medical College of Virginia, Box 57, MCV Station, Richmond, Virginia 23298.

ligate or to repair. We present our experience with a patient involving life-threatening trauma to the left iliac artery and vein treated by combined arterial and venous cross-femoral bypass grafting.

CASE REPORT A 25-year-old black man was seen in the emergency department at the Medical College of Virginia Hospitals, having sustained a .22 caliber gunshot wound to the abdomen at close range. Initially hemodynamically stable, he quickly developed hypotension as his abdomen became tense and distended. The entrance wound was located in the left lower quadrant. There was no external hemorrhage, and rectal examination was guaiac-negative. Vascular examination was normal with the exception of diminished pulses throughout the left lower extremity. Airway management was accomplished by nasotracheal intubation. Bilateral 8 French subclavian catheters were placed, and fluid resuscitation begun. Gross hematuria necessitated a one shot intravenous pyelogram, which was normal, and a cystogram which demonstrated intraperitoneal extravasation. Exploratory laparotomy revealed a bladder perforation, which was repaired. Proximal control of the distal aorta was obtained, and a large, left retroperitoneal pelvic hematoma was entered, revealing injury to the left external iliac artery just beneath the inguinal ligament. Distal control necessitated exposure of the left common femoral

286

VOLUME 5

No 3 - 1991

Superficial femoral a. \

Saphenous v. <

287

CROSS-FEMORAL BYPASS GRAFT

!

flap coverage was used to encourage primary healing at the contaminated, reoperative left groin site. Postoperatively, the patient had immediate return of all left lower extremity pulses; Doppler flow overlying the venous bypass was easily heard. The patient was maintained on low molecular weight Dextran for five days, and elevation of the left lower extremity was effected, resulting in resolution of edema over the ensuing 72 hours. A prophylactic Greenfield filter was placed transjugularly at 36 hours. The patient's fasciotomy sites were skin-grafted on postoperative day five, and the patient was placed on "low-dose" Coumadin to maintain his prothrombin time at 16-18 seconds, as the Dextran was discontinued. The suprapubic tube was removed on postoperative day 10. A venogram was performed (Fig. 2) on postoperative day 14, and it demonstrated a widely patent saphenous vein crossover graft and multiple ipsilateral, dilated pelvic collaterals communicating with medial femoral circumflex venous channels on the left side. The patient was discharged from the hospital on postoperative day 16, all wounds having healed, ambulatory on crutches with no left lower extremity edema. "Lowdose" Coumadin was continued for 12 weeks. At that interval, the patient maintained a non-edematous left lower extremity and, unfortunately, was subsequently lost to further follow-up.

DISCUSSION

Fig. 1. Artist's rendition of operative repair of combined left lilac arterial and venous injury shows rightto-left superficial femoral artery 8 mm PTFE crossfemoral bypass graft, left-to-right saphenous vein venous bypass graft, and infrarenal IVC filter in place.

artery. Extensive tangential through-and-through injury to the left external iliac vein had occurred as well. Both of these injuries were treated by ligation as a lifesaving maneuver. A suprapubic tube was brought out through the distal portion of the midline abdominal wound and tunneled beneath the anterior rectus fascia to exit the skin just below the umbilicus. The abdomen was irrigated copiously with antibiotic solution and closed. The patient was thereupon transferred to the surgical intensive care unit for correction of hypothermia, coagulopathy, metabolic acidosis, and persistent hypovolemia. Within several hours, the patient's left lower extremity became tensely edematous and remained pulseless. Although Doppler arterial flow could be heard at the level of the groin and popliteal space, no signals were present at the ankle. The lower portion of the left lower extremity clearly demonstrated compartmental hypertension. The patient was returned to the operating room where a four-compartment, left, lower extremity fasciotomy was performed expeditiously with no return of arterial signals at the pedal level. The patient then underwent exploration of the left groin vessels through the previous incision, and venous thrombectomy was performed followed by left-to-right saphenous vein venous bypass and right-to-left superficial femoral artery-to-superficial femoral artery bypass, using 8 mm polytetrafluoroethylene (PTFE) (Gore-tex) (Fig. 1). Sartorius muscle rotational

In many ways, injury to major venous structures of the abdomen and lower extremities presents a more formidable challenge to the vascular surgeon than a similar arterial injury. The decision to repair a major vein is made more difficult because venous repair is often not necessary for limb salvage, long-term patency of venous repairs is questionable, and associated injuries may make time-consuming repair inadvisable in terms of lifesaving maneuvers. Historically, direct venous reconstruction can be traced to attempts in the early 19th century which were sporadic and generally unsuccessful. Very few venous repairs were performed during the early part of this century; however, renewed interest was sparked by the Vietnam conflict and subsequent review of Vietnam Vascular Registry results [5,6]. Decreasing amputation rates in the face of lower extremity vascular trauma seen during the Korean and Vietnam conflicts (13-15%) as opposed to 50% in the same setting during World War II, are not directly traceable to repair of concomitant venous injuries as a commonplace, since even as late as the Korean conflict very few venous repairs Were undertaken [7,8]. By far the most c o m m o n etiology of civilian vascular injuries confined to the lower extremity involves penetrating trauma and the most commonly injured arteries and veins consist of femoral, popliteal, and iliac vessels. Some 80% of those patients presenting in shock with a peripheral arte-

288

CROSS-FEMORAL B Y P A S S GRAFT

rial injury have concomitant venous injury [8]. Combined arterial and venous injury results not only in a greater limb loss but also vastly increased mortality [9]. Diagnosis of isolated major venous injury may often be obscure since there may be few clinical signs. Most often it is concomitant arterial injury which leads one to explore the anatomic region in which the injury has Occurred and to make a diagnosis of venous injury as well. Management principles directed towards patients presenting with injury to major arterial or venous structures are well established and include attempts to arrest hemorrhage, resuscitate shock, stabilize fractures, and assess and treat associated injuries in order of priority. The surgical approach should be made through longitudinal (elective) incisions and in general, when both structures are injured, the artery should be repaired first to minimize distal tissue anoxia. Under some circumstances it is more expeditious to repair the vein first, from the point of view of hemostasis, exposure, and prevention of air embolism. Under these circumstances it may be appropriate to place an inlying arterial shunt to promptly restore arterial flow during the course of venous repair. Local or systemic anticoagulation with heparin is of paramount importance, as are attempts to remove thrombus from the distal arterial or venous system with the aid of surgical balloon catheters, and on the venous side with "milking" and compression maneuvers, as well. Meticulous vascular surgical technique is required for successful repair, and, especially on the venous side, includes liberal use of interrupted sutures. Completion evaluation techniques, including interrogation with Doppler ultrasound, arteriography, venography, and angloscopy, are all important to insure adequate repair. In general, following arterial repair alone, perioperative anticoagulation with either heparin or low molecular weight Dextran, is not usually indicated. Following combined arterial and venous repair or venous repair alone, postoperative anticoagulation is probably beneficial. It is fundamental to maintain elevation of the injured extremity (and perhaps employ intermittent pneumatic compression stockings as well) to encourage resolution of edema. The question of long-term anticoagulation following repair of major venous injury remains to be settled. However, based on data obtained from direct venous reconstruction for chronic venous insufficiency, it is probably important. In specific situations, it is clearly more appropriate to ligate a major vein that has been injured during the first procedure, as was done in the present case. When the patient is hemodynamically unstable, when there has been extensive venous injury, or when a prolonged operation is necessary to manage multi-system injury, ligation may be the

ANNALS OF VASCULAR SURGERY

procedure of choice. Major venous injury confined to the upper extremity may be safely ligated with no long-term sequelae [8]. Lower extremity compartmental hypertension should be anticipated and carefully evaluated in all cases of extremity vascular trauma. Specifically, arterial injury and distal ischemia, compounded by venous ligation, often results in compartment syndromes, and liberal use of concomitant fasciotomy is indicated. General guidelines for fasciotomy, in addition to combined arterial-venous injury of the lower leg, include popliteal venous injury, long periods of arterial ischemia (greater than six hours), shorter periods of arterial ischemia with associated hypotension compounding ischemia, crush injury, and associated fractures. Whether to ligate or repair major injured veins remains controversial [6-13]. Those who favor ligation for all venous injuries suggest that this prevents the "inevitable" post-repair thrombosis, clot propagation, and potential pulmonary embolism [13]. The incidence of thrombophlebitis following lower extremity major venous ligation for trauma is reported in the range of 10-14% [13,14]. In contrast, deep venous thrombosis followed in only 2% of 36 repairs of the superficial femoral vein reported by Rich [11] with no episodes of pulmonary embolism. Pulmonary embolism occurred in less than 2% of 55 lower extremity venous repairs reported by Hardin and associates [12]. Repair of large caliber veins is aimed at producing significant diminution of acute venous hypertension, improving patency of arterial repair, and salvaging limbs [15]. Less secure is the anticipated prevention of chronic venous insufficiency. Data from the Vietnam Vascular Registry would suggest that patency for as little as 24-72 hours is enough to allow resolution of spasm and development of venous collateral channels. Furthermore, repairs that were followed long-term were found to recanalize following occlusion [11]. Despite the relatively low incidence (but keeping in mind the high lethality) of deep venous thrombosis and pulmonary embolism following major venous injury, whether or not repair is undertaken, we have instituted a policy of prophylactic caval interruption in all patients sustaining major venous injury in the abdomen or proximal lower extremity. This is based on our experience with a small series of patients [16]. No patient has died of a pulmonary embotus since this policy has been in force. Following life-threatening injury to the iliac artery and vein which precludes repair of either one at the initial operative setting, the decision to re-enter the contaminated initial operative field or to perform extraanatomic bypass to restore limb perfusion is of considerable clinical importance. Longterm results following femorofemoral bypass graft for chronic arterial insufficiency in the presence of a

VOLUME 5 No 3 - 1991

CROSS-FEMORAL BYPASS GRAFT

widely patent donor arterial tree have been good [21. Similarly, the use of PTFE in potentially contaminated fields has been supported by excellent results in terms of low long-term risk of infection [17]. More challenging is the approach to the injured vein, where prosthetic, size-matched conduits have been clearly shown to be inferior to autogenous tissue [17,18]. Construction of a spiral vein graft [19] or use of a size matched jugular or axillary venous segment can often be a good solution to this problem. Saphenous vein cross:femoral venovenous bypass graft has been used for relief of chronic venous insufficiency in the presence of recipient limb proximal iliac venous occlusion with good results obtained in 60-70% of patients followed long-term [20-22]. The advantages of this technique include an extraanatomic, extra-cavitary approach, minimal morbidity, need for only one anastomosis, and a conduit with intact competent valves. The major disadvantage is the small diameterconduit, which may not allow complete relief of venous outflow resistance. This latter factor may be compensated for by preexisting ipsilateral channels which dilate in the presence of the need to augment flow (Fig. 2). Yet another advantage of this procedure is the ability to accurately follow longitudinally the patency of femoral-femoral venous bypass with duplex imaging [22]. To our knowledge, there are no previous reports describing this procedure in the acute trauma setting.

i~

289

~"~ ..

Fig. 2. Left lower extremity venogram performed on postoperative day 14 demonstrates patent left-toright saphenous vein venous bypass as well as ipsilateral medial femoral circumflex venous collateral channels which have dilated in interim.

in-line reconstruction, especially when contamination or other circumstance makes the primary operative field unsuitable.

CONCLUSION The case presented is illustrative of the principles involved in managing combined major lower extremity arterial and venous injuries. Limb salvage demands repair of major arterial injury in almost all circumstances and is generally straightforward. Appropriate treatment of major venous injury is somewhat more obscure, however. In general the stable patient with a simple injury or a single popliteal venous injury should, under most circumstances, undergo primary repair [23,24]. Patients presenting with massive soft tissue trauma, extensive venous injury, prolonged shock, or multi-system injury requiring prolonged operative repair, are appropriate candidates for primary venous ligation, with subsequent direct venous reconstruction, as indicated by their clinical course. The majority of patients with combined arterial and venous lower extremity vascular trauma, especially if complicated by hypotension, should be considered for concomitant adjuvant lower leg fasciotomy to provide the optimum circumstances for limb salvage. Extraanatomic arterial or venous bypass, in the form of cross-femoral grafting for unilateral iliac vessel injuries, is a viable alternative to direct

REFERENCES 1. MILLIKAN JS, MOORE EE, VAN WAY CW III, et al. Vascular trauma in the groin: contrast between iliac and femoral injuries. Am J Surg 1981 ;t42:695--698. 2. SIRINEK KR, GASKILL HV, ROOT HD, et al. Truncal vascular injury--factors influencing survival. J Trauma 1989 ;23:372-377. 3. KALMAN PG, H O S A N G M, CINA C, et al. Current indications for axillounifemoral and axillobifemoral bypass grafts. J Vasc Surg 1987;5:828-832. 4. BLAISDELL FW, GOLDSTONE J, SAUVAGE LR, et al. Symposium on extraanatomic bypass. Contemp Surg 1984; 25:109-144. 5. RICH NM, BAUGH JH, HUGHES CW. Acute arterial injuries in Vietnam: 1,000 cases. J Trauma 1970;10:359-369. 6. RICH NM, HUGHES CW, BAUGH JH. Management of venous injuries. Ann Surg 1970;171:724-730. 7. TIMBERLAKE GA, O'CONNELL RC, KERSTEIN MD. Venous injury: to repair or ligate, the dilemma. J Vasc Surg 1986;4:553-558. 8. RICH NM. Management of venous trauma. Surg Clin N Am 1988;68:809-821. 9. PHIFER TJ, GERLOCK AJ, VEKOVIUS WA, et al. Amputation risk factors in concomitant superficial femoral artery and vein injuries. Ann Surg 1984;199:241-243. 10. RICH NM. Principles and indications for primary venous repair. Surgery 1982;9l :492-496. 11. RICH NM, COLLINS CJ, ANDERSON CA, et al. Autog-

290

12. 13. 14. 15. 16. 17. 18.

CROSS-FEMORAL BYPASS GRAFT

enous venous interposition grafts in repair of major venous injuries. J Trauma 1977;17:512-520. HARDIN WD, ADINOLFI MF, O'CONNELL RC, et al. Management of traumatic peripheral vein injuries. Am J Surg 1982;144:235-238. MULLINS RJ, LUCAS CE, LEDGERWOOD AM. The natural history following venous ligation for civilian injuries. J Trauma 1980;20:737-743. GASPAR MR, TREIMAN RL. The management of injuries to major veins. Am J Surg 1960;100:171. HAIMOVICI H, HOFFERT PW, ZINICOLA N, et al. An experimental and clinical evaluation of grafts in the venous system. Surg Gynecol Obstet 1970;131:1173. McNEILL PM, POSNER MP, SOBEL M, et al. Greenfield filter insertion following repair of intraabdominal venous trauma. Arch Surg (in press). FELICIANO DV, MATTOX KL, GRAHAM JM, et al. Five-year experience with PTFE grafts in vascular wounds. J Trauma 1985;25:71-82. HASEGAWA T, F U K U S H I M A K, HASEGAWA S, et al.

mum

19. 20. 21.

22.

23.

24.

ANNALS OF VASCULAR SURGERY

Venous reconstruction using prosthetic grafts. J Cardiovasc Surg 1989;30:833-837. DOTY DB, BAKER WH. Bypass of superior vena cava with spiral vein graft. Ann Thorac Surg 1976;22:490--493. DALE WA. Reconstructive venous surgery. Arch Surg 1979;114:1312-1318. SMITH DE. Surgical management of chronic obstructive venous disease of the lower extremity. In: RUTHERFORD RB (ed). Vascular Surgery. WB Saunders Co., 1984, pp 1421. HARRIS JP, KIDD J, BURNETT A, et al. Patency of femorofemoral venous crossover grafts assessed in duplex scanning and phlebography. J Vasc Surg 1988;8:679-682. RICH NM, JARSTFER BS, GEER RM. Popliteal artery repair failure: cause and possible prevention. J Cardiovasc Surg 1974;15:340. HOBSON RW, YEAGER RA, LYNCH TG, et al. Femoral venous trauma: techniques for surgical management and early results. Am J Surg 1983;146:220-224.