Results of reconstruction in major pelvic and extremity venous injuries☆☆☆★

Article Outline

• Abstract
• PATIENTS AND METHODS
• RESULTS
• DISCUSSION
• Acknowledgements
• References
• Copyright

Abstract 

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. (J Vasc Surg 1998;28:901-8.)

The optimal management of major venous injuries remains controversial.¹ Although ligation of many major venous injuries may be performed with relative impunity,² reconstruction of injured veins results in a more complete restoration of venous circulation and may be associated with better short-term and long-term outcomes. Although proof of prolonged venous patency after reconstruction for trauma has been lacking, we have favored repair over ligation whenever it can be performed safely. We examined the results and long-term patency associated with aggressive venous reconstruction in major venous injuries.

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PATIENTS AND METHODS 

All patients with major venous injuries of the extremities and pelvis who were treated by the Department of Vascular Surgery at the Hadassah University Hospital from January 1988 to December 1996 were included in the study. Their charts were reviewed, and preoperative data retrieved included site and mechanism of injury, application of tourniquet, associated injuries, interval between injury and operation, and the results of arteriography. Operative reports were reviewed for the description of vascular injuries, type of venous repair, performance and timing fasciotomy, and additional procedures. Postoperative complications were noted. Follow-up information included functional capacity of the extremity and the presence of extremity swelling. Short-term and long-term venous patency was evaluated by means of continuous-wave Doppler, impedance plethysmography, and duplex scanning (Acuson 128xp/10, Acuson Corporation, Mountain View, Calif).

All patients admitted to the Hadassah University Hospital with traumatic injuries were initially evaluated by the trauma team. Patients who were hemodynamically unstable and those with arterial bleeding from extremity wounds were taken directly to the operating room. Stable patients with evidence of vascular injury underwent preoperative arteriography. All vascular procedures were supervised by a vascular surgeon. In cases with combined vascular and skeletal injury, our policy was to insert temporary arterial and venous shunts before skeletal fixation and proceed with definitive vascular repair after skeletal fixation. The most frequently used shunt was the Heyer-Schulte Sundt carotid shunt. Intravenous heparin was administered after vascular control was obtained, unless there was ongoing bleeding. The need for and the type of vascular repair was determined by the vascular surgeon. Interposition vein grafts were spatulated and anastomosed with a continuous suture of 6-0 or 7-0 polypropylene. Panel grafts were prepared by opening the saphenous vein longitudinally, removing the valves, folding it over a chest tube of a desirable size, and sewing the vein onto itself with a continuous suture of 7-0 polypropylene.³ A spiral graft was prepared in a similar fashion, by wrapping the open vein helically around the chest tube. Fasciotomy was performed liberally, whenever ischemia was severe or prolonged (6 hours or longer), whenever the calf was tense after revascularization, and, recently, in all patients who had a tourniquet applied in the field. Postoperative anticoagulation was not used routinely, and pneumatic compression devices were not used. Full limb function was defined as normal musculoskeletal and neurological function as assessed by the physician and full function as perceived by the patient during the last follow-up examination. The presence of edema was not included in this definition and is reported separately.

Statistical analysis was performed with statistical package for the social sciences (SPSS) release 5.0, using χ² and logistic regression analysis for examination of factors associated with outcome; P < .05 was considered significant.

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RESULTS 

From January 1988 through December 1996, 46 patients with 47 major extremity or pelvic venous injuries were treated by the Department of Vascular Surgery at Hadassah University Hospital. The mean patient age was 26.6 years (range, 5 to 74 years), and 41 (89.1%) of the patients were men. Penetrating trauma, with a preponderance of high-velocity missile injury, accounted for 37 injuries (79.2%), blunt trauma for 6 injuries (12.5%), and 4 injuries (8.3%) were iatrogenic (Fig. 1; Table I).

Table I. Mechanism of injury

Lower-extremity veins were injured in 39 limbs in 38 patients, pelvic veins in 4 patients, and upper-extremity veins in 4 patients (Table II).

Table II. Distribution of venous injuries

Associated injuries in the same extremity occurred in 43 patients; arteries were injured in 37 instances in 36 patients (Table III).

Table III. Associated injuries related to same extremity

SFA, Superficial femoral artery; CFA, common femoral artery; DFA, deep femoral artery; EIA, external iliac artery.

Venous injury was unaccompanied by arterial injury in 10 patients, including 3 of the iatrogenic injuries.

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• Fig. 1. 

  Anteroposterior radiogram of the left thigh after close range injury by 2 large fragments of an explosive-filled lead pipe. Entry wound was in the lateral lower thigh, with massive bone and soft tissue destruction and avulsion of the superficial femoral vessels. The sciatic nerve was spared. The artery and the vein were repaired with interposition grafts of reversed saphenous vein and panel graft, respectively, and the bone was stabilized with intramedullary fixation. The wound was reexplored after 7 days, and the patient underwent full recovery, with a 4-cm shortening of the left femur.

An arteriovenous fistula was present in 5 cases. Remote injuries included abdominal (n = 8), chest (n = 5), another extremity (n = 5), perineal (n = 3), and head (n = 2) injuries.

Sixteen patients arrived in the trauma unit with a tourniquet applied to the extremity; 2 patients were in Military Anti-Schock Trousers suits, and 1 extremity was compressed manually. Twenty-seven patients were hypotensive (systolic blood pressure < 80 mm Hg). Arteriography was performed in 15 patients. The findings were normal in 4 patients, arterial injuries were demonstrated in 7 patients, and arteriovenous fistulas were demonstrated in 4 patients. No patient underwent preoperative venography. Indications for operation were overlapping and included bleeding in 31 limbs, ischemia in 29 limbs, and arterial injury verified by means of arteriography in 11 limbs. All 7 isolated traumatic venous injuries were found on exploration for bleeding. The mean duration from injury to operation, excluding 4 missed injuries, was 3.9 ± 2.7 hours, and in 12 cases, it was longer than 6 hours, predominantly because of delays in transport to the hospital. Four patients underwent exploration more than 24 hours after injuries that were not clinically evident or associated with ischemia or external bleeding. These vascular injuries were missed initially and included 2 arteriovenous fistulas and 2 arterial pseudoaneurysms with concomitant venous laceration.

After isolation of blood vessels and before skeletal stabilization, temporary venous shunts were placed in 12 patients, and arterial shunts were placed in 10 patients. The dominant venous injury was repaired in 45 limbs (95.7%) and ligated in 2 limbs (4.3%). Repairs using vein grafts were undertaken in 34 instances and included spiral (n = 7), panel (n = 8), interposition grafts (n = 12), and patch venoplasties (n = 8; Table IV).

Table IV. Repair of venous injuries

SFV, Superficial femoral vein; CFV, common femoral vein; CIV, common iliac vein; DFV, deep femoral vein; EIV, external iliac vein; SCV, subclavian vein; ia, iatrogenic.

Ligation was performed in a patient with coagulopathy, abdominal injury, and superficial femoral vein transection and for a deep femoral vein transection. For all cases of lower-extremity venous graft repair, the contralateral saphenous vein was used, except 1 case in which, because of size considerations, the basilic vein was used as an interposition graft in the superficial femoral vein. Two noteworthy cases involved bilateral lower limb injury. One young man had a high-velocity gunshot injury to both superficial femoral arteries, veins, and femurs and underwent panel graft repair of 1 superficial femoral vein and spiral vein graft repair of the other. A young woman had bilateral popliteal arterial and venous injury caused by a motorboat rotor, and blood vessels from the nonsalvagable leg were used to reconstruct the remaining leg.

Arterial injuries were repaired with saphenous interposition grafts in 28 cases, polytetrafluroethylene (PTFE) interposition in 4 cases early in the series, a saphenous vein patch in 1 case, and end-to-end anastomosis in 1 case of axillary injury. Arterial ligation was performed twice, on 1 profunda femoris branch and 1 distal profunda artery. All fractures were stabilized during the initial operation. External fixation was used in 12 cases, intramedullary nailing in 4 cases, and plating in 1 case. Calf fasciotomy was performed in 23 limbs, and in 17 cases, formal 4-compartment fasciotomies were performed using lateral and medial incisions. All fasciotomies were performed at the initial operation, used long skin incisions, and were covered with split thickness skin grafts. The mean duration of operation was 7.2 ± 4.1 hours, and the estimated time for venous repair was approximately 1 hour. The mean transfusion requirement was 10.9 ± 10.9 units.

There were no perioperative deaths. Acute respiratory distress syndrome with prolonged ventilation requirements developed in 1 patient. Two patients (4.3%) underwent delayed amputation of the injured limb. One patient with a gunshot injury to the upper thigh, femur fracture, and profunda femoris injury had a panel graft repair of a superficial femoral vein injury. A deep-wound infection, dehiscence of the venous repair site, and acute bleeding developed. He underwent an above-knee amputation on postoperative day 14. The second patient sustained a massive crushing injury to the popliteal fossa, with extensive soft tissue damage, arterial injury, and bone fractures, and had an interposition graft repair of the popliteal vein. His injury may have been too extensive for salvage. Muscle necrosis without thrombosis of the arterial repair developed, and he underwent a below-knee amputation on the seventh day after injury.

No patient required delayed fasciotomy. Early reoperations were performed in 8 patients and included control of bleeding in 2 patients and a femoropopliteal bypass for a missed superficial femoral artery injury in 1 patient. In 5 patients, irrigation, debridement, and wound coverage with muscle flaps or skin grafts was performed for persistent fever, leukocytosis, or wound discharge.

Of the 45 limbs that were salvaged, 38 regained full function. In the lower extremity, 3 patients had a foot-drop, 1 transiently, 1 had a pedal sensory loss, and reflex sympathetic dystrophy developed in 1. In the upper extremity, 1 patient had complete paralysis after a brachial plexus injury caused by a tree that fell on his shoulder. He underwent brachial plexus neurolysis 3 months after the injury, and after 1 year, digital sensation and limited motion returned.

Thirty-day patency was evaluated by means of duplex scan (n = 17), continuous-wave Doppler and impedance plethysmography (32), or venography (3) in 32 patients. Venous occlusion was identified in 4 cases, all involving the superficial femoral vein. Two patients underwent a panel graft repair, 1 patient underwent saphenous vein interposition, and 1 patient underwent patch venoplasty. In 2 of these patients, the initial operation was delayed by more than 24 hours. Four patients, 2 of whom had patent venous reconstructions, had transient early leg edema. No patient had chronic leg edema. Long-term follow-up was available for 27 patients. All other patients could not be located. Evaluation of venous patency by means of duplex scanning (n = 18), continuous wave Doppler and impedance plethysmography (n = 9), and venography (n = 2) was performed after a mean period of 27.7 ± 30.6 months (range, 1 to 94 months, SE 5.9). Only 1 occlusion was found, 6 weeks after spiral graft repair of a common femoral vein injury sustained during repair of an inguinal hernia. All other venous reconstructions were patent (Fig. 2).

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• Fig. 2. 

  Follow-up examination of a fully recovered young man, 8 months after high-velocity gunshot injury of the right thigh with spiral graft repair of the superficial femoral vein. A, A patent superficial femoral vein of the right leg demonstrated by means of venogram. The intramedullary nail and the femoral callus are evident. B, Patency and phasic flow with respiratory variation demonstrated by means of duplex of the same vein.

We retrospectively applied 4 injury scores to 39 noniatrogenic lower extremity injuries (Table V). These scores were not used by the physicians caring for the patients. The scores were quite divergent, but mangled extremity severity score (MESS)⁴ and limb salvage index (LSI)⁵ were indicative of a large number of severe injuries. A high injury score was not associated with outcome, functional result, or venous patency. A high injury score was significantly associated with the need for reexploration of wounds on all 4 scoring systems (Table V).

Table V. Injury scores for 39 noniatrogenic lower extremity injuries

MESS, Mangled extremity severity score; LSI, limb salvage index; MESI, mangled extremity syndrome index; PSI, predictive salvage index.

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DISCUSSION 

Treatment of major venous injury remains controversial. Reasons often stated in favor of venous ligation are the saving of operative time, particularly important in the unstable patient with multiple injuries²; a low incidence of edema and disability after ligation⁸, ⁹; and a high rate of thrombosis¹⁰ and thromboembolic complications after venous repair¹¹ without increase in the need for fasciotomy.⁹ Factors stated in favor of repair, as opposed to ligation, are a lower amputation rate,¹², ¹³ particularly in the popliteal vein,¹⁴ a lower rate of edema and disability,¹⁵, ¹⁶ less thromboembolism,¹⁷ and the possibility of recanalization and patency even after early thrombosis of repair.¹⁸

Venous injury is common; it occurs in approximately 30% (13% to 51%) of vascular injuries.¹, ¹⁹ It is quite surprising that conflicting observations and opposing therapeutic approaches persist despite continued interest and debate. Several factors contribute to the difficulty in arriving at a unified approach and substantiated recommendations. The foremost is the variability in the etiology and magnitude of injury, which makes comparison between series difficult. A series with a high rate of stab wounds or low-velocity missiles will present many more opportunities for primary or “simple” venous repair than a series, such as ours, with a preponderance of injuries caused by high-velocity missiles and military weapons. In addition, the combination of satisfactory functional recovery after venous ligations, the susceptibility of venous repair to thrombosis and occlusion, and the paucity of long-term, objective follow-up make differentiation between the outcomes of these reports difficult. We have greatly favored repair over ligation of venous injuries. However, because this is not a prospective or controlled study, a comparison of both treatments and their outcome is not possible.

Venous reconstructions are notoriously unforgiving. To achieve patency in a severely injured vein requires adequate debridement of the traumatized vein margins and a tension-free repair. This often mandates the use of an interposition graft. In the iliofemoral segment, where many of the injuries occur, the use of such grafts is problematic. Saphenous vein interposition grafts are usually too narrow for this location, as shown by means of late venograms.²⁰ Because the optimal conduit is autologous and isodiametric, the best interposition graft for this location is a spiral²¹ or panel vein graft. However, the fashioning of such grafts is time-consuming and technically demanding. Consequently, the use of these grafts is low in most series (Table VI).

Table VI. Method of repair of venous injuries in reported series

*Only femoral injuries. †Number of iliofemoral injuries.

Arm veins are less desirable. They are often not large enough, their handling characteristics are inferior, and in the setting of lower-extremity trauma, the arms are usually used for cannulation. Similar considerations apply to neck veins.

A relatively high proportion of our repairs was done with spiral or panel grafts, and we share the belief of Sharma and associates²³ that meticulously repaired veins remain patent. The coexistence of multiple injuries often mandates, within the framework of damage control, an expedient repair with some residual luminal narrowing. However, this has to be done with the realization that an imperfect venous reconstruction has been accomplished and a higher occlusion rate can be anticipated.

The important benefit of repair compared with ligation is in the immediate perioperative period and is, in our opinion, of critical importance in the most severely injured limbs. Perhaps the most important benefit is the dramatic reduction in bleeding observed after the release of the venous clamps. This effect, which is hard to quantify, is caused by venous decompression and results in a reduced need for blood replacement and more effective hemostasis. Reestablishment of normal venous outflow also avoids the transient decrease of arterial flow and increase in peripheral resistance induced by venous ligation.²⁴, ²⁵ Because most venous injuries (more than 80%) are associated with adjacent arterial injury,¹, ¹⁹ venous repair is important and may enhance patency of concomitant arterial repair. In addition, the rates of acute postreperfusion calf swelling and compartment syndrome are reduced.¹⁶, ²³ These early benefits may be more important than intermediate-term limb dysfunction or edema, as shown by the lack of limb dysfunction or edema in limbs in which the venous repair occluded.

Our approach to venous reconstruction has evolved within a philosophy of very aggressive management of extremity vascular injury. We apply every measure to improve survival of the extremity, as long as it does not jeopardize the patient. This includes, in addition to venous reconstruction, insertion of temporary arterial and venous shunts whenever skeletal stabilization delays vascular repair and liberal performance of fasciotomy. To achieve maximal decompression, fasciotomy is performed predominantly in all 4 compartments, including the skin, using long incisions, and is covered with skin grafts. Our indications for fasciotomy include an interval of 6 hours or more between injury and vascular repair, tension over calf muscles after revascularization, and having a tourniquet applied to the extremity in the field.

In our experience, the incidence of early venous occlusion is low. We do not agree that “complex venous repairs,” and particularly spiral and panel grafts, are associated with a higher rate of thrombosis.²⁶ Clearly, the injury underlying a more elaborate reconstruction is often more extensive. Otherwise, these reconstructions do not predispose a patient to complications. They have a definite size advantage over saphenous interposition grafts in the larger veins. Even in venous repairs that have occluded, recanalization has been reported,¹⁸ although we have not documented it. A more important point in favor of repair, and one that is especially important in the young age group affected by trauma, is that beyond the first few weeks the occlusion rate is low and prolonged patency is the rule¹⁸, ²⁷(Fig. 2). There are few thromboembolic complications, and crippling venous insufficiency may be avoided.

A significant number of limbs in this series sustained very severe injury, and we retrospectively applied 4 extremity injury scores (MESS, LSI, MESI and PSI; Table V). Outside their original sample, none of the 4 scoring systems is a reliable predictor of amputation for the individual patient, and in previous reports, no correlation with functional outcome was found.²⁸, ²⁹ We found significant correlation of a high score on all 4 indices with the need for reexploration of the extremity, but with no other outcome variable. This association reflects the need for repeated exploration, drainage, irrigation, and soft tissue coverage in the most severely injured limbs. Indeed, if this continued care is neglected, an association between high scores and the amputation rate may emerge. Exploration of the wound should continue to be based on the usual indications of persistent fever and leukocytosis or wound discharge. A high injury score on admission may alert the surgeon to the increased likelihood of requiring a reexploration.

In conclusion, venous reconstructions for trauma with frequent use of spiral or panel vein grafts are possible with high early and late patency rates and good functional results. Venous occlusions usually occur within weeks after the injury, and thereafter, prolonged patency is the rule. A high extremity injury score may predict the need for repeated exploration of the extremity.

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Acknowledgements 

We thank Dr Albert Yellin for his insightful comments and critical review of the manuscript.

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