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ICVTS on-line discussion B Traumatic venous injury: ligation or repair?

Bursa Yüksek Ihtisas Education and Research Hospital, Bursa 16330, Turkey

Venous trauma in the Lebanon War – 2006

eComment: I read with great interest the paper by Nitecki et al. [1] regarding their experience in patients with major venous trauma during battle conditions. This report is on the treatment of a small series of venous injuries which continue to challenge surgeons in many areas of the world. The authors are to be congratulated on their success in venous repair. I would like to add some comments on this topic.

Traumatic venous injuries are seen in penetrating and blunt trauma. Venous injuries are often associated with concomitant injuries. They have been well documented during wartime, but there have been an increasing number of reports from the civilian arena.

Ligation vs. repair as management of traumatic major 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 answer.

In the past, historically, ligation of injured veins was the most used modality of surgical approach. Later, various repair techniques including primary repair, interposition grafts, and sometimes endovascular techniques were put into practice.

Vein ligation should be considered as a clinical option of choice, especially in an unstable patient with life-threatening venous injuries. In civilian experience, permanent sequelae of venous injury ligation are rare and in patients with hemodynamic instability from blood loss, extensive local injury, associated organ injury, anesthesia requirements, or other concerns; venous ligation is an acceptable option. It does not increase in postoperative morbidity, the need for fasciotomy, or leg edema. In venous traumas, edema of the extremity may develop regardless of vein injury ligation or repair [2, 3]

Patients treated with venous ligation have a higher transfusion requirement, a greater incidence of shock, and a greater venous injury staging system, ranging from grade I (less than 50% laceration) to grade IV (complete interruption with soft-tissue injury).

Based on clinical and experimental research, there is an increasing interest in repairing venous injures. However, overall treatment strategies remain largely unchanged since the Vietnam War. In spite of limitations, successful venous repair has been possible without complications of thrombophlebitis or pulmonary embolism. Venous repair is supposed to prevent or ameliorate the complications of pain, edema, and phlegmasia.

The type of venous repair was primarily affected by the mechanism of injury and hemodynamic instability. Extended repairs are more complex and time-consuming procedures [4]. Venous injuries are treated with primary repair (lateral venorrhaphy or end-to-end anastomosis), or complex repair (vein patch, spiral vein graft, reversed saphenous vein interposition graft or interposition ringed polytetrafluoroethylene graft).

Venous repair is a safe and durable surgical approach associated with minimal morbidity, good long-term patency, and preservation of venous competence. In patients with thrombosed venous repair, thrombus absorption with recanalization may occur [5].

Early detection of traumatic venous injury, prompting early operative exploration, vascular control, and repair increase the success in venous trauma.

Finally, the obvious limitations to the authors' series are a small number of patients and the lack of long-term follow-up. As stated by Nitecki et al., we also recommend venous repairs in all hemodynamically stable patients, whereas ligation continues to be the primary indication for an unstable or multi-trauma patient.

	References

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1. Nitecki S, Karram T, Hoffman A, Bass A. Venous trauma in the Lebanon war – 2006. Interact CardioVasc Thorac Surg 2007; 6:647–651.[Abstract/Free Full Text]
2. Timberlake GA, Kerstein MD. Venous injury: to repair or ligate, the dilemma revisited. Am Surgeon 1995; 61:139–145.[Medline]
3. Yelon JA, Scalea TM, Mullins RJ, Kerstein M, Shackford S, Hirsch E, Feliciano D, Mattox K. Venous injuries of the lower extremities and pelvis: repair versus ligation. J Trauma 1992; 33:532–538.[Medline]
4. Pappas PJ, Haser PB, Teehan EP, Noel AA, Silva MB Jr, Jamil Z, Swan KG, Padberg FT Jr, Hobson RW II. Outcome of complex venous reconstructions in patients with trauma. J Vasc Surg 1997; 25:398–404.[CrossRef][Medline]
5. Nypaver TJ, Schuler JJ, McDonnell P, Ellenby MI, Montalvo J, Baraniewski H, Piano G. Long-term results of venous reconstruction after vascular trauma in civilian practice. J Vasc Surg 1992; 16:762–768.[CrossRef][Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Senol Yavuz Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yavuz, S. Search for Related Content PubMed PubMed Citation Articles by Yavuz, S. Related Collections Related Article