Iatrogenic Major Venous Injury Is Associated with Increased Morbidity of Aortic Reconstruction

Abstract

Major venous injury during open aortic reconstruction though uncommon often result in sudden and massive blood loss resulting in increased morbidity and mortality. This study details the etiology, management, and outcome of such injuries. A retrospective review of 945 patients (1981-2017) undergoing aortic reconstruction from 2 midsized (350 bed each) teaching hospitals was conducted. Seven hundred twenty-three patients (76.5%) underwent open abdominal aortic aneurysm (AAA) repair/iliac aneurysm repair, 222 patients (23.5%) underwent aortofemoral grafting (AFG). Patients sustaining major venous injury (sudden loss of more than 500mL of blood) during major aortic reconstruction were studied. The number of units of packed red blood cells transfused, location of injured vessel, type of repair, postoperative morbidity, and mortality were collected in our vascular registry on a continuous basis. All patients identified with iliac vein/inferior vena cava/femoral vein injury had follow-up noninvasive venous examination of the lower extremities. Eighteen major venous injuries (1.9%) occurred during aortic reconstruction in 17 patients (1 patient had 2 major venous injuries): IVC (n=4), iliac vein (n=10), left renal vein (n=4, this includes a posterior retroaortic renal vein injury n=1). Of the 18 major venous injuries, 7 occurred during open AAA repair for ruptured AAA and another 9 occurred during repair of intact AAA (P=0.001), 2 venous injuries occurred after AFG, and 1 after primary AFG (P=0.05). Using multivariate regression analysis, periarterial inflammation had significant association with major venous injury (P<0.001). The presence of associated iliac aneurysm with abdominal aortic aneurysm also increased the incidence of major venous injury during AAA surgery (P=0.05). Two patients (11.8%) died, one from uncontrolled bleeding due to tear of right common iliac vein during ruptured AAA repair and second patient from disseminated intravascular complication following repair of ruptured AAA. Intraoperative transfusion requirements were 3-28 units, (median 8 units). Three of 9 (33%) surviving patients developed iliofemoral venous thrombosis following repair of iliac/femoral vein injury. Major venous injury during aortic reconstructions occurs more commonly during the repair of ruptured AAA and redo AFG. Following repair of iliac/femoral vein injury,surveillance for possible deep venous thrombosis by duplex imaging should be considered.