Although some lower limbs' arterial injuries might be treated with ligation in extreme trauma cases, arterial repair is the gold standard. However, in the case of an isolated vein injury, management is still a matter of debate. Ligate or repair are both valid options. Are the outcomes similar?
To evaluate the impact of the operative management of isolated venous injuries of lower limbs in civilian patients following trauma, was the objective of a retrospective study from Nathan Manley et al from Memphis, Tennessee, USA. The authors compared results of isolated venous injuries of the lower limbs treated with ligation versus repair. Primary outcomes were symptomatic edema and venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE).
In WWII ligation was the main option to deal with those injuries. During the Korean and Vietnam wars more aggressive aproaches were used, and repair was the main objective. Venous repair takes longer operative time (which can have a negative impact in a trauma patient) with risk of thrombosis at the suture line with risk of VTE. Ligation is faster but with risk of edema and compartment syndrome. So... What should we do? There is no consensus.
During a 10y period, Nathan Manley et al retrospectively analysed 84 patients with isolated venous injuries of lower limbs. 93% were male, mean Injury Severity Score was 17, and mean Coma Glasgow Score was 14. Intraoperative anticoagulation consisted in unfractionated heparin. All patients received some form of postoperative VTE prophylaxis (50% LMWH, 45% heparin, 4% heparin drip, 1% aspirin). No therapeutic doses of LMWH were used in any patient. My first question is: why use aspirin for VTE prophylaxis? Venous thrombus is different from the arterial one. The latter has great amounts of platelets, while the first is a fibrin thrombus.
Injury location was as follows: common iliac vein - 24%; external iliac vein - 32%; femoral vein - 44%. Forty nine (49/84 - 58,3%) patients were submitted to vein repair, and thirty five (35/84 - 41,7%) to ligation. Repairs included all the following:
84% venorraphy
6% vein patch
8% vein bypass
2% vein shunting and posterior bypass
0% prosthetic bypass
In overall there were 18 patients with symptomatic VTE (14 DVT's, 3 PE's, 1 DVT plus PE). Comparing patients with VTE and patients without VTE there was no difference in timing and type of chemoprophylaxis, no difference in mean lenthg of stay, in ICU days and in-hospital mortality. However, VTE was more frequent in external iliac vein injury (p=0,03), and lower limb edema was more frequent in the presence of a VTE (p=0,007).
The most important is to know if venous ligation is linked to more or less cases of VTE than venous repair. Results are clear.
In repair group there was a 31% rate of VTE, and in ligation group a VTE rate of 9% (p=0,02). Must not forget groups were similar.
This study demonstrates that patients submitted to vein repair are more likely to develop a VTE than patients who underwent vein ligation following a trauma lesion. These data matches other studies, but there are works from civilian and military institutions showing no difference. Controversy continues...
According to the authors most surgeons agree in ligation of major venous injury in patients with multiple and complex lesions, significant tissue destruction, and those "in extremis". For this approach a wisely use of lower limbs elevation, compression stockings, and early or prophylactic fasciotomies is crucial. On the other hand, venography may restore venous outflow and reduce edema (not demonstrated). However, it violates all criteria of the Virchow's triad: endothelial damage due to trauma; trauma-induced hypercoagulability; patients will have long periods of postoperative stasis. These put the patient submitted to venous repair at higher risk of VTE.
Additionally, Nathan Manley et al talk about an interesting and important idea that needs some action. In the presence of thrombosis at the suture line without clinical evidence of DVT, venous outflow continues through a vein containing a recent thrombosis, which puts the patient at risk of thrombus growing and subsequent PE. Because this higher risk of PE continues even after discharge, the surgeon must decide if long-term anticoagulation is necessary. On the contrary, vein ligation prevents the long-term risk of PE, avoiding the need for long-term anticoagulation.
"With extensive damage to the vein, patient instability or other major injuries, vein ligation is a viable option..."
Nathan Manley et al.
In resume, the authors state that is acceptable to ligate the common iliac vein, external iliac vein and femoral vein in the present of an isolated vein injury. However, this decision must be individualised, and many factors (venous injury extention, patient stability, associated lesions, ...) will contribute to the final decision: repair or ligate.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon