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Iatrogenic venous injuries (IVIs)

University Hospital Sestre Milosrdnice, Zagreb 1000, Croatia

The management of arterial and venous injuries during saphenous vein surgery

The article by Marcucci et al. [1] reports two rare cases of major iatrogenic venous injuries [IVIs] following varicose vein vascular surgery. My search of our database (last eight years), shows that the incidence of IVIs especially after varicose vein surgery is increasing. This increase seems to be associated with the introduction of fairly sophisticated techniques such as radiofrequencies and lasers combined with simple crossectomy with/without phlebectomy, and performed in one-day-surgery clinics by teams consisting of young general surgeons and radiologists. The average number of civil venous vascular injuries was 12 per year from 2000–2007, but increased from 7 in 2000 to 18 in 2007. All injuries occurred out of our clinic. The proportion caused by IVIs increased, from 33% during the 4-year-period 2000–2003 to 50% 2004–2007. While the number of registered procedures per year in the database was stable during this eight-year period, the proportion of procedures for IVIs also increased. Emergency repair was performed in 100% of the IVIs. The most common surgical procedure was direct suture repair of the vessel (49%), followed by bypass or interposition graft (29%), and end-to-end anastomosis (22%). For IVIs, injuries in the groin predominated. We assume this is likely due to the great number of therapeutic procedures performed by inexperienced teams consisting of young general surgeons and interventional radiologists who performed surgical procedures in one-day private clinics. Numerous ethical considerations emerging from recent tendencies in managing for varicose vein disease must be taken into account, such as the ethical aspects of sending a patient of one's own to another specialist for specific problems such as varicose vein diseases, for instance to a dermatologist, radiologist, or for surgery, for instance to a colleague with more experience in that particular kind of case [2].

I would like to congratulate the authors for a fantastic description of two cases which absolutely support the conclusion that adequate surgical technique is mandatory for ablative surgery or/and endovascular obliteration for varicose vein disease and it should be performed by a trained vascular surgeon, in order to minimize unpredictable postoperative complications.

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1. Marcucci G, Accrocca F, Antonelli R, Siani A. The management of arterial and venous injury during saphenous vein surgery. Interact CardioVasc Thorac Surg 2008;7:432–434.[Abstract/Free Full Text]
2. Jones JW. Surgical ethics challenger. When to refer to another surgeon. J Vasc Surg 2002;35:192.[Medline]

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