Current concepts in repair of extremity venous injury

Abstract

Objective: Extremity venous injury management remains controversial. The purpose of this communication is to offer perspective as well as experiential and technical insight into extremity venous injury repair.

Methods: Available literature is reviewed and discussed. Historical context is provided. Indication, the decision process for repair, including technical conduct, is delineated. In particular, the authors' experiences in both civilian and wartime injury are used for perspective.

Results: Extremity venous injury repair was championed within data from the Vietnam Vascular Registry. However, patterns of extremity venous injury differ between combat and civilian settings. Since Vietnam, civilian descriptive series opine the benefits and potential complications associated with both venous injury repair and ligation. These surround extremity edema, chronic venous insufficiency, thromboembolism, and limb loss. Whereas no clear superiority in either approach has been identified to date, there appears to be no increased risk of pulmonary embolism or chronic venous changes with repair. Newer data from the wars in Iraq and Afghanistan and meta-analysis have reinforced this and also have suggested limb salvage benefit for extremity venous repair in combined arterial and venous injuries in modern settings. The patient's physiologic state and associated injury drive five triage categories suggesting vein injury management. Vein repair thrombosis occurs in a significant proportion, yet many recanalize and possibly have a positive impact on limb venous return. Further, early decompression favors reduced blood loss, acute edema, and inflammation, supporting collateral development. Large soft tissue injury minimizing collateral capacity increases the importance of repair. Constructs of repair are varied with modest differences in patency. Venous shunting is feasible, but specific roles remain nebulous.

Conclusions: An aggressive posture toward extremity venous injury repair seems justified today because of the likely role in reducing venous hypertensive sequelae as well as a potential role in limb salvage. Appropriate triage selection for extremity vein repair is essential.