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Injury to the peripheral veins in the extremities occurs via a wide variety of mechanisms. The presence of peripheral venous injuries is an often overlooked problem in extremity trauma given the more profound effects of similar arterial injury as noted by the small number of studies regarding prevalence, operative indications, and postoperative management. The heterogeneity of these injuries and the sequela of their management also contribute to the paucity of literature relative to arterial injuries. This is especially true of upper extremity injuries, which have been historically ligated with few long-standing implications to patient morbidity. Trauma to the peripheral venous systems can negatively impact both associated arterial repairs and long-term morbidity associated with extremity injuries.
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Case series from civilian literature indicate that about 1% to 4% of trauma patients have a vascular injury and about 25% of these involve an injury to the vein.1,2 The majority of these result from penetrating trauma. In a recently military review, isolated venous injuries accounted for 16% of 1570 vascular injuries, and combined injuries to both the veins and arteries made up about 20% of vascular injuries.3 These data may be skewed by both the under reporting of venous injuries and the limitation of retrospectively extracting incidence from the medical record. In any case, the prevalence of venous injuries and their impact on limb salvage mandate a thorough understanding of management options by the treating surgeon.
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HISTORICAL PERSPECTIVE
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The literature prior to the Vietnam War provided scant data or commentary on surgical options to treat venous injury of the extremities other than ligation. The seminal work of DeBakey and Simeone on World War II vascular injuries, for example, is primarily focused on arterial injuries and provides little insight into the management of venous trauma other than the epidemiology of World War II vascular injuries. They also debunked the practice of concomitant ligation of uninjured major associated veins after artery injury, which was promoted by some of their contemporaries.4 During the Korean War, Dr. Carl W. Hughes began to provide data and commentary on venous injuries. Some of these insights foreshadowed conclusions later promulgated by Dr. Norman M. Rich, including the risk of limb loss due to acute venous insufficiency in the setting of patent arterial repairs and the efficacy of venous repair with lateral suture venorrhaphy or end-to-end anastomosis.5,6
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Dr. Rich was the central figure in the establishment of the Vietnam Vascular Registry in late 1966 at Walter Reed General Hospital. He and Dr. Carl Hughes presented preliminary data on 1000 arterial injuries among the 4500 patients within the Registry and strongly recommended a more aggressive approach to repairing traumatized peripheral veins, particularly of the lower extremities.7 Analysis from registry data demonstrated a high frequency of amputation following injuries to the popliteal artery and vein, including many instances of amputation after successful repair of popliteal artery ...