Journal of Emergencies, Trauma, and Shock
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LETTER TO EDITOR  
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 231
Outcomes associated with femoral vein segmental oversew/ligation in penetrating trauma


1 Department of Surgery, Port-of-Spain General Hospital, Port-of-Spain, West Indies
2 San Fernando General Hospital, San Fernando, Trinidad, West Indies

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Date of Submission02-Jun-2020
Date of Acceptance07-Jun-2020
Date of Web Publication18-Sep-2020
 

How to cite this article:
Ramdass MJ, Spence R, Harnarayan P. Outcomes associated with femoral vein segmental oversew/ligation in penetrating trauma. J Emerg Trauma Shock 2020;13:231

How to cite this URL:
Ramdass MJ, Spence R, Harnarayan P. Outcomes associated with femoral vein segmental oversew/ligation in penetrating trauma. J Emerg Trauma Shock [serial online] 2020 [cited 2020 Dec 2];13:231. Available from: https://www.onlinejets.org/text.asp?2020/13/3/231/295374




Sir,

The femoral vein (vena femoralis) otherwise known as the subsartorial vein or superficial femoral vein (SFV), as it is traditionally known, accompanies the superficial femoral artery. It receives numerous muscular tributaries, and is joined by the vena profunda femoris (PFV) and greater saphenous vein to become the common femoral vein (CFV). The PFV receives perforating branches and establishes communications with the popliteal, inferior gluteal, and medial/lateral femoral circumflex veins.[1]

Trauma to the SFV is seen in high volume trauma settings and management dilemmas may develop for surgeons who are unfamiliar in this territory. The literature reveals unclear and misleading guidelines with regard to interposition Polytetrafluoroethylene (PTFE) grafting/primary repair versus ligation/oversew.[2],[3],[4] Of note, a recent publication concluded that ligation carries a higher morbidity than repair.[3] Conclusions were based on a wide mixture of veins throughout the lower extremity and in particular there was no differentiation of outcome based on injury to the CFV, SFV, or PFV. The study mixed ligation of crural veins with popliteal or iliac veins. Surgeons in direct clinical practice with these injuries would know that the outcomes can be vastly different based on the type and level of injury and most would never attempt to realistically repair crural veins. Therefore, the generalized conclusions drawn of repairing all venous injuries and performing fasciotomies liberally does not seem sensible.

A high volume of vascular trauma is seen in our setting due to the illicit drug and arms trade in our part of the world which is geographically located off the South-American coastline.[5] Over a 6-year period (2007–2012), there were 14 cases with segmental injury to the SFV that required exploration. The age range was 17–42 (mean = 24) with 93% male. There were 10 gunshots and 4 stabs to the SFV with the SFA involved in 12 cases, traumatic arteriovenous fistulae occurring in 3 and femoral fracture in one. The SFV was oversewn and ligated at the point of injury in 11 cases. In 3 cases, PTFE grafting, primary repair, and stenting were done. The limb salvage rate in the oversew group was 73% (8/11) at 1-year with 3 Above the knee amputation (AKAs) in the 1st week and 8 cases viable and functional at 1-year. Two amputations were related to delayed transfers >24 h with severely ischemic limbs that were not salvageable and the third due to a severe shotgun blast at close range with a mangled limb. There was no long-term neurologic deficit, prolonged swelling, phlegmasia, venous gangrene, or pain in the 8 limb salvage patients.

It is with this evidence that we herein make recommendations on the management based on anatomic and surgical principles of the vessel. The venous drainage of the lower limb is designed to adapt in trauma and nature has created these in the form of Hunterian perforators, muscular/collateral branches, geniculate, and circumflex vessels. Segmental ligation of the SFV provided the injury is a single gunshot or stab wound without prolonged ischemia or blast-type injury carries little morbidity. We also recommend that postoperative low-molecular weight heparin and limb elevation should be routine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gray H. The veins of the lower extremity, abdomen, and pelvis. In: Anatomy of the Human Body. 3rd ed. Philadelphia: Lea & Febiger, 1918; 2000. Available from: http://www.bartelby.com/107/173.html.  Back to cited text no. 1
    
2.
Ratnayake AS, Samarasinghe B, Bala M. Challenges encountered and lessons learnt from venous injuries at Sri Lankan combat theatres. J R Army Med Corps 2017;163:135-9.  Back to cited text no. 2
    
3.
Matsumoto S, Jung K, Smith A, Coimbra R. Outcomes comparison between ligation and repair after major lower extremity venous injury. Ann Vasc Surg 2019;54:152-60.  Back to cited text no. 3
    
4.
Arrillaga A, Bynoe R, Frykberg ER, Nagy K. Penetrating Venous Extremity Trauma, Management of. Eastern Asscociation for the Surgery of Trauma. Available from: https://www.east.org/education/practice-management-guidelines/penetrating-venous-extremity-trauma-management-of. [Last accessed on 2020 May 26].  Back to cited text no. 4
    
5.
Ramdass MJ, Harnarayan P. A decade of major vascular trauma: Lessons learned from gang and civilian warfare. Ann R Coll Surg Engl 2017;99:70-5.  Back to cited text no. 5
    

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Correspondence Address:
Prof. Michael James Ramdass
Department of Surgery, Port-of-Spain General Hospital, Charlotte Street, Port-of-Spain, Trinidad
West Indies
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JETS.JETS_50_20

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