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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.
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