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.