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Br. J. Surg. Vol. 64 (1977) 200-202 Prosthetic replacement of a long segment of vein in the treatment of a lower limb injury S. S . T A C H A K R A A N D J . E. M . S M I T H * a bridge of skin, approximately 7.5 cm in width, on the outer side of the thigh. Much of the damaged muscle was ischaemic. The femoral artery and vein (including both the common and superficial femoral) and profunda artery and vein were torn and unrecognizable. The proximal stumps of the femoral artery and vein were located high in the groin. The upper parts of the popliteal vessels were also crushed and lacerated. Although we were well aware of the desirability of using autogenous vein grafts, it was clear that such lengths of veins were unobtainable. The opposite saphenous vein was being RECENTLY there has been an increasing awareness of used as an additional route for transfusion of large amounts of the importance of venous trauma, although until a blood and the cephalic and jugular veins were not long enough. Therefore an 8-mm wide Teflon graft was attached to the few years ago the treatment recommended was proximal stump of the femoral artery. As it was clear that there ligation of the vein (Levitsky et al., 1968; Rich and were insufficient intact collateral veins to maintain an adequate circulatory return, prosthetic replacement of the femoral vein Hughes, 1969). also done. An 8-mm wide Dacron prosthesis was attached About 55 per cent of patients with arterial trauma was to the proximal stump of the femoral vein, leaving the loops of have an associated venous injury. Injury of the the continuous suture somewhat looser than those used in the accompanying vein is present in 58-80 per cent of arterial suture line to prevent constriction. The patient was cases of popliteal artery trauma, and some surgeons then turned on to his right side and the ends of the prostheses were attached to the distal stumps of the popliteal artery and now repair veins because venous occlusion must reduce vein in the popliteal fossa. Special care was taken to ensure arterial blood flow and impair long term patency of the that the venous prosthesis was inserted without any tension. repaired artery. The procedures used are lateral suture, The length of each of the prostheses was 27 cm. Good skin and end-to-end suture and replacement of segments of muscle cover was obtained for both implants initially. Postoperatively wound infection developed, the wound veins with autogenous vein grafts. Replacement of broke down behind the knee, thevein prosthesis becameexposed segments of vein with prosthetic materials has hitherto and, during subsequent dressings, it was observed to be been felt to be of little benefit as these materials functioning for 30 days after its insertion. I t was felt to be encourage infection and rapidly become thrombosed patent for the following reasons: 1. The popliteal vein distended when the prosthesis was (Silver and Anlyan, 1961 ; Rich and Hughes, 1972; pinched. Rich, 1973). The purpose of the present report is to 2. Pinching the femoral vein at the upper end resulted in show that when injury to a limb is so severe that in partial obliteration of the convolutions of the prosthesis. 3. The prosthetic wall sprung back to its normal shape when addition to severance of the main artery, nearly all it was released after pinching. When the prosthesis thrombosed, collateral venous channels are destroyed, a long the wall could be indented easily, presumably because the prosthetic vein replacement can function for a sub- thrombus broke at that particular site. stantial length of time; it remains patent presumably 4. When removed, the whole length of the venous prosthesis was found to be well endothelialized. because of the high rate of flow through it. After 33 days it became obvious that the venous prosthesis was acting as an infected foreign body, preventing healing, for a Case report portion of it was exposed in a gap in the muscles, 1.3 cm in A 38-year-old man fell into a sand-rolling machine and was diameter. The arterial prosthesis was well covered by granulaspun inside it. H e was brought to the Birmingham Accident tion tissue. The venous prosthesis remained patent for at least Hospital 20 minutes after the accident. When first seen he was 33 days before it finally thrombosed; it was then removed, the severely exsanguinated; his pulse was felt with difficulty and infection subsided and the extensive skin defects in the various was in excess of 160/min and his blood pressure was unrecord- parts of the limb were covered with split skin grafts. The able. The patient was resuscitated and found to have the patient had a lateral popliteal paralysis, which was probably following injuries. There was a large, almost circumferential, associated with the fracture of the neck of the fibula, and which spiral laceration of the lower third of the left thigh and upper has now recovered. part of the leg with a bridge of skin approximately 7.5 cm in About 11 months after the injury the patient, who was then width on the outer side of the limb. An extensive muscle defect ambulant, had sudden pain in the thigh. There was a warm and could be seen and felt in the lower half of the thigh. No pulses tender swelling which when drained was found to be a large were felt in the foot which was cold and blue. Active bleeding haematoma. After initial difficulty in finding the source of the had ceased. Radiographs showed a fracture of the neck of the bleeding, it was noticed that the arterial prosthesis had fibula. In addition, he had a laceration of the right occipital fractured where it was being kinked during knee flexion. The region with a fracture of the right temporal bone, a fracture prosthesis was pulsating as well as o n the first day after insertion of the left clavicle and an anterior dislocation of the left shoulder. At operation it was found that the muscles had been divided * Birmingham Accident Hospital. through the entire circumference of the lower third of the thigh, Present address of S. S. Tachakra: Robert Jones and Agnes the only intact structures being the femur, the sciatic nerve and Hunt Orthopaedic Hospital, Oswestry, Salop. SUMMARY A patient who sustained exceptionally severe damage to the main blood vessels and to the collateral circulation of his left lower limb is reported. The femoropopliteal vein was replaced by a Dacron prosthesis which remained patent for 6 weeks until an adequate collateral circulation was established. Prosthetic replacement of lower limb vein 201 but it was decided to accept the risk of gangrene and remove the prosthesis. There was an adequate collateral circulation and the limb survived. When last seen 18 months after injury the patient had no intermittent claudication. He walks moderate distances without support although he still limps. Active knee movements are 0-50". The limb shows some gravitational oedema and is wasted in the lower part of the thigh where the muscles were extensively damaged (Fig. 1). Discussion Much experimental work has been done to evaluate grafts of the vena cava, pulmonary artery and the portal system (East and Muller, 1960; Dale and Scott, 1963; Moore and Mandelbaum, 1963; Haimovici et al., 1970), but there have been few studies of the replacement of peripheral veins, particularly those of the lower limbs (Silver and Anlyan, 1961). One report of replacement of the femoral artery and vein with nylon prostheses following excision of a tumour showed both implants to be patent after a year (Lawrence, 1957). Infection and thrombosis are the most common complications of the use of prostheses for repair of vascular injuries in contaminated wounds (Rich and Hughes, 1972). An additional problem in the utilization of prostheses across joints arises from damage due to kinking and possible thrombosis in the implant. This was demonstrated radiographically when a Dacron prosthesis used to repair a popliteal artery was shown to become kinked when the knee was flexed (Hershey and Spencer, 1963). The majority of plastic implants bridging vascular defects remain patent if there is a high flow rate through them (Bryant et al., 1958; Dale and Scott, 1963; Haimovici et al., 1970). Acute venous insufficiency has been documented in 4 patients following venous trauma of the lower limb. Two cases required an amputation after ligation of a major vein in the lower limb (Rich et al., 1975). There have been several reports of venous bypass grafts using the long saphenous vein and synthetic material (Allansmith and Richards, 1958 ; Palma and Esperon, 1960; Izquierdo, 1963). In one case a femorofemoral venous Teflon graft was found to be patent after 11 days (Hamer and Smith, 1974). The patient reported here had a severe combination of extensive damage to the skin and muscles with large defects of the femoral, profunda femoris and popliteal vessels. Venous return was grossly impeded, the only bridge of continuity being a narrow skin flap, which was already contused, and the intramedullary channels of the femur via some muscle attachments at its lower end. While it is well recognized that autogenous vein grafts fare better than prosthetic implants, an autogenous graft was not possible in this patient: the long saphenous was already damaged on the left side, the opposite saphenous vein was being used for rapid blood transfusion and the cephalic and jugular veins would have been too short to bridge the defects. A 27-cm long Dacron vein prosthesis was therefore used, and it remained patent for 5 weeks because there Fig. 1. Appearance of the limb 18 months after injury. was a high flow rate through it. As new collateral channels formed, the flow through the prosthesis presumably diminished in rate until it reached a point where the venous prostheses became thrombosed. The predictable complications of infection and thrombosis did occur, but insertion of the venous prosthesis ensured an adequate circulatory return until a good collateral circulation was established. There has not been an associated increase of thrombophlebitis and pulmonary embolism following the use of autogenous vein grafts in the venous system (Gaspar and Treiman, 1960). This may also apply for prosthetic materials currently in use. From the experience gained in the care of this patient we feel that a more aggressive approach should be adopted in lower limb venous trauma, as first suggested by Rich et al. (1974). In a limited number of cases prosthetic replacement of vessels may be the only operative procedure available to save a limb. Further experience may show that the end result in such cases can be suprisingly good. Acknowledgements Our thanks are due to Mr J. Cason for the skingrafting procedure used in this case, Mr R. Gill for the illustration and Mrs A. V. Turner for secretarial assistance. References and RICHARDS v. (1958) Superior vena caval obstruction. Am. J. Surg. 96,353-359. BRYANT M. F. jun., LAZENBY w. D. and HOWARD J. M. (1958) Experimental replacement of short segments of vein. Arch. Surg. 76, 289-293. DALE w. A. and SCOTT H. w. jun. (1963) Grafts of the venous system. Surgery 53, 52-74. EAST w . M. and MULLER w . H. jun. (1960) An experimental study of resection and replacement of the superior vena cava. Am. J. Surg. 99,6-12. GASPAR M. R. and TREIMAN R. L. (1 960) The management of injuries to major veins. Am. J. Surg. 100, 171-175. HAIMOVICI H., HOFFERT P. w., ZINICOLA N. et al. (1970) An experimental and clinical evaluation of grafts in the venous system. Surg. Gynecol. Obstet. 131, 1173-1186. 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