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Management of traumatic peripheral vein injuries
Management of Traumatic Peripheral Vein Injuries Primary Repair or Vein Ligation
William D. Hardin, Jr., MD, New Orleans, Louisiana Michael F. Adinolfi, MD, New Orleans, Louisiana Ruary C. O’Connell, MD, FACS, New Orleans, Louisiana Morris D. Kerstein, MD, FACS, New Orleans, Louisiana
The definitive management of traumatic peripheral vein injuries is currently aimed at the prevention of outflow obstruction by primary vein reconstruction. Using data gathered in the Vietnam Vascular Registry, Rich and his colleagues [1,2] identified vein ligation as a major determinant of postoperative morbidity related to venous insufficiency. With the refinement of vascular surgical techniques and the introduction of antimicrobials, primary vein repair was advocated as a means of maintaining outflow and allowing venous and lymphatic collateralization [3]. Techniques of repair utilized include lateral suture, primary end-to-end reanastomosis, and interposition autogenous vein grafting. Before the Vietnam era, vein ligation was the management of choice for venous injuries. Paradoxically, it was postoperative morbidity that prompted this recommendation. It was argued that vein repair inevitably led to thrombosis with clot propagation and potential pulmonary embolization. Rich et al [2] refuted these claims and called attention to the early compromise of associated arterial repairs after ligation. The controversy over postoperative morbidity has been refueled by a recent report from Mullins et al [4], who noted minimal sequelae from vein ligation when the patients were appropriately managed with limb elevation postoperatively. These findings prompted us to examine our experience with traumatic venous injuries, their management, and the postoperative sequelae. Clinical Material The medical records of 233 patients who had sustained traumatic peripheral vascular injuries between January 1967 and December 1979 were retrospectively reviewed. All patients were treated at one of three Tulane-affiliated hospitals: Charity Hospital of Louisiana at New Orleans, Fromthe Departmentof Sugety. Tulane University School of Medicine, New Orleans, Louisiana. Requests for reprints should be addressed to Morris D. Kerstein, MD, Departmentof Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112. Presented at the 10th Annual Meeting of the Society for Clinical Vascular Surgery, Palm Springs, California, April 1-4, 1982.
Volume 144, August 1982
Huey P. Long Memorial Hospital in Pineville, Louisiana, and Lallie Kemp Charity Hospital in Independence, Louisiana. The latter two institutions are rural hospitals in central Louisiana. Patients with incomplete or irretrievable medical records, those not operated on, or those who died from associated injuries were excluded from study. Three hundred fifty-six vascular injuries were identified in these 233 patients. Two hundred two patients were male and 31 were female. The mean age was 28.8 years (range 3 to 67). One hundred fifty patients had arterial injuries only, 60 patients had combined arterial and venous injuries, and 23 had venous injury only. A total of 86 venous injuries were identified in these 83 patients. The locations of these venous injuries are shown in Figure 1. Over 80 percent of the injuries, 69 of 86, were located in the leg. The common femoral vein was injured in .34 patients and the superficial femoral vein in 20. Of the 13 patients with popliteal vein injuries, 10 had combined arterial and venous injuries. Seventeen patients had venous injuries of the arm. Over 60 percent of the venous injuries were caused by gunshot wounds, in 51 of the 83 patients. The vast majority of injuries were the result of low velocity handguns, reflecting the increase in availability and use of these weapons in urban centers. Shotgun injury was the second most common cause of venous injury (17 patients, or 20.5 percent). Venous injuries due to blunt trauma were identified in only two patients. The distribution of the causes of injury in our series is shown in Figure 2. Significant associated skeletal, nerve, or soft tissue injuries were identified in 40 patients, or 48.2 percent of our series. Sixteen patients had skeletal injury, 29 had associated nerve damage, and 13 had extensive soft tissue loss accompanying their venous injury. Complications directly attributable to these injuries were omitted from this analysis. Surgical techniques utilized in the management of these venous injuries are presented in Table I. In those three patients with injuries to more than one extremity vein the distal injury was managed by ligation. Distal injuries were excluded from Table I since they appeared not to adversely affect outcome. Two of these distal vein injuries were to the saphenous vein and one to the superficial femoral vein. Vein reconstruction was attempted in 55 of 83 patients (66 percent). Primary repair was accomplished by lateral suture in 17 patients (21 percent), while debridement and primary end-to-end reanastomosis were used in 26 (31
235
Hardin et al
50
PENETRATING
TRAUMA
12
17 ( 15
34 2:) I
Gunshot Wounds
69
13 i
percent). Autogenous vein interposition was performed in 12 patients, representing 14 percent of our series. Three of these patients (4 percent) required vein patch only. Vein ligation was performed in 29 patients representing 35 percent of our series. Two patients (2 percent) were managed with primary amputation due to massive associated skeletal, nerve, and soft tissue injuries. Adjunctive methods employed included fasciotomy, performed intraoperatively in 5 patients, perioperative anticoagulation (36 patients), and antibiotic therapy (66 patients). Results were broadly divided into three groups based on postoperative course. Patients with no postoperative sequelae were classified as having good results. Fair results
Outcome of Venous Injury Based on Cause of Injury, Location of Injury, and Management Technique Results
Cause Gunshot wound Shotgun wound Stab wound or laceration Blunt trauma Total Location Axillaty veins Brachial veins Common femoral veins Superficial femoral veins Popliteal veins Total Management technique Primary repair Vein interposition Ligation Amputation Total
236
Stab Wounds
locerotions
F-&we 2. Causeof venousfn)utyIn 8 7 pattents( 87.8 percent) wilh penetrating trauma and 2 patients (2.4 pefceti) wltl, blunt trauma.
F&we 1. Location of 88 venousInjurIes.
TABLE I
Shotgun Wounds
Good
Fair
Poor
31 4 6 0 43
14 9 5 3%
6 4 0 0 10
9 4 17 9 4 43
3 1 14 5 7 30
0 0 3 5 2 10
24 6 13 0 43
15 3 12 0 30
4 3 1 2 10
were defined as transient postoperative sequelae with no long-term functional loss. Patients in whom long-term function was impaired were classified as having poor results. Results were then compared with the location and cause of these injuries, the vessels involved, and the surgical management.
Results The sequelae of peripheral venous injuries identified in this series are presented in Table II. Longterm recovery of full function was accomplished in 438percent of patients. Thirty-six percent of patients experienced short-term sequelae, most notably transient peripheral edema. Only 10 patients (12 percent) had long-term sequelae directly attributable to venous injury. Nine patients developed signs consistent with chronic venous insufficiency, either brawny edema (seven) or stasis ulcers (two). Pulmonary emboli were suspected in one patient who had been managed by autogenous vein interposition for a shotgun injury to the superficial femoral artery and vein. The one amputation required postoperatively occurred in a 23 year old who had sustained a shotgun injury to the superficial femoral artery and vein and had been managed with autogenous vein interposition to both artery and vein. He required a Ray amputation of the great toe on the 12th postoperative day. Table I documents the clinical outcome based on the cause and location of injury and the management technique. Four of 17 patients with shotgun injuries (22 percent) had a poor outcome. Six of 51 patients (11.7 percent) with gunshot wounds had a poor long-term result. Stab wounds, lacerations, and blunt trauma resulted in no long-term sequelae related to venous injury. Vein interposition was associated with the highest rate of long-term morbidity, occurring in 3 of 12 patients (25 percent) managed in this fashion. Primary vein repair and vein ligation were associated with
The American Journal of Surgery
Traumatic
long-term morbidity in 9.3 and 3.5 percent of patients, respectively. The use of anticoagulants and antibiotics resulted in no significant difference in long-term morbidity. Fasciotomy performed at the time of initial surgery produced a good clinical outcome in three of five patients. A fair result due to transient edema was identified in two patients. Analysis of therapeutic failures by location and surgical management is presented in Table II. Comments The importance of vascular reconstruction to limb viability was recognized before the turn of the century. Eck performed the first vascular anastomosis in the mid-19th century when he joined the portal vein and the vena cava. Yet, it was not until the turn of the century that surgeons like Carrel, Payr, Guthrie, and Matas began to apply these techniques in clinical practice. In a review of the British experience with vascular injuries during World War I, Makins [5] recognized the life-for-limb tradeoff incurred when vascular repair was attempted. For this reason vascular ligation was the procedure of choice for traumatic vascular injuries in the military setting. Since then, however, the evolution of modern surgical therapy in the management of these injuries has paralleled our involvement in further military campaigns. In the classic work of DeBakey and Simeone [6], 2,471 cases of arterial injury during World War II were examined. Ligation of arterial injuries in this setting resulted in a 40 percent amputation rate. The authors further noted the importance of associated in,juries, time to definitive therapy, and risk factors associated with infection. Despite their belief in and ability to perform vascular repair, they contended that further progress would have to await logistic changes in the handling of battle casualties. It was not until the Korean conflict that primary repair of arterial injuries became feasible because of improvements in casualty evacuation and proximity of definitive surgical care. Two reports, one by Hughes [7] and the other by Jahnke and Seely [8], outlined the basic principles of management as practiced in Korea. One of the great advances in modern surgery-the widespread availability of antibiotics-facilitated these surgeons’ success. Between the Korean and Vietnam Wars, the first civilian reports on traumatic vascular injuries began to appear. Gaspar and Treiman [9] reported their experience with these injuries in Los Angeles in 1960. They also recognized the clinical importance of venous injuries. In their series, venous injury was associated with a 19.6 percent mortality. Ligation of venous injuries was recommended in 21 of 27 patients handled in this fashion. The wisdom of venous ligation was, however, quickly criticized. In 1966, the Vietnam Vascular Registry was established at Walter Reed General
Volume 144, August 1982
TABLE II
Peripheral
Vein Injuries
Analysis of Therapeutic Failures Based on Injury Locatlon and Surgical Management
Management
Common Femoral
Vein Superficial Femoral
Popliteal
Primary repair Vein interposition Ligation Amputation
2 1 1 1
1 2 1 1’
1 0 0 1’
l
Primary surgical management.
Hospital in Washington to further document the incidence and management of vascular injuries incurred in Southeast Asia. In a preliminary report issued in 1969, Rich and Hughes [1] reported on 500 patients with a total of 718 vascular injuries. One hundred ninety-four of these injuries involved major veins. Citing limb loss in patients who had undergone arterial repair and venous ligation, they recommended venous repair whenever feasible by lateral suture. Vein patency was maintained in over 50 percent of patients treated in this fashion. In a later report, these investigators again cited the complications of vein ligation [2] and recommended vein repair by autogenous vein interposition in patients in whom lateral suture or end-to-end reanastomosis was not technically feasible [3]. Despite a high incidence of graft thrombosis, it was felt that transient graft patency permitted venous and lymphatic collateralization, thereby preserving limb outflow. Further support for this position was provided by an analysis of popliteal artery and vein injuries in which ligation was again noted to result in significant ‘morbidity and limb loss [lO,ll]. Several more recent reports reiterate this experience [12,13]. The problem of vein thrombosis has been troublesome in vessels repaired primarily or, more frequently, in vessels managed by interposition autogenous vein grafting. Early experimental work by Dale and Scott [14] showed that thrombosis within the venous system was frequently followed by vein recanalization, a phenomenon unique to the venous system. This work was clinically confirmed in a report by Rich and Sullivan [15], who documented recanalization with venography in a patient who had undergone an autogenous vein interposition in the popliteal vein. The maintenance of graft patency provided the impetus for work directed in two other areas, the use of anticoagulants and the construction of a distal arteriovenous fistula. With respect to anticoagulation, attention must again be directed to the work of Hobson et al [16], who looked at the efficacy of heparin and low molecular weight dextran in the maintenance of graft patency in the experimental model. While heparin offered no clear advantages, the use of dextran 40 resulted in graft patency in 100 percent
237
Hardin et al
of animals. Construction of a distal arteriovenous fistula similarly improved graft patency of interposition grafts in the experimental model, but because of hemodynamic consequences distal to the fistula, its use in the clinical setting was questioned [I 71. The concept of vein repair at all costs was recently questioned by the work of Mullins et al [4] at Detroit General Hospital. Although they advocated repair if technically easy, 46 patients in their series were managed with vein ligation and aggressive postoperative management. Forty of these 46 patients were discharged from the hospital without edema. Six were discharged with mild edema. Their success with vein ligation in the leg was attributed to the use of early and extensive fasciotomy and postoperative elevation with trial ambulation until the patient was free of edema. This experience was the first to question the advisability of vein repair in all patients with venous injury secondary to trauma. Our experience supports the points raised by the Detroit group. Although we performed vein repair in nearly two thirds of our patients, vein ligation was performed in over one third of the patients and resulted in long-term morbidity in only 3.6 percent of these. Admittedly, half of our patients managed with vein ligation did have perioperative edema which, in all but one instance, disappeared by discharge. We attribute this success to the appropriate use of fasciotomy and conservative postoperative management. Postoperative limb elevation is clearly efficacious in the prevention of long-term sequelae in patients with venous injury who are managed with vein ligation. Venous injuries of the arm are not associated with long-term sequelae, and it appears that vein ligation may be innocuous in this setting. This point also raises the question of whether arterial injuries of the arm may be managed safely with ipsilateral vein harvesting for autogenous vein interposition. The role of autogenous vein interposition grafting in the venous system is seriously brought into question by the efficacy of vein ligation and by the 25 percent failure rate in our experience with vein grafting. In the long run, it may turn out that the only site in which vein interposition is indicated is in the popliteal system. The vast majority of evidence still supports an aggressive approach to venous reconstitution in this area. Primary repair of venous injuries is still recommended when it can be accomplished easily. In the unstable patient who can ill afford further operative time, vein ligation appears to be a viable alternative. The use of intraoperative fasciotomy is strongly urged when indicated, and along with postoperative limb elevation may be responsible for the minimal long-term morbidity identified in our patients managed by vein ligation. Finally, use of the autogenous vein interposition graft is seriously questioned in all but popliteal vein injuries.
238
Summary The management and outcome of 83 patients who had 86 venous injuries were retrospectively reviewed to identify optimal management techniques in patients with peripheral vein injuries. Venous injuries of the arms were associated with no long-term sequelae, and management with vein ligation appears safe. In patients with venous injuries of the legs, primary repair by lateral suture or primary endto-end reanastomosis is recommended when technically easy. In patients who are unstable or in whom primary repair cannot be performed, vein ligation is recommended. Autogenous vein interposition grafting appears indicated only in the popliteal area when vein reconstitution should be aggressively sought. Vein ligation in peripheral vein injuries should be followed with aggressive postoperative management to prevent the development of distal edema. Limb elevation is effective in minimizing the development of adverse sequelae. References 1. Rich NM, Hughes CW. Vietnam vascular registry: a Preliminary report. Surgery 1969;65:218-28. 2. Rich NM, Hughes CW, Baugh JH. Management of venous injuries. Ann Surg 1970;171:724-30. 3. Rich NM, Hobson RW, Wright CB, Fedde CW. Reoair of lower extremity venous trauma: a more aggressive approach reauired. J Trauma 1974;14:639-52. 4. Muilins RJ, Lucas CE, Ledgerwood AM. The natural history following venous ligation for civilian injuries. J Trauma 1980;20:737-43. 5. Makins GH. On the vascular lesions produced by gunshot injuries and their results. Br J Surg 1916;3:353-421. 6. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War II. Ann Surg 1946123534-79. 7. Hughes CW. Acute vascular trauma in Korean War casualties. Surg Gynecol Obstet 1954;99:9 1. 8. Jahnke EJ, Seely SF. Acute vascular injuries in the Korean War:, an analysis of 77 consecutive cases. Ann Surg 1953;138: 158-77. .--
9. Gaspar MR, Treiman RL. The management of injuries to major veins. Am J Surg 1960;100:171-5. 10. Rich NM, Jarstfer BS, Geer TM. Popliteal artery repair failure: causes and possible prevention. J Cardiovasc Surg 1974; 15:340-51. 11. Sullivan WG, Thornton FH, Baker LH, LaPlante ES, Cohen A. Early influence of popliteal vein repair in the treatment of oooliteal vessel injuries. Am J Surg 197 1: 122:528-3 1. 12. Sc’hramek A, Hashmonai M, Farbstein J, Adler 0. Reconstructive surgery in major vein injuries in the extremities. J Trauma 1975;15:816-22. 13. Rich NM, Hobson RW, Collins 61, Andersen CA. The effect of acute popliteal venous interruption. Ann Surg 1976;163: 365-8. 14. Dale WA, Scott HW. Grafts of the venous system. Surgery 1963;53:52-74. 15. Rich NM, Sullivan WG. Clinical recanalization of an autogenous vein graft in the popliteal vein. J Trauma 1972;12:91920. 16. Hobson RW, Croom RD, Rich NM. Influence of heparin and low molecular weight dextran in the patency of autogenous vein grafts in the venous system. Ann Surg 1973; 178:773-6. 17. Hobson RW, Croom RD, Swan KG. Hemodynamics of the distal arteriovenous fistula in venous reconstruction. J Surg Res 1973;14:483-9.
The American Journal of Surgery
William D. Hardin, Jr., MD, New Orleans, Louisiana Michael F. Adinolfi, MD, New Orleans, Louisiana Ruary C. O’Connell, MD, FACS, New Orleans, Louisiana Morris D. Kerstein, MD, FACS, New Orleans, Louisiana
The definitive management of traumatic peripheral vein injuries is currently aimed at the prevention of outflow obstruction by primary vein reconstruction. Using data gathered in the Vietnam Vascular Registry, Rich and his colleagues [1,2] identified vein ligation as a major determinant of postoperative morbidity related to venous insufficiency. With the refinement of vascular surgical techniques and the introduction of antimicrobials, primary vein repair was advocated as a means of maintaining outflow and allowing venous and lymphatic collateralization [3]. Techniques of repair utilized include lateral suture, primary end-to-end reanastomosis, and interposition autogenous vein grafting. Before the Vietnam era, vein ligation was the management of choice for venous injuries. Paradoxically, it was postoperative morbidity that prompted this recommendation. It was argued that vein repair inevitably led to thrombosis with clot propagation and potential pulmonary embolization. Rich et al [2] refuted these claims and called attention to the early compromise of associated arterial repairs after ligation. The controversy over postoperative morbidity has been refueled by a recent report from Mullins et al [4], who noted minimal sequelae from vein ligation when the patients were appropriately managed with limb elevation postoperatively. These findings prompted us to examine our experience with traumatic venous injuries, their management, and the postoperative sequelae. Clinical Material The medical records of 233 patients who had sustained traumatic peripheral vascular injuries between January 1967 and December 1979 were retrospectively reviewed. All patients were treated at one of three Tulane-affiliated hospitals: Charity Hospital of Louisiana at New Orleans, Fromthe Departmentof Sugety. Tulane University School of Medicine, New Orleans, Louisiana. Requests for reprints should be addressed to Morris D. Kerstein, MD, Departmentof Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112. Presented at the 10th Annual Meeting of the Society for Clinical Vascular Surgery, Palm Springs, California, April 1-4, 1982.
Volume 144, August 1982
Huey P. Long Memorial Hospital in Pineville, Louisiana, and Lallie Kemp Charity Hospital in Independence, Louisiana. The latter two institutions are rural hospitals in central Louisiana. Patients with incomplete or irretrievable medical records, those not operated on, or those who died from associated injuries were excluded from study. Three hundred fifty-six vascular injuries were identified in these 233 patients. Two hundred two patients were male and 31 were female. The mean age was 28.8 years (range 3 to 67). One hundred fifty patients had arterial injuries only, 60 patients had combined arterial and venous injuries, and 23 had venous injury only. A total of 86 venous injuries were identified in these 83 patients. The locations of these venous injuries are shown in Figure 1. Over 80 percent of the injuries, 69 of 86, were located in the leg. The common femoral vein was injured in .34 patients and the superficial femoral vein in 20. Of the 13 patients with popliteal vein injuries, 10 had combined arterial and venous injuries. Seventeen patients had venous injuries of the arm. Over 60 percent of the venous injuries were caused by gunshot wounds, in 51 of the 83 patients. The vast majority of injuries were the result of low velocity handguns, reflecting the increase in availability and use of these weapons in urban centers. Shotgun injury was the second most common cause of venous injury (17 patients, or 20.5 percent). Venous injuries due to blunt trauma were identified in only two patients. The distribution of the causes of injury in our series is shown in Figure 2. Significant associated skeletal, nerve, or soft tissue injuries were identified in 40 patients, or 48.2 percent of our series. Sixteen patients had skeletal injury, 29 had associated nerve damage, and 13 had extensive soft tissue loss accompanying their venous injury. Complications directly attributable to these injuries were omitted from this analysis. Surgical techniques utilized in the management of these venous injuries are presented in Table I. In those three patients with injuries to more than one extremity vein the distal injury was managed by ligation. Distal injuries were excluded from Table I since they appeared not to adversely affect outcome. Two of these distal vein injuries were to the saphenous vein and one to the superficial femoral vein. Vein reconstruction was attempted in 55 of 83 patients (66 percent). Primary repair was accomplished by lateral suture in 17 patients (21 percent), while debridement and primary end-to-end reanastomosis were used in 26 (31
235
Hardin et al
50
PENETRATING
TRAUMA
12
17 ( 15
34 2:) I
Gunshot Wounds
69
13 i
percent). Autogenous vein interposition was performed in 12 patients, representing 14 percent of our series. Three of these patients (4 percent) required vein patch only. Vein ligation was performed in 29 patients representing 35 percent of our series. Two patients (2 percent) were managed with primary amputation due to massive associated skeletal, nerve, and soft tissue injuries. Adjunctive methods employed included fasciotomy, performed intraoperatively in 5 patients, perioperative anticoagulation (36 patients), and antibiotic therapy (66 patients). Results were broadly divided into three groups based on postoperative course. Patients with no postoperative sequelae were classified as having good results. Fair results
Outcome of Venous Injury Based on Cause of Injury, Location of Injury, and Management Technique Results
Cause Gunshot wound Shotgun wound Stab wound or laceration Blunt trauma Total Location Axillaty veins Brachial veins Common femoral veins Superficial femoral veins Popliteal veins Total Management technique Primary repair Vein interposition Ligation Amputation Total
236
Stab Wounds
locerotions
F-&we 2. Causeof venousfn)utyIn 8 7 pattents( 87.8 percent) wilh penetrating trauma and 2 patients (2.4 pefceti) wltl, blunt trauma.
F&we 1. Location of 88 venousInjurIes.
TABLE I
Shotgun Wounds
Good
Fair
Poor
31 4 6 0 43
14 9 5 3%
6 4 0 0 10
9 4 17 9 4 43
3 1 14 5 7 30
0 0 3 5 2 10
24 6 13 0 43
15 3 12 0 30
4 3 1 2 10
were defined as transient postoperative sequelae with no long-term functional loss. Patients in whom long-term function was impaired were classified as having poor results. Results were then compared with the location and cause of these injuries, the vessels involved, and the surgical management.
Results The sequelae of peripheral venous injuries identified in this series are presented in Table II. Longterm recovery of full function was accomplished in 438percent of patients. Thirty-six percent of patients experienced short-term sequelae, most notably transient peripheral edema. Only 10 patients (12 percent) had long-term sequelae directly attributable to venous injury. Nine patients developed signs consistent with chronic venous insufficiency, either brawny edema (seven) or stasis ulcers (two). Pulmonary emboli were suspected in one patient who had been managed by autogenous vein interposition for a shotgun injury to the superficial femoral artery and vein. The one amputation required postoperatively occurred in a 23 year old who had sustained a shotgun injury to the superficial femoral artery and vein and had been managed with autogenous vein interposition to both artery and vein. He required a Ray amputation of the great toe on the 12th postoperative day. Table I documents the clinical outcome based on the cause and location of injury and the management technique. Four of 17 patients with shotgun injuries (22 percent) had a poor outcome. Six of 51 patients (11.7 percent) with gunshot wounds had a poor long-term result. Stab wounds, lacerations, and blunt trauma resulted in no long-term sequelae related to venous injury. Vein interposition was associated with the highest rate of long-term morbidity, occurring in 3 of 12 patients (25 percent) managed in this fashion. Primary vein repair and vein ligation were associated with
The American Journal of Surgery
Traumatic
long-term morbidity in 9.3 and 3.5 percent of patients, respectively. The use of anticoagulants and antibiotics resulted in no significant difference in long-term morbidity. Fasciotomy performed at the time of initial surgery produced a good clinical outcome in three of five patients. A fair result due to transient edema was identified in two patients. Analysis of therapeutic failures by location and surgical management is presented in Table II. Comments The importance of vascular reconstruction to limb viability was recognized before the turn of the century. Eck performed the first vascular anastomosis in the mid-19th century when he joined the portal vein and the vena cava. Yet, it was not until the turn of the century that surgeons like Carrel, Payr, Guthrie, and Matas began to apply these techniques in clinical practice. In a review of the British experience with vascular injuries during World War I, Makins [5] recognized the life-for-limb tradeoff incurred when vascular repair was attempted. For this reason vascular ligation was the procedure of choice for traumatic vascular injuries in the military setting. Since then, however, the evolution of modern surgical therapy in the management of these injuries has paralleled our involvement in further military campaigns. In the classic work of DeBakey and Simeone [6], 2,471 cases of arterial injury during World War II were examined. Ligation of arterial injuries in this setting resulted in a 40 percent amputation rate. The authors further noted the importance of associated in,juries, time to definitive therapy, and risk factors associated with infection. Despite their belief in and ability to perform vascular repair, they contended that further progress would have to await logistic changes in the handling of battle casualties. It was not until the Korean conflict that primary repair of arterial injuries became feasible because of improvements in casualty evacuation and proximity of definitive surgical care. Two reports, one by Hughes [7] and the other by Jahnke and Seely [8], outlined the basic principles of management as practiced in Korea. One of the great advances in modern surgery-the widespread availability of antibiotics-facilitated these surgeons’ success. Between the Korean and Vietnam Wars, the first civilian reports on traumatic vascular injuries began to appear. Gaspar and Treiman [9] reported their experience with these injuries in Los Angeles in 1960. They also recognized the clinical importance of venous injuries. In their series, venous injury was associated with a 19.6 percent mortality. Ligation of venous injuries was recommended in 21 of 27 patients handled in this fashion. The wisdom of venous ligation was, however, quickly criticized. In 1966, the Vietnam Vascular Registry was established at Walter Reed General
Volume 144, August 1982
TABLE II
Peripheral
Vein Injuries
Analysis of Therapeutic Failures Based on Injury Locatlon and Surgical Management
Management
Common Femoral
Vein Superficial Femoral
Popliteal
Primary repair Vein interposition Ligation Amputation
2 1 1 1
1 2 1 1’
1 0 0 1’
l
Primary surgical management.
Hospital in Washington to further document the incidence and management of vascular injuries incurred in Southeast Asia. In a preliminary report issued in 1969, Rich and Hughes [1] reported on 500 patients with a total of 718 vascular injuries. One hundred ninety-four of these injuries involved major veins. Citing limb loss in patients who had undergone arterial repair and venous ligation, they recommended venous repair whenever feasible by lateral suture. Vein patency was maintained in over 50 percent of patients treated in this fashion. In a later report, these investigators again cited the complications of vein ligation [2] and recommended vein repair by autogenous vein interposition in patients in whom lateral suture or end-to-end reanastomosis was not technically feasible [3]. Despite a high incidence of graft thrombosis, it was felt that transient graft patency permitted venous and lymphatic collateralization, thereby preserving limb outflow. Further support for this position was provided by an analysis of popliteal artery and vein injuries in which ligation was again noted to result in significant ‘morbidity and limb loss [lO,ll]. Several more recent reports reiterate this experience [12,13]. The problem of vein thrombosis has been troublesome in vessels repaired primarily or, more frequently, in vessels managed by interposition autogenous vein grafting. Early experimental work by Dale and Scott [14] showed that thrombosis within the venous system was frequently followed by vein recanalization, a phenomenon unique to the venous system. This work was clinically confirmed in a report by Rich and Sullivan [15], who documented recanalization with venography in a patient who had undergone an autogenous vein interposition in the popliteal vein. The maintenance of graft patency provided the impetus for work directed in two other areas, the use of anticoagulants and the construction of a distal arteriovenous fistula. With respect to anticoagulation, attention must again be directed to the work of Hobson et al [16], who looked at the efficacy of heparin and low molecular weight dextran in the maintenance of graft patency in the experimental model. While heparin offered no clear advantages, the use of dextran 40 resulted in graft patency in 100 percent
237
Hardin et al
of animals. Construction of a distal arteriovenous fistula similarly improved graft patency of interposition grafts in the experimental model, but because of hemodynamic consequences distal to the fistula, its use in the clinical setting was questioned [I 71. The concept of vein repair at all costs was recently questioned by the work of Mullins et al [4] at Detroit General Hospital. Although they advocated repair if technically easy, 46 patients in their series were managed with vein ligation and aggressive postoperative management. Forty of these 46 patients were discharged from the hospital without edema. Six were discharged with mild edema. Their success with vein ligation in the leg was attributed to the use of early and extensive fasciotomy and postoperative elevation with trial ambulation until the patient was free of edema. This experience was the first to question the advisability of vein repair in all patients with venous injury secondary to trauma. Our experience supports the points raised by the Detroit group. Although we performed vein repair in nearly two thirds of our patients, vein ligation was performed in over one third of the patients and resulted in long-term morbidity in only 3.6 percent of these. Admittedly, half of our patients managed with vein ligation did have perioperative edema which, in all but one instance, disappeared by discharge. We attribute this success to the appropriate use of fasciotomy and conservative postoperative management. Postoperative limb elevation is clearly efficacious in the prevention of long-term sequelae in patients with venous injury who are managed with vein ligation. Venous injuries of the arm are not associated with long-term sequelae, and it appears that vein ligation may be innocuous in this setting. This point also raises the question of whether arterial injuries of the arm may be managed safely with ipsilateral vein harvesting for autogenous vein interposition. The role of autogenous vein interposition grafting in the venous system is seriously brought into question by the efficacy of vein ligation and by the 25 percent failure rate in our experience with vein grafting. In the long run, it may turn out that the only site in which vein interposition is indicated is in the popliteal system. The vast majority of evidence still supports an aggressive approach to venous reconstitution in this area. Primary repair of venous injuries is still recommended when it can be accomplished easily. In the unstable patient who can ill afford further operative time, vein ligation appears to be a viable alternative. The use of intraoperative fasciotomy is strongly urged when indicated, and along with postoperative limb elevation may be responsible for the minimal long-term morbidity identified in our patients managed by vein ligation. Finally, use of the autogenous vein interposition graft is seriously questioned in all but popliteal vein injuries.
238
Summary The management and outcome of 83 patients who had 86 venous injuries were retrospectively reviewed to identify optimal management techniques in patients with peripheral vein injuries. Venous injuries of the arms were associated with no long-term sequelae, and management with vein ligation appears safe. In patients with venous injuries of the legs, primary repair by lateral suture or primary endto-end reanastomosis is recommended when technically easy. In patients who are unstable or in whom primary repair cannot be performed, vein ligation is recommended. Autogenous vein interposition grafting appears indicated only in the popliteal area when vein reconstitution should be aggressively sought. Vein ligation in peripheral vein injuries should be followed with aggressive postoperative management to prevent the development of distal edema. Limb elevation is effective in minimizing the development of adverse sequelae. References 1. Rich NM, Hughes CW. Vietnam vascular registry: a Preliminary report. Surgery 1969;65:218-28. 2. Rich NM, Hughes CW, Baugh JH. Management of venous injuries. Ann Surg 1970;171:724-30. 3. Rich NM, Hobson RW, Wright CB, Fedde CW. Reoair of lower extremity venous trauma: a more aggressive approach reauired. J Trauma 1974;14:639-52. 4. Muilins RJ, Lucas CE, Ledgerwood AM. The natural history following venous ligation for civilian injuries. J Trauma 1980;20:737-43. 5. Makins GH. On the vascular lesions produced by gunshot injuries and their results. Br J Surg 1916;3:353-421. 6. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War II. Ann Surg 1946123534-79. 7. Hughes CW. Acute vascular trauma in Korean War casualties. Surg Gynecol Obstet 1954;99:9 1. 8. Jahnke EJ, Seely SF. Acute vascular injuries in the Korean War:, an analysis of 77 consecutive cases. Ann Surg 1953;138: 158-77. .--
9. Gaspar MR, Treiman RL. The management of injuries to major veins. Am J Surg 1960;100:171-5. 10. Rich NM, Jarstfer BS, Geer TM. Popliteal artery repair failure: causes and possible prevention. J Cardiovasc Surg 1974; 15:340-51. 11. Sullivan WG, Thornton FH, Baker LH, LaPlante ES, Cohen A. Early influence of popliteal vein repair in the treatment of oooliteal vessel injuries. Am J Surg 197 1: 122:528-3 1. 12. Sc’hramek A, Hashmonai M, Farbstein J, Adler 0. Reconstructive surgery in major vein injuries in the extremities. J Trauma 1975;15:816-22. 13. Rich NM, Hobson RW, Collins 61, Andersen CA. The effect of acute popliteal venous interruption. Ann Surg 1976;163: 365-8. 14. Dale WA, Scott HW. Grafts of the venous system. Surgery 1963;53:52-74. 15. Rich NM, Sullivan WG. Clinical recanalization of an autogenous vein graft in the popliteal vein. J Trauma 1972;12:91920. 16. Hobson RW, Croom RD, Rich NM. Influence of heparin and low molecular weight dextran in the patency of autogenous vein grafts in the venous system. Ann Surg 1973; 178:773-6. 17. Hobson RW, Croom RD, Swan KG. Hemodynamics of the distal arteriovenous fistula in venous reconstruction. J Surg Res 1973;14:483-9.
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