Early Palma procedure after iliac vein injury in abdominal penetrating trauma
Article Outline
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.
Isolated iliac vein injury after penetrating abdominal trauma occurs infrequently. Vein ligation may represent a better choice than a direct vascular repair in an unstable patient. Although venous ligation can often be tolerated, symptoms of chronic venous occlusion may appear over time. Theoretically, immediate reconstruction of an iliac vein injury would avoid most of those complications by preserving optimal venous drainage for the affected leg. However, in the unstable multi-injured patient, ligation may be required to allow time for resuscitation. After such an unstable patient is resuscitated, major vein reconstruction may avoid the delayed effects of chronic venous hypertension. In order to avoid re-entering a potentially contaminated field and the potential complications of immediate iliac vein repair, we propose an alternative venous reconstruction that includes immediate vein ligation followed by an extra-anatomic venous bypass after the patient has been stabilized.
Case report
A 51-year-old obese man without relevant past medical history was brought to the emergency room after suffering a gunshot wound to the abdomen. He arrived in hypovolemic shock (blood pressure 70/50, heart rate 110, body temperature 35°C) and an emergency laparotomy was performed. The right common external and hypogastric iliac veins were destroyed. Additionally, there was a severed right ureter and injury to the ileum with intestinal spillage. Bleeding was controlled by ligating all injured veins. Next, intestinal and urinary lesions were repaired, the abdomen was closed, and the patient was resuscitated in the intensive care unit (ICU). Four days later, the patient's overall status was improved, but he had massive leg swelling. Under regional anesthesia, a Palma derivation was performed. Deep venous thrombosis was found during this second surgery and thrombectomy was accomplished. Massive leg swelling was relieved and the patient was discharged on warfarin therapy for 3 months. At 20-months of follow-up he remains asymptomatic with patent vein bypass and without signs of venous hypertension.
Summary of all cases
We retrospectively reviewed the clinical course and outcome of 4 patients who suffered iliac vein injury secondary to penetrating abdominal trauma between Jan 2003 and Jan 2006. Wound mechanism and preoperative information was retrieved and surgical notes were reviewed for the description of other intra-abdominal injuries and complementary procedures. Postoperative complications were tabulated. Once discharged, the patients were followed every 3 months and functional capacity of the extremity was examined. Signs of venous outflow obstruction were investigated. Conduit patency was assessed by means of continuous wave Doppler and duplex scanning. The average duration of clinical follow-up was 34 months (median, 31, range, 20-51).
Surgical approach
At arrival, clinical signs of hypovolemic shock were evident and patients were rushed to the operating room. A midline laparotomy was performed and the bleeding controlled with ligation of injured veins and clamping major arteries for an immediate reconstruction. Subsequently, other intra-abdominal injuries were addressed and the patients were sent to the ICU for postoperative management. One patient was treated with an open abdomen using a temporary abdominal closure technique and there were no signs of elevated intra-abdominal pressures in this patient or the other 3 patients. Following the initial operation, all patients received prophylactic doses of enoxaparin. In the early postoperative period, all patients had signs of significant venous hypertension in the affected limb with severe asymmetric lower extremity swelling. Given the extent of the intra-abdominal injuries and with plans to avoid another severe physiologic insult, re-entering the abdomen to attempt in-situ repair of the iliac veins was considered an inferior option. Given these circumstances, extra-anatomic venous bypass using a modification of the Palma procedure was pursued. Timing of the second operation was delayed until 3 of the 4 patients were extubated and all completed their resuscitation. The procedures were performed without preoperative duplex scan, venography, or invasive venous pressure measurement of the affected or contralateral lower extremity. We performed a modification of the original description of the Palma operation1 with anastomosing the contralateral saphenous vein onto the superficial femoral vein in an end-to-end fashion instead of end-to-side saphenous-common femoral veins (Fig 1).
Fig 1.
Modified Palma Procedure: The saphenous vein is anastomosed to the femoral vein in an end-to-end fashion as opposite to the original end-to-end anastomosis. CFV, Common femoral vein; FV, femoral vein; GSV, greater saphenous vein; PFV, profunda femoral vein.
Results
Five patients with iliac vein injury were evaluated for this study. All patients were male with a median age of 27 years. One patient died from multiple organ failure 5 days after the initial injury without having additional vein reconstruction. The remaining 4 patients underwent the delayed second operation of the modified Palma procedure. Associated injuries are depicted in Table I. The three hypogastric vessels (2 veins, 1 artery) were ligated and the external iliac artery injury was repaired by an interposition distal saphenous vein graft from the external iliac artery to the common femoral artery. Average blood loss per patient was of 4000 mL. Venous duplex scan of the lower extremities was not performed in the early postoperative period and in two cases thrombosis of the deep system of the affected limb was discovered at the second operation (ie, Palma procedure) requiring open thrombectomy and supplemented with an Esmarch bandage (Productos Galeno S. de R.L. Naucalpan, Edo de Mexico, Mexico). These 2 patients in particular received 3 months of full anticoagulation with warfarin in contrast to the 2 patients without deep venous thrombosis who received only peri-operative enoxaparin and then long term aspirin. Patients who developed deep vein thrombosis (DVT) had suffered more complex venous injuries and required ligation of the common as well as the external iliac and hypogastric veins (Table II). One patient developed an intra-abdominal abscess which was resolved by percutaneous drainage one week after the second surgery. The patient who suffered the external iliac artery injury also experienced thrombosis of the arterial conduit that was discovered during the Palma procedure and arterial thrombectomy was performed. During follow-up, this arterial graft remains open and the patient has palpable distal posterior-tibial pulse. One of the patients who suffered DVT had diminished Doppler scan signal over the graft 2 days after the Palma procedure and bypass thrombosis was confirmed by duplex ultrasound scan. The patient refused subsequent thrombectomy and during follow-up he developed leg eczema and pigmentation dermatitis without ulceration (CEAP: C3,4-Es-Ap,d-Pr14,18O-I). The remaining 3 patients continue asymptomatic without clinical signs of venous hypertension and with patent cross-over vein grafts. All of these three grafts had functioning valves with no venous reflux by duplex ultrasound scan.
Table I. Wound mechanism and intraoperative findings
| Patient | Age | Mechanism of injury | Iliac vein injury | Associated injuries | Lowest recorded temperature | Bleeding |
|---|---|---|---|---|---|---|
| 1 | 22 | GSW | Right external | External iliac artery, ileum | 35.5°C | 4500 mL |
| 2 | 24 | stab | Right common | hypogastric artery | 35.2°C | 4000mL |
| 3 | 30 | GSW | Left common, external, hypogastric | jejunum | 35.3°C | 4000mL |
| 4 | 51 | GSW | Right common, external, hypogastric | ureter, ileum | 35.5°C | 3500mL |
Table II. Correlation between surgeries interval, DVT, and outcome
| Patient | Time between surgeries | Iliac vein injury | Deep venous thrombosis | Follow-up | Months patent |
|---|---|---|---|---|---|
| 1 | 48h | Right external | no | Palma open, asymptomatic | 31 |
| 2 | 144h | Right common | no | Palma open, asymptomatic | 51 |
| 3 | 240h | Left common, external, hypogastric | yes | Palma thrombosed, posthrombotic syndrome | 0 |
| 4 | 96h | Right common, external, hypogastric | yes | Palma open, asymptomatic | 20 |
Discussion
Management of pelvic and iliac vein injuries in trauma patients continues to be a controversial question in vascular surgery. Patients with iliac vein injuries carry a nearly 50% mortality that increases when other organs or vessels are involved.2 Generally, these patients are hemodynamically unstable making vein ligation a suitable alternative to salvage “life over limb” rather than pursue a complex venous repair. Primary vein ligation requires less operative time and is associated with few adverse long-term venous complications in some series.3, 4, 5 Nonetheless, symptomatic chronic venous occlusion usually occurs after iliac vein ligation but subsequent venous disability is likely under-reported. Careful search of the literature suggest that severe venous disability to be as high as 18%.6, 7 Interestingly, recent reports of long-term follow up of iliac vein stenting show that alleviating outflow obstruction resulted in major symptom relief in patients with chronic venous disease regardless of presence of remaining reflux or etiology of obstruction.8 However, when the unstable trauma patient requires formal ligation, a stent will not be able to traverse the ligated vein. Moreover, more distal deep venous thrombosis after iliac vein ligation can occur, as shown in this report, adding valvular dysfunction to the outflow problem.
Immediate venous repair maintains venous outflow potentially offering better functional capacity.9, 10 Still, the in-situ repair may not be feasible at the immediate or delayed procedure. Size mismatch between iliac and saphenous vein precludes the latter vessel for ideal conduit. If technically feasible, end-to-end repair or vein patches result in better outcome than interposition panel and spiral grafts.11
In 1993, Rotondo et al12 described the concept of “damage control surgery” (DCS) where quick control of surgical hemorrhage and enteric lesions were followed by ICU resuscitation. Then a staged definitive abdominal reconstruction was accomplished. This strategy is being used more frequently in penetrating abdominal trauma with better survival outcomes but with significant morbidity.13 In the present series, we apply this same DCS concept to the management of iliac vein injuries. Allowing the trauma patient to recover from the initial insult followed for an extra-anatomic bypass may represent less surgical stress, providing the advantages of immediate control with a definitive early reconstruction. Furthermore, a competent contralateral saphenous vein would provide an efficient anti-reflux conduit that, at least theoretically, would limit chronic venous insufficiency, which commonly remains after successful direct repair of complex venous injuries.14 The Palma crossover has previously been described for chronic unilateral iliac occlusion with an acceptable 4 year patency rate of 70% to 85%.15, 16, 17 The original description of the procedure includes venous anastomoses between the saphenous vein and the common femoral vein. We use a modification of the original technique that matches the diameter of the superficial femoral vein to the saphenous vein using an end-to-end anastomosis to improve flow dynamics.
There is no consensus about anticoagulation for venous bypasses. We used oral anticoagulation for 3 months only for those patients that had DVT. We only reserve long-term anticoagulation when long Palma bypasses are needed for chronic iliac vein occlusion. Although deep venous thrombosis in the effected limb may limit patency of the subsequent crossover bypass (ie, Palma), we cannot say from our limited experience whether this finding should preclude attempts at the venous outflow procedure altogether. While one of the two bypasses in patients with DVT failed, the other patient remains symptom free with a patent venous bypass at 20 months.
This group of patients may be small to establish a definitive method of treatment of iliac vein injuries, however, we believe it represents a good option for venous outflow maintenance without adding excessive morbidity for the severely injured trauma patient.
Conclusion
Immediate iliac vein ligation after penetrating abdominal trauma with early post-operative venous bypass, offers a safe, effective means of providing vascular reconstruction to avoid the long term morbidity of chronic venous insufficiency.
Author contributions
References
- . Cirugía de las venas de las extremidades. In: 1984;p. 96;Chapter 5
- Analysis of 185 iliac vessel injuries: risk factors and predictors of outcome. Arch Surg. 2003;138:1187–1194
- . Venous injuries of the lower extremities and pelvis: repair versus ligation. J Trauma. 1992;33:532–536
- . Venous injury: to repair or ligate, the dilemma revisited. Am Surg. 1995;61:139–145
- . The natural history following venous ligation for civilian injuries. J Trauma. 1980;20:737–743
- . Penetrating iliac vascular injuries: recent experience with 233 consecutive patients. J Trauma. 1990;30:1450–1459
- . Alternatives in the management of penetrating injuries to the iliac vessels. Journal of Trauma-Injury Infection & Critical Care. 1998;44:1024–1029
- . Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result. J Vasc Surg. 2007;46:979–990
- A quantitative approach to lower extremity vein repair. J Vasc Surg. 2002;36:1213–1218
- . Operative management and outcome of iliac vessel injury: a ten-year experience. Am Surg. 2003;69:581–586
- Outcome of complex venous reconstructions in patients with trauma. J Vasc Surg. 1997;25:398–404
- ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35:375–383
- Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma. 2003;55:1095–1108
- . Long-term results of lower-extremity venous injuries. Arch Surg. 1997;132:963–967
- . Vein transplants and grafts in the surgical treatment of the postphlebitic syndrome. J Cardiovasc Surg. 1960;1:94–107
- . Surgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease. Journal of Vascular Surgery. 2001;33:320–327discussion 327-8
- . Venous obstruction: an analysis of one hundred thirty-seven cases with hemodynamic, venographic, and clinical correlations. J Vasc Surg. 1991;14:305–313
Competition of interest: none.
PII: S0741-5214(08)00654-X
doi:10.1016/j.jvs.2008.04.042
© 2008 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
