Venous Repair Question - Forum

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Sweden surgeon

Venous Repair Question - Ärzteforum

Post#1 »

I would like to ask for some discussion about venous repair after treating a gunshot wound to the upper thigh recently.

The patient (4th admision for GSW in 3 years) had 4 GSWs to the lower body. One of them transversed the right upper thigh from lateral and exited on the anteromedial side, then hit both testis and then tranversed the contralateral leg. It was a low velocity 9mm caliber and the patient presented with a sitolic BP of 60, a large haematoma of the right thigh. After fluid resus he had palpable peripheral pulses in all limbs.

On exploration the bullet passed posterior to the artery and hit the Femoral vein, destroying about 4cm of vein.

What is your feeling about repairing peripheral veins?

I have searched Medline and there seems to be confusing literature on the matter. The millitary articles (Israel and Vietnam) seem to advise tying of the vein. Others advise repair (lateral repair, simple suture and complex repair) even though patency on follow up is poor. Two things seem to filter through:
1) Complex repair occludes irrespective of the material used (PTFE or Autologous vein).
2) Long term morbidity after tying of the veins, seem to be high with a high insidence of chronic venous insuficiency.

Does any of you employ small A-V fistulas to keep complex repairs open?

For injuries below the Sapheno-femoral junction, what about an "in situ" side on side anastomoses of the Femoral and greater saphenous veins distal to the injury with tying of the injured ends. That is to say if the greater saphenous vein is intact. I have not read of this being described.

In animal models, PTFE seem to work. What would you use in practice?

Obviously I am not talking about a critically injured patient where any prolonged procedure is to be avoided.


Grandpa Phil

Re: Venous Repair Question - Ärzteforum

Post#2 »

This is a question near and dear to my heart--there is no reason whatever to repair the superficial femoral vein in your case, as it adds virtually no benefit to justify the extensive additional time and complexity of repair it would require. As ageneral rule of thumb, any extremity vein requiring anything more than lateral suture or end to end anastomosis should be ligated, which can be done with virtual impunity in the absence of associated soft tissue or bony injury. Most venous injuries are from penetrating agents, and most are found on exploration for bleeding--only 10-15% are isolated without a concomitant arterial injury. The series out of Vietnam by Rich dealt with high velocity wounds and a high incidence of bone and soft tissue destruction, destroying venous collaterals and impairing drainage if ligation was done. The overwhelming bulk of civilian literature since Vietnam clearly demonstrates the safety and preference of ligation (see refs below), which the consensus agrees should be done in any unstable patient or for wounds with large vessel length lost as in this case. The incidence of post op venous insufficiency is at least as low as if veins were repaired as a rule, and when it happens is easily managed by limb elevation and generally resolves. Patients with these injuries have typically lost a lot of blood, present in shock, and frequently have associated injuries that do not warrant the extra time necessary for complex repairs. If the popliteal vein is injured, we generally try a little harder to fix, sometimes even with autogenous interposition, but even here can be ligated pretty safely--in this case, we would tend to do a prophylactic fasciotomy, or at least monitor compartment pressures closely postop--fasciotomy is also indicated for any combined vein and artery injury. In the upper extremity, any repair of a vein should be considered a tour de force by someone who obviously has a lot of time to kill.

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Billroth

Re: Venous Repair Question - Ärzteforum

Post#3 »

If the repair is sitting up and asking to be done then do it, otherwise ligate it. If there is a concomitant arterial injury have a very low threshold for doing fasciotomy. Forget anything fancy - its a waste of time. You really can ligate anything if you have to. Often there will be a lot of swelling but it goes rapidly. Can't comment on the long term morbidity in patients like yours - but you won't see many of them in vascular clinics with signs of venous insufficiency. What happens to them who knows - probably a 5th GSW! I'm surprised he didn't have an arterial injury as solo venous injuries don't often give such a large blood loss unless they bleed out rather than into a haematoma. did he lose much from his other GSW's?

Scalpel

Re: Venous Repair Question - Ärzteforum

Post#4 »

As long as the profunda femoris vein is intact, the superficial femoral vein can be safely ligated without anxiety. Some authors in fact use superficial femoral vein for arterial bypass (reversed or in situ) without any reported venous insuffficiency. The concept of venous repair for arterial trauma is much more critical at the level of the popliteal artery, where several studies (obviously not randomized) have shown fewer amputations with concommitant venous repair, even if it occludes within a few weeks.

bonjorno

Re: Venous Repair Question - Ärzteforum

Post#5 »

I would however be more agressive with popliteal venous injuries in that. I would always do a four compartment fasciotomy with a very bad popliteal vein injury especially if one ligates it.

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