Kuralay Erkan, Demirkiliç Ufuk, Ozal Ertugrul, Oz Bilgehan Savas, Cingöz Faruk, Gunay Celalettin, Yildirim Vedat, Arslan Mehmet, Tatar Harun
Department of Cardiovascular Surgery, Gülhane Military Medical Academy, Etlik/Ankara, Turkey 06010.
J Vasc Surg. 2002 Dec;36(6):1213-8. doi: 10.1067/mva.2002.128934.
We prospectively investigated the patency of venous repair in a quantitative fashion with measurement of vein blood flow velocities after lower extremity injuries caused by either military or civilian trauma.
During a 10-year study period (March 1990 to December 2000), surgical intervention was performed after lower extremity vascular injuries in 130 patients. Most of these patients were men (n = 125), with a mean age of 23 +/- 5 years (range, 17 to 44 years). One hundred ten direct venous injuries were identified in 97 patients, involving the common femoral vein in seven, the deep femoral vein in three, the superficial femoral vein in nine, the popliteal vein in 46, and the posterior tibial (n = 21), anterior tibial (n = 17), or peroneal veins (n = 7) in 45. Popliteal vein thrombosis without apparent venous injury was found in seven patients. Bone fractures (n = 45), nerve injuries (n = 27), or extensive tissue loss (n = 7) often were associated with vascular injuries. Duplex color ultrasonography was used to evaluate patency and to measure blood flow velocity in repaired veins during the early postoperative period and at the time of late follow-up examinations.
Significant differences were seen in venous blood flow velocities between severe (extremity diameter more than twice normal) and moderate (diameter 1.5 to 2 times normal) reperfusion injuries. The mean flow velocity in repaired popliteal veins was 15 +/- 2 cm/s with severe reperfusion injuries compared with 8.4 +/- 1.1 cm/s with moderate reperfusion injuries (P <.0001). Flow velocities were lower than 5 cm/s in repaired infrapopliteal veins, and most of these veins occluded on the first postoperative day. Amputations were necessary in 11 patients, all of whom had both tibial fractures and extensive tissue loss. Sodium warfarin therapy was routinely administrated before hospital discharge. The mean follow-up period was 6.2 years (range, 1.3 to 10 years). Repaired common femoral and superficial femoral veins had relatively high patency rates (100% and 89% at 1 year, 100% and 78% at 6 years, respectively), whereas the patency rates for repaired popliteal veins were disappointing (86% at 1 year, 60% at 6 years). All seven popliteal veins that required thrombectomy in the absence of direct injuries remained patent, however. Patch angioplasty had the highest 6-year patency rate (75%) in comparison with all other techniques that were used for venous injuries (lateral repair, 58%; end-to-end anastomosis, 43%; saphenous vein graft interposition, 36%).
Venous repair has a high patency rate at the femoral and popliteal levels, but the patency rate for infrapopliteal venous repair is extremely poor because of low flow velocities. Therefore, we conclude that repair of infrapopliteal venous injuries is unnecessary.
我们前瞻性地以定量方式研究了下肢因军事或民用创伤导致损伤后静脉修复的通畅情况，并测量了静脉血流速度。
在10年研究期间（1990年3月至2000年12月），对130例下肢血管损伤患者进行了手术干预。这些患者大多数为男性（n = 125），平均年龄23±5岁（范围17至44岁）。在97例患者中发现110处直接静脉损伤，其中7例累及股总静脉，3例累及股深静脉，9例累及股浅静脉，46例累及腘静脉，45例累及胫后静脉（n = 21）、胫前静脉（n = 17）或腓静脉（n = 7）。7例患者发现无明显静脉损伤的腘静脉血栓形成。骨折（n = 45）、神经损伤（n = 27）或广泛组织缺失（n = 7）常与血管损伤相关。在术后早期和晚期随访检查时，使用双功彩色超声评估修复静脉的通畅情况并测量血流速度。
重度（肢体直径超过正常两倍）和中度（直径为正常1.5至2倍）再灌注损伤的静脉血流速度存在显著差异。重度再灌注损伤时，修复后的腘静脉平均血流速度为15±2 cm/s，而中度再灌注损伤时为8.4±1.1 cm/s（P <.0001）。修复后的腘静脉以下静脉血流速度低于5 cm/s，且这些静脉大多在术后第一天闭塞。11例患者需要截肢，所有这些患者均有胫骨骨折和广泛组织缺失。出院前常规给予华法林钠治疗。平均随访期为6.2年（范围1.3至10年）。修复后的股总静脉和股浅静脉通畅率相对较高（1年时分别为100%和89%，6年时分别为100%和78%），而修复后的腘静脉通畅率令人失望（1年时为86%，6年时为60%）。然而，所有7例在无直接损伤情况下需要进行血栓切除术的腘静脉均保持通畅。与用于静脉损伤的所有其他技术相比，补片血管成形术6年通畅率最高（75%）（侧方修复，58%；端端吻合，43%；大隐静脉移植搭桥，36%）。
静脉修复在股部和腘部水平通畅率较高，但由于血流速度低，腘静脉以下静脉修复的通畅率极低。因此，我们得出结论，腘静脉以下静脉损伤的修复是不必要的。
