Central and regional hemodynamics determine optimal management of major venous injuries.

Abstract

Controversy continues in the selection of optimal management of major venous injuries. We analyzed our experience with 191 major venous injuries in 163 patients (1986 to 1991). The mechanism of injury was gunshot (112), stab (44), blunt (six), and iatrogenic (one). Eighteen cervicothoracic, 51 caval, 30 iliac, 36 visceral, and 56 extremity veins were involved. Of the 191 injuries, 105 (54.9%) were repaired (lateral repair 76, end-to-end anastomosis 15, vein patch four, vein graft five, Gore-Tex graft four, and compilation one). Of the remaining venous injuries, 64 were ligated as a result of hemodynamic instability. Twenty-two injuries in 18 patients did not receive treatment because 16 of 18 patients died before vascular control or repair. The overall amputation rate was 1.2%, and the mortality rate was 28.2% (46/163). The highest mortality rate occurred in those patients who required resuscitative thoracotomy (100%, p < 0.00001), retrohepatic caval injuries (90%, p < 0.0004), and multiple venous injuries (81.8%, p < 0.00001). Seventeen patients underwent fasciotomies (15 prophylactic and two therapeutic). Clinical or measured venous hypertension by stump pressure assisted in deciding for venous repair in 20 patients. A significant decrease in venous stump pressure (p < 0.000001) was noted after venous reconstruction. Thus the decision to ligate or repair venous injuries correlated primarily with (1) hemodynamic stability, and in stable patients, with (2) extent and location of injury and (3) clinical and measured venous hypertension. Venous ligation in clinically stable patients did not increase the need for fasciotomy or amputation.(ABSTRACT TRUNCATED AT 250 WORDS)