VENOUS INJURY REPAIR VERSUS LIGATION

This study aimed to assess the option of choice concerning venous reconstruction and simple venous ligation especially in unstable patient with life threatening visceral injuries. A retrospective study of 347 patients operated upon for injuries of the venous system at vascular surgical unit, Al-Sader teaching hospital, from 1st of January 2005 to 31st of March 2012. Males were affected more than females with ratio of 6.7:1, however we had increased number of the injured female. Most of the cases had either shell injury (38.3%) or bullet injury (32.6%) with total percentage (70.9%). The majority of the patients had associated injuries (90%). In this series amputation rate, and revision surgeries done for ischemic limbs were lower when patients underwent repair. Disappearance of edema in post-operative period was significantly more rapid when the injured vein was repaired. The site of venous injury was found in this study to be the major factor that determines the morbidity. In conclusion, repair of the vein is favored when the conditions are optimal. In the presence of uncontrolled bleeding with persistent hemodynamic instability, ligation is recommended. Introduction he optimal management of major venous injuries continues to be a controversial topic. Although successful venous repair was reported as early as the latter part of the 19th century, ligation of a major vein trauma was an accepted method of treatment during world wars I and II. Hughes 1 reported on repair of selected cases of venous injury during the Korean War, but it was not until the Vietnam conflict that routine repair of venous injuries was advocated by Rich and Hughes 2 . Civilian experience in the past decade has corroborated the previously cited military experience in some aspect; however, the difference in wounds in civilian practice has also been emphasized in variety of experiences and results 2 . As with arterial injuries, most venous injuries occur in the extremities. Many veins are vulnerable to injury, because their relatively superficial location 3 . Reports on venous trauma are relatively sparse. Sever venous trauma is manifested by hemorrhage, not ischemia. Bleeding may be internal or external and may lead to hypovolemic shock 4 . In contrast to bright red blood in arterial injury, there is usually dark steady bleeding from venous injury 3 . In closed wound, a massive hematoma may develop. It may be impossible to determine whether such a hematoma is due to trauma to multiple small vessels or arterial injury, consequently, many venous injuries are 1st recognized at time of surgical exploration 3 . Vascular trauma occurs in about 3% of all civilian and military injuries. They follow cutting and stabbing incidents, gunshots injuries, pelvic fractures, road traffic injuries (particularly motor vehicle injuries), blunt trauma and surgical misadventures (iatrogenic) like in varicose T Venous injury repair versus ligation AK Benyan, Fouzi Alhassani, Muayyad Almudhafer & Tahseem Habash Bas J Surg, June, 20, 2014 48 vein, herniorrhaphy, and hip replacement surgeries. Missile injury is the common etiology in the military traumas 5 . The number of iatrogenic injuries to the venous system has increased during the past 35 years as a result of rapid development of vascular and cardiac angiography and catheterization 6 . A positive history of trauma with symptoms and signs of venous injuries in the form of dark steady bleeding (in open wound) or massive hematoma (in closed wound) with or without symptoms and signs of shock may be highly indicative for venous injuries, however the features can be obscured or predominated by an associated arterial, peripheral nerve injuries and bone fractures. It was believed previously prompt operation based on the clinical assessment without specialized diagnostic studies, result in limb salvage and minimal morbidity 7 . Patients & Methods A retrospective review of the records of 347 patients operated upon for injuries of venous system at the vascular surgery department, (Al-Sader teaching hospital in Basrah, south of Iraq), between 1st of January 2005 to 31st of March 2012. They were 302 male (87%) and 45 females (13%). The age range was 8-70 years with an average of 28 years, table (I) shows the demographic features of the patients. Major central venous injuries were excluded, venous surgical interference for late complicated vascular injuries and iatrogenic venous injuries were also excluded. Patients on whom we could not trace comprehensive assessment or follow up were omitted from the study. Information was obtained from the hospital records and direct evaluation of patients. Table I: The demographic features of the 347 patients.


Introduction
he optimal management of major venous injuries continues to be a controversial topic.Although successful venous repair was reported as early as the latter part of the 19th century, ligation of a major vein trauma was an accepted method of treatment during world wars I and II.Hughes 1 reported on repair of selected cases of venous injury during the Korean War, but it was not until the Vietnam conflict that routine repair of venous injuries was advocated by Rich and Hughes 2 .Civilian experience in the past decade has corroborated the previously cited military experience in some aspect; however, the difference in wounds in civilian practice has also been emphasized in variety of experiences and results 2 .As with arterial injuries, most venous injuries occur in the extremities.Many veins are vulnerable to injury, because their relatively superficial location 3 .Reports on venous trauma are relatively sparse.Sever venous trauma is manifested by hemorrhage, not ischemia.Bleeding may be internal or external and may lead to hypovolemic shock 4 .In contrast to bright red blood in arterial injury, there is usually dark steady bleeding from venous injury 3 .In closed wound, a massive hematoma may develop.It may be impossible to determine whether such a hematoma is due to trauma to multiple small vessels or arterial injury, consequently, many venous injuries are 1st recognized at time of surgical exploration 3 .Vascular trauma occurs in about 3% of all civilian and military injuries.They follow cutting and stabbing incidents, gunshots injuries, pelvic fractures, road traffic injuries (particularly motor vehicle injuries), blunt trauma and surgical misadventures (iatrogenic) like in varicose T vein, herniorrhaphy, and hip replacement surgeries.Missile injury is the common etiology in the military traumas 5 .The number of iatrogenic injuries to the venous system has increased during the past 35 years as a result of rapid development of vascular and cardiac angiography and catheterization 6 .A positive history of trauma with symptoms and signs of venous injuries in the form of dark steady bleeding (in open wound) or massive hematoma (in closed wound) with or without symptoms and signs of shock may be highly indicative for venous injuries, however the features can be obscured or predominated by an associated arterial, peripheral nerve injuries and bone fractures.It was believed previously prompt operation based on the clinical assessment without specialized diagnostic studies, result in limb salvage and minimal morbidity 7 .

Patients & Methods
A retrospective review of the records of 347 patients operated upon for injuries of venous system at the vascular surgery department, (Al-Sader teaching hospital in Basrah, south of Iraq), between 1st of January 2005 to 31st of March 2012.They were 302 male (87%) and 45 females (13%).The age range was 8-70 years with an average of 28 years, table (I) shows the demographic features of the patients.Major central venous injuries were excluded, venous surgical interference for late complicated vascular injuries and iatrogenic venous injuries were also excluded.Patients on whom we could not trace comprehensive assessment or follow up were omitted from the study.Information was obtained from the hospital records and direct evaluation of patients.Intra-operative heparin administration, when not contraindicated, is given and continued until patients become ambulatory and then switched to aspirin.Time interval between the time of injury and time of operation ranged between 1 and 72 hours with a mean of 7.4 hours.The diagnosis of major venous injuries was made in the operating room in all cases, isolated venous injuries were found in 35 patients (10%), the majority of patients had associated injuries (90%); arterial injuries were most common associated injuries (table III).The patency of the repaired vein estimated by Doppler study and clinical examination.Doppler ultrasound was performed for 30 repaired veins of the lower extremities between 3rd and 5th post-operative days.All of them showed positive flow; the remaining cases followed clinically and there were no clinical evidence of venous thrombosis; actually there were no signs of deep venous thrombosis or pulmonary embolism recorded clinically at period of follow up whether the vein was ligated or repaired.Nine patients died (mortality rate 2.6%), all of them presented in poor hemodynamic state (group D) at time of arrival.Two of them suffered from femoral artery and vein injuries with abdominal injury; while the other from Innominate vein injury.All of them died in the theater from irreversible shock.

Discussion
Ligation versus repair as a management of venous injury currently remains a controversial topic.Therefore, our inquiry is do we have any evidence that venous repair is better than ligation?This is clearly the most important question to be answered.In this study we had 347 patients underwent venous surgery in Al-Sader teaching hospital between 1st of January 2005 to 31st of March 2012.This can be considered as a high number of cases if we compare it with studies that done by others like the study done by Sharba 8 which included 87 patients had been taken in two years and another study done by Meyer J.P 9 that included 36 patients taken in tow years also.This difference, as we think is due to unstable political situation and increase violence action in Iraq in the last decade.Eighty seven percent of patients in our study were male while (13%) were female, which is high in comparison to other studies [8][9][10][11] .This significant difference may be explain by that most of patients in our study were injured by shell that affect both male and female in the same ratio, however, the percentage still higher in male because the male is the more active gender in Iraq.The age range was 6-70 years with an average of 28 years, most of patients were young (2nd and 3rd decade of life = 63.4%), that is similar to other studies [8][9][10][11][12] .The mechanism of injury was either penetrating (89%) or blunt trauma (11%).This is similar to Meyer, 1987 9 and Ekim et al 1998 10 results, but higher than other authors results 8,12,13 .Most of the cases had either shell injury (38.3%) or bullet injury (32.6%) with total percentage (70.9%),other authors have no patients got shell injuries, they have only patients with bullet injuries 8,9,13 , this is mostly due to the weak grip of law and lawlessness in Iraq at time of the study.Hemodynamic state of patients played an important role in planning the decision of types of surgery.Patients with poor hemodynamic state (group D) (7.2%) underwent ligation of their injured veins regardless the site of the injured vein.This results supported by all other studies 8,10,11,14 .Isolated venous were found in 35 patients (10%), the majority of patients had associated injuries (90%); and this findings are greatly differ from other studies 8,15 that show (13.3%) and (23.4%) for isolated venous injury because most of our patients had shell injury that accompanied by additional insult to soft tissue, bone and internal viscera.In this series amputation rate in femoral and Popliteal veins injury was 4.9% all of them had venous ligation, we hadn't lost any limb following venous repair 8,10,16,17 regardless of long term results.Insurance of venous patency during the initial 2 weeks following the injury perhaps improves patency rate in a new arterial anastomosis before development of collateral venous canals 10 .Revision surgeries were done for ischemic limbs in 10 patients (2.9%) where ligation of lower limbs injured vein were done with concomitant arterial reconstruction 4,8 .This may reflect that ligation of injured vein may increases the need for revision surgeries, and that the repair of veins in the lower limbs (femoral and popliteal veins) is far better than ligation.The site of venous injury was found in this study to be the major factor that determine the morbidity.No significant morbidity were recorded after ligation of upper limb veins, neck veins or veins distal to the knee; while most morbidity resulted from ligation of popliteal and femoral veins.Although repair of injured vein is recommended whenever possible, these veins should just be ligated if the injury is extensive, if the patient is unstable, or if there are other multiple sever injuries.The effectiveness of venous reconstruction versus ligation in the prevention of post operative oedema is also contested issue.In our study, the overall incidence of post operative limb oedema was 19.8% of injured veins whom underwent repair; while it was 45.4% when the veins ligated (neck veins injuries are excluded).Rich, 1982 2 reported a 51% incidence of significant post operative oedema in patients with popliteal vein injuries managed by ligation compare with a 13% incidence if venous repair was attempted.Timberlake et al 1986 15 reported that although transient oedema developed in up to 32% of patients managed by venous ligation, no patient had a permanent problem with extremity swelling on long term follow up.We conclude that venous repair is associated with lower post operative morbidity than ligation.
Open fasciotomies were performed as a prophylactic measures for 97 injured veins; all of them underwent venous ligation.(following ligation a prophylactic Fasciotomy may be done to obviate the risk of compartment syndrome) 18,19 .
We hadn't recorded any case of deep vein thrombosis and pulmonary embolism in our follow up period 4,20 , while other studies recorded (39%) 1 , (22%) 10 , and (19%) (13) of the patients had developed deep venous thrombosis, our treatment protocol of intra operative Heparin administration, when not contraindicated, and hence continued until the patients became ambulatory after that switched to Aspirin tablet 100 mg a day, might have help in the prevention of thrombosis.Overall mortality rate was 2.6% in this series i.e. nine patients died secondary to profound bleeding and shock.In Ekim et al 1998 10 study, the mortality rate was (3%) while in Nitecki et al, 2007 4 study, the mortality rate was zero, this difference in mortality rate depends on the selection of cases, site of injury chosen for study and complexity of the injury.In conclusion, repair of the injured vein is favored when the conditions are optimal, in the presence of uncontrolled bleeding with persistent hemodynamic instability, ligation has been recommended.It is obvious that disappearance of oedema in post operative period was significantly more rapid when the vein was repaired.The only disadvantage of venous repair is the time required for repair, and possibly the only indication for venous ligation are complex lacerations or associated injuries that mandate priority.

Table II : Classification of patients according to their hemodynamic state.
Initial assessment and care of the patient with peripheral vascular trauma focuses on control of external hemorrhage and diagnosis of ischemia.Hypovolemia and shock were managed by controlling external blood loss, and restoring blood volume by an adequate infusion of crossmatched blood and i.v.fluid, adequate peripheral line were ensured.In The management of injured veins consisted of lateral vienorrhaphy, venous patch angioplasty, end to end anastomosis, interposition saphenous vein graft, and ligation.