Challenges encountered and lessons learnt from venous injuries at Sri Lankan combat theatres

The objective of this study was to characterise the spectrum of peripheral venous injury in the Sri Lankan war theatres, including categorisation of anatomic patterns, mechanism and management of casualties, including short-term results of surgical repair of traumatic venous injuries versus ligation. In addition, the effects and outcome of combined arterial and venous injuries versus arterial injury alone are compared.

All adults with extremity vascular injuries admitted to a military base hospital during an 8-month period were prospectively recorded and those with a venous injury were analysed.

A total of 123 vascular injuries were recorded in the study period, of which 70 had a venous injury, combined with an arterial injury in 58 (83%) and in isolation in 12 (17%). There were 43 transections, 26 lateral tears and a single through and through penetrating injury. Twenty-five (36%) vein injures were repaired and 45 ligated. Only six popliteal veins were repaired in 21 lower limbs that underwent arterial revascularisation. In the combined arterial/venous injuries group 13 primary amputations were performed and five delayed amputations were necessary. There were no amputations in the isolated venous injury group. There were three deaths (4.3%), 18 infections with four cultures positive for pseudomonas species, five arterial graft thromboses were recorded. There were significantly more blood transfusions and concomitant skeletal injuries, resulting in more amputations, in combined arterial and venous injuries in comparison with arterial injury alone (all p values<0.05).

In an ideal setting, venous injuries should be repaired when possible and tolerated by the patient in order to ameliorate the risk of thrombotic and infectious complications. An aggressive use of shunting, fasciotomies and venous repair in wartime limb injuries at echelon structured care may prevent preventable limb loss in these challenging case scenarios.