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TRAUMATIC VENOUS INJURIES

TRAUMATIC VENOUS INJURIES. WHICH TO FIX WHEN TO LIGATE DO YOU ANTICOAGULATE LARRY N DIEBEL MD 6Oth DETROIT TRAUMA SYMPOSIUM NOVEMBER 9 2012. THE HISTORY OF THE MANAGEMENT OF EXTREMITY VENOUS TRAUMA. SCHEDE 1882: LATERAL REPAIR OF LACERATED FEMORAL VEIN

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TRAUMATIC VENOUS INJURIES

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  1. TRAUMATIC VENOUS INJURIES • WHICH TO FIX • WHEN TO LIGATE • DO YOU ANTICOAGULATE • LARRY N DIEBEL MD • 6Oth DETROIT TRAUMA SYMPOSIUM NOVEMBER 9 2012

  2. THE HISTORY OF THE MANAGEMENT OF EXTREMITY VENOUS TRAUMA SCHEDE 1882: LATERAL REPAIR OF LACERATED FEMORAL VEIN LIGATION OF VENOUS INJURIES ACCETPED STANDARD OF CARE WWI MAKINS (1919) RECOMMENDED LIGATION OF UNINJURED VEIN WHEN AN ARTERIAL INJURY TREATED BY LIGATION DEBAKEY (1954) REPORTED ON MANAGEMENT OF VASCULAR INJURIES IN WWII THE SIXTY YEAR TIME POINT KOREAN CONFLICT AND EVEN MORE SO VIETNAM CONFLICT THE IMPORTANCE OF VENOUS REPAIR PARTICULARLY AT THE POPLITEAL LEVEL TODAY: THERE IS STILL ONGOING DEBATE ABOUT THE PROS AND CONS OF REPAIR, RECONSTRUCT OR LIGATION FOR VENOUS INJURIES PARTICULARY IN THE LOWER LIMBS

  3. VENOUS TRAUMA EXACT INCIDENCE UNKNOWN AND DIFFICULT TO ESTIMATE MANY ARE NOT DIAGNOSED UNTIL SURGICAL EXPLORATION FOR ARTERIAL OR OTHER ASSOCITATED INJURIES MANY REMAIN UNDISCOVERED DUE TO LACK OF SX OR DIAGNOSTIC IMAGING IN CIVILIAN SECTOR: VENOUS INJURIES ACOUNT FOR 35-63% OF ALL EXTREMTIY VASCULAR INJURIES, AND UP TO 85% HAVE AN ASSOCIATED ARTERIAL INJURY

  4. DETECTION OF MAJOR VENOUS INJURY • USUALLY FOUND AT OPERATION FOR ASSOCIATED ARTERIAL INJURY • IF ISOLATED, MAY BE RELATIVELY OCCULT WITH NO COMPELLING HARD OR SOFT SIGNS OF VASCULAR INJURY • BEWARE: “HISTORY OF SIGNIFICANT BLOOD LOSS”, WITH NORMAL ARTERIAL EXAM.

  5. DIAGNOSTIC IMAGING FOR VENOUS INJURY • ANGIOGRAPHY/CTA DETECTION OF AVF • CTA- “VENOUS PHASE” or DELAYED IMAGING AFTER INJECTION OF CONTRAST • USUALLY DETECT THROMBOSIS • VENOUS DUPLEX

  6. REPAIR, RECONSTRUCT OR LIGATE VENOUS INJURIES ATTEMPTS AT VENOUS REPAIR, IF SUCCESSFUL, IMPROVE OUTCOME BY IMPROVING ARTERIAL FLOW AND DECREASING ACUTE AND LONG TERM EFFECTS OF LEG EDEMA SEEN AFTER LIGATION IF THEY FAIL- RISK DVT AND PE

  7. MANAGEMENT OF VENOUS INJURY: ?OLYMPIC MEDAL COMPARISON

  8. MANAGEMENT OF VENOUS INJURY: CLINT EASTWOOD MOVIE COMPARISON ?

  9. BLEEDING FROM VENOUS vs ARTERIAL INJURY • VEINS THIN WALLED AND LESS ELASTIC THAN ARTERY, DON’T RETRACT AND BLEED MORE WHEN EXPOSURE IS GAINED • VEIN INJURY USUALLY MORE DESTRUCTIVE THAN ACCOMPANYING ARTERY AND MORE LIKELY MADE WORSE BY THE SURGEON IN ATTEMPTS AT VASCULAR CONTROL

  10. VASCULAR REPAIR OF VEIN vs ARTERY • IF VESSEL COMPLETELY TRANSECTED, LESS LENGTH GAINED BY MOBILIZATION OF ENDS AND DIVISION OF TRIBUTARIES • INSTILLATION OF HEPARINIZED SALINE AND FOGARTY CATHETERS LESS EFFECTIVE DUE TO COMPONENT VENOUS VALVES

  11. VEIN vs ARTERIAL VASCULAR REPAIR • THE BAD NEWS : AS A LOW FLOW SYSTEM, NARROWING OF REPAIR MORE LIKEY WITH VEIN VS ARTERY • THE GOOD NEWS; THE IMPLICATION OF FAILED REPAIR IS DRASTICALLY DIFFERENT.

  12. TECHNIQUES FOR SURGICAL MANAGEMENT OF VENOUS INJURY • LATERAL REPAIR ? HOW MUCH NARROWING; CLOSE HORIZONTAL • VEIN PATCH • END TO END REPAIR • GSV INTERPOSITION GRAFT NOT REVERSE • NON-AUTOLOGOUS INTERPOSITION GRAFT • COMPLICATED VEIN GRAFTS

  13. “GROWTH FACTOR” FOR VENOUS ANASTOMOSIS

  14. ADJUNCTS FOLLOWING REPAIR • INTRAOPERATIVE ASSESSMENT FOR VENOUS FLOW (NOT VENOGRAM) • PROPHYLACTIC DOSE LMWH WHEN”SAFE” • ?OTHER ADJUNCTS INCLUDING SEQUENTIAL COMPRESSIVE DEVICES, OTHER RHEOLOGIC AGENTS (DEXTRAN)

  15. OUTCOME OF VENOUS REPAIRS..BY TECHNIQUE PAPPAS (JVS 1997) : GSV GRAFT 75%, VEIN PATCH 87% AND END-TO-END REPAIRS 88% PATENCY AT 30 DAYS. POOR OUTCOME WITH MORE COMPLEX REPAIRS PARRY (AJS 2003) SHORT TERM PATENCY 74% WITH PRIMARY REPAIR , 76% WITH AUTOGENOUS VEIN GRAFT AND74% WITH RINGED-PTFE

  16. ? Improved Patency with ringed PTFE interposition for venous trauma Parry (AJS 2003 73% patency at 10+/- 6 days in 19pts with CFV, SFV and Popliteal venous injury Feliciano (JT 1985, virtually all unsupported ptfe grafts failed)

  17. Heparin-bonding may have an added benefit to ringed-grafts

  18. RESULTS OF VENOUS REPAIR BY LOCATION KURALAY (JVS 2002) PATENCY AT 6YRS WAS 100% FOR CFV, 78% FOR SFV AND 60% FOR POPLITEAL VENOUS REPAIRS AT 6 YRS POSTINJURY. ALL INFRAPOPLITEAL VEIN REPAIRS THROMBOSED.

  19. WHEN IF EVER TO USE PTFE GRAFT FOR VENOUS INJURY COMBINED MAJOR ARTERIAL AND VENOUS INJURY NO AUTLOGOUS VEIN THAT IS SUITABLE FOR VENOUS REPAIR MANIFESTATIONS OF BLEEDING FROM VENOUS HYPERTENSION ON REPERFUSION OF LIMB (DO NO ATTRIBUTE THIS TO SUDDEN ONSET COAGULOPATHY)

  20. SPIRAL VEIN GRAFT or PANEL GRAFT…DUMB AND DUMBER

  21. RESULTANT SPRIAL FEON GRAFT FROM 50 cm length GSV

  22. ADJUNCTIVE MEASURES IF LIGATION OF INJURED (MAJOR) VEIN • LIBERAL PERFORMANCE OF FASCIOTOMY • BED REST AND ELEVATION OF LIMB UNTIL EDEMA RESOLVES • COMPRESSION STOCKINGS IF EDEMA PERSISTS • CAREFUL FOLLOWUP

  23. EFFECT OF VEIN REPAIR ON RISK OF VTE QUAN (JVS 2008 MILITARY EXPERIENCE WITH 103 NAMED VENOUS INJURIES VENOUS INJURIES TREATED BY LIGATION IN 63% OF PATIENTS AND BY OPEN REPAIR IN 37% THROMBOSIS IN 6 OF 38 CASES (15.8%) POSTOPERATIVE EDEMA OCCURRED IN ALL PATIENTS PE NOTED IN OPEN PATIENT WITH REPAIR AND TWO AFTER LIGATION. NO DIFFERENCE

  24. PART TWO • IMPORTANT INJURIES • FROM INFRARENAL IVC TO POPLITEAL VEIN LEVEL • BELOW POPLITEAL...

  25. IVC Injuries and HIGH Mortality • Asensio et al (AJS2000) 57/77 or 75% • Tyburski et al (JT2001) 81/142 or 57% (90% to 100% with supra or retrohepatic IVC locations • Navsaria et al (Eur JVas Endovas Surg 2005) 15/48 or 19% (most were low velocity GSW)

  26. Exposure of IVC

  27. Techniques for IVC Hemorrhage Control

  28. Management of IVC injuries • Lateral repair • Posterior injury: repair by mobilization and rotation of IVC (need to divide lumbar veins) • Avoid extensive repairs or prosthetic repairs in most cases • Stop the bleeding is main priority, therefore IVC ligation is OK

  29. IVC INJURIES BURCH (AJS 1988) REPAIR IN 84% OF CASES, STATED THAT NARROWING UP TO 25% OF THE ORIGINAL LUMEN WAS “OK” PORTER (JT 1997, PATENCY OF 86% OF IVC REPAIRS ON FOLLOW UP IMAGING STUDIES VTE RISK AFTER IVC INJURIES: (JSR 2012 308 PTS: 4.2% VS 1.7% IN LIGATION VS REPAIR p=N.S.

  30. IVC Injuries • Sullivan et al (AJS2010 ) • 100 IVC injuries, 54 were infrarenal • 22/54 infrarenal IVC injuries ligated • Worse outcome than IVC repair, associated with shock and Tx • No long-term leg edema • THEY DIE BECAUSE THEY BLEED TO DEATH

  31. Sequelae of IVC Ligation ???BIG LEGS • Feliciano: low threshold to perform leg and/or thigh fasciotomies • Mullins et al: no fasciotomies done after IVC ligation and minimal or no long term limb swelling • Navsaria et al: early leg swelling (transient), treated with elevation and compression stockings. NO prophylactic or delayed fasciotomy

  32. No Long-term Swelling After IVC Ligation

  33. PATIENT C.B. GSW TO ABDOMEN • INJURIES SMALL BOWEL X 9, TRANSVERSE COLON AND LEFT COMMON ILIAC VEIN • INTRAOPERATIVE EBL 1O L, GIVEN 12 U PRBC AND 4 U FFP • NO ARDS, NO COMPLICATIONS, GOES HOME IN A WEEK, NO LEG SWELLING AND A COMPRESSIVE STOCKING FOR LEG • RETURNS ONE WEEK LATER TO ED FOR LEG SWELLING

  34. ILIAC VASCULAR INJURIES MORTALITY 30-50+ % . SIMILAR MORTALITYWITH ARTERY OR VEIN AND INCREASES 1.5-2 FOLD WITH COMBINED INJURIES MORTALITY DUE TO LARGE BLOOD LOSS BEFORE AND DUING THE OPERATION (ASENSIO ET AL 4.5 L WITH EITHER A OR V) PROBLEM IS MADE WORSE BY RELATIVELY POOR EXPOSURE IN PELVIS, PARTICULARY WITH RIGHT ILIAC VEIN INJURIES, AND DISTAL CONTROL WITH BOTH DAMAGE CONTROL PRINCIPLES: TVS FOR BOTH ..AND NOT LIGATION ( LIFE AND LIMB PRESERVED

  35. Exposure of Distal IVC AND RIGHT COMMON ILIAC VEIN

  36. THE INGUINAL LIGAMENT: THE KEY TO TAMPONADE AND VASCULAR CONTROL MILIKAN (AJS 1988) NO DEATHS WITH FEMORAL VASCULAR INJURIES AND A 37% MORTLITY WITH ILIAC VASCULAR INJURIES

  37. IMPROVEMENTS IN ILIAC VASCULAR TRAUMA • TEMPORARY VASCULAR SHUNTS…SAVE LIFE AND LIMB • BORROW FROM ENDOVASCULAR TECHNIQUES FOR VASCULAR CONTROL • NOVEL USE OF TORNIQUET

  38. Temporary Vascular Shunts

  39. VASCULAR SHUNT FOR ARTERIAL and VENOUS INJURY

  40. ENDOVASCULAR CONTROL FOR ILIAC VASCULAR TRAUMA

  41. VASCULAR SHUNTS: also useful for MAJOR VENOUS HEMORRHAGE

  42. BACK TO OUR PATIENTSSTORY One Week post-discharge Venous Duplex

  43. THROMBOEMBOLISM AFTER TRAUMA KNUDSON (ANN SURG 2004) 1602 EPISODES IDENTIFIED FROM THE ACS-NTDB

  44. PATIENT A.S. GSW X 2 TO LEG • SIGNICIFANT BLOOD LOSS AT SCENE AND ON ARRIVAL TO ED (SAPHENOUS VEIN) • SBP IN FIELD 84, ON ARRIVAL TO ED 130 • ABI DONE AND IS ABNORMAL • INTIAL Hb 8.4, blood requested.

  45. A.S.- GSW x 2 to THIGH

  46. WHAT HAPPENS NEXT

  47. A.S. Sues the Doctor…Plaxico Burress goes to jail. WAYNE COUNTY PROSECUTOR KYM WORTHY: “ THE REALITY IS WE HAVE A REPUTATION; IF YOU WANT TO COMMIT A CRIME, COME HERE”. Quote from Detroit News 2009

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