Venous injury: To repair or ligate, the dilemma

Abstract

Surgical management of major venous injuries remains controversial. The medical records of 184 patients with major venous injury were reviewed. Forty-three patients had isolated venous injury; 31 of 43 patients (72%) underwent ligation to treat their vein injury. Another 141 patients had combined arterial and venous injury; 117 of these patients (83%) had ligation. Injured were the inferior vena cava, iliac, femoral, popliteal, distal leg, and arm veins; all patients underwent surgical exploration. Arterial injuries were repaired by standard techniques and venous injuries were either ligated or repaired by end-to-end or lateral phleborrhaphy. Adjunctive fasciotomy was used when clinically indicated. The patients were followed up for 1 month to 9 years. No permanent sequelae of venous ligation were identified. Transient extremity edema developed in up to 32% of patients, regardless of whether vein ligation or repair was performed. This edema resolved completely within 12 weeks of the injury. No extremity was lost after ligation of a venous injury. Although it may be ideal to repair all venous vascular injuries, selective management reflecting mechanism of injury, blood loss, anesthesia requirements, associated organ injury, and other concerns may mitigate against extensive venous repair.

Is the inferior vena cava dispensable?

“…Lumbar, ascending lumbar and the vertebral veins also contribute to the collateral drainage. Transient oedema of the extremities will develop in 35% of patients [17]. Oedema goes on to become permanent in 2% of them [17].…”

“…Transient oedema of the extremities will develop in 35% of patients [17]. Oedema goes on to become permanent in 2% of them [17]. Ivy et al reported one patient who following a suprarenal ligation of the IVC developed extensive pedal oedema and an abdominal compartment syndrome [4].…”

Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents

“…The highest priorities in such instances are to arrest hemorrhage and to restore perfusion by liberal use of temporary shunts without ligation of critical vessels. Almost any significant vein injury may be ligated with impunity [103]. In addition, a tight compartment should be considered for decompression after vascular injury; however, we do not perform mandatory fasciotomies in such instances.…”

Clinical anatomy of the popliteal blood vessels

“…Several reports have implicated popliteal venous ligation as a contributing factor to lower extremity amputations in patients with popliteal venous trauma (Gorman, 1968;Sullivan et al, 1971;Phifer et al, 1985). Others have reported no increased risk of lower extremity amputation in patients with venous injuries managed by ligation in conjunction with postoperative limb elevation and fasciotomy (Mullins et al, 1980;Timberlake et al, 1986). The effectiveness of venous reconstruction versus ligation in the prevention of postoperative edema, and later postphlebitic syndrome, is a contested issue.…”

“…Mullins et al (1980) demonstrated a 23% incidence of mild edema in patients with lower extremity venous damage managed by ligation. Timberlake et al (1986) reported that, although transient edema developed in 32% of patients managed by venous ligation, none had permanent adverse effects related to lower extremity edema on long-term follow-up. More recently, in a study to assess long-term venous function in ligated versus repaired lower extremity injuries, Bermudez et al (1997) determined that most patients treated by either method exhibited evidence of chronic venous insufficiency as demonstrated by color flow Doppler ultrasound imaging and plethysmography.…”